Mode of Work Organization in Nursing: Management Practices in Private Healthcare in India

Abstract

The article intends to look into the mode of work organization in nursing, which is constantly evolving owing to technological innovations, in the context of rising private healthcare in India and management rationales behind it. Locating the study within the framework of scientific management techniques and analyzing through lens of Weberian power structure and Marx’s concepts of work alienation and subjugation, the article contributes to understanding how in the absence of standard mode of work design, management in private healthcare recruits workers hailing from migrated ethnic communities without formal skills and qualification. The organization of work is based on subjectivities and social institutions such as race, class and ethnicities of workers. In the name of efficiency, those workers are selected who respond positively to workplace controls. Thus, while Taylorist concepts of efficiency, fragmentation and specialization of work are used to design work, they are reconceptualized and merged with informal social institutions to fulfil the management’s goals of higher accumulation in service industries.

Keywords

Nursing work organization Taylorism India private healthcare

Introduction

Mode of work organization in health services is complex in nature, it varies across size of organizations and is constantly evolving in response to technological innovations along with various other external and internal factors. While public healthcare in India is state sponsored, employing skilled and qualified nurses, following a formal, hierarchical and standardized mode of work organization, private healthcare is owned and managed by individual entrepreneurs or corporate houses with changing modes of work organization (Bajpai, 2014; Baru, 1998, 2000, 2003, 2006; Baru, Qadeer, & Priya, 2002; Bhat, 1993, 1996, 1999; Gill, 2016; Khot & Nandraj, 2003; Nandraj, 1994, 2012; Rao, 2012; Rao, Shehrawat, & Bhatnagar, 2016; Nair, 2011, 2012; Nair, Timmons, & Evans, 2016). This article examines the mode of work organization and work arrangements within private healthcare services. Nursing is a part of the larger domain of institutional care work, performed in both public and private hospitals, involving delivery of mental, physical, emotional and cognitive care services to the patients (Smith, 1992; Theodosius, 2008). The work requires professional, scientific, empirical and theoretical knowledge along with personal ethics and emotions (England, 2005; Phillip & Taylor, 1980). Nurses in private healthcare in India are informal wage workers within the formal workplace setting and their work organization differs from those of nurses employed in public healthcare. Against this backdrop, the paper analyzes work organizations and its structure within the premises of private nursing homes.

During the 1980s, neo-liberal market reforms in health and education in countries of the Global North led to casual employment relationships and reduced numbers of trained staff (Ackroyd & Bolton, 1999; Porter, 1992). Taylorism, which was hitherto reserved for organizing industrial work and certain services, was now applied in case of care work of nurses. It was based on the two-fold rationales of the management—raising productivity at lower costs and meeting the growing demand for nursing care workers (Brannon, 1990, 1994, 1996; Melosh, 1982; Reverby, 1987; Tattershall & Altenderfer, 1944), resulting in coexistence of formally trained workers with semi-skilled nursing aides (Tattershall & Altenderfer, 1944). In the UK, influenced by the efficiency principle of neo-Taylorism, the nursing workforce was restructured with the incorporation of time and contract flexibility, leading to employment of low-waged contractual healthcare assistants (Cooke, 2006a, 2006b; Pollitt, 1993). There were core nurses or ward managers with flexible work schedules, who did a lot of the routine paper work (Atkinson, 1984; Mc Keown, 1995). However, rising work intensities, associated with the application of these measures resulted in frustration, exhaustion, low morale and alienation of nurses from their work (Cooke, 2006a). So the actual care work was performed by periphery workers who suffered from low pay, insecure employment and control of the core workers.

Thus, the adoption of rationalization strategies in healthcare management led to reduction of costs of labour (Ackroyd & Bolton, 1999; Adams & Bond, 2000; Bolton, 2000a, 2000b, 2004; Brannon, 1990, 1994, 1996; Cooke, 2006a, 2006b; Melosh, 1982; Reverby, 1987; Tattershall & Altenderfer, 1944). However, it also induced changes in power relations between nurses and the management, enhancing power and authority of the latter over labour processes (Cooke, 2006a, 2006b; Norrish & Rundall, 2001; Theodosius, 2008). Following the case of UK, in the context of healthcare in India, use of total quality management (TQM) as an instrument of work organization in private corporate sector, followed technological innovations in healthcare industry in the 1990s (Baru, 1998; Talib, Rahman, & Azam, 2011). Built on the objectives of higher efficiency and customer satisfaction, the best practices under TQM included team work, process management, training and educational improvement of human resources catering to the performance requirements of both customers and the management (Agarwal, Garg, & Pareek, 2011). Although there were elements of decentralization, incorporating greater employee participation as prescribed under TQM practices, the HR manager was entrusted with ultimate decision-making power for the fulfilment of the management’s objectives (Agarwal et al., 2011). TQM entails substantial investments and its application is therefore limited to corporate healthcare organizations. Irrespective of whether the modes of work organization reflect Taylorism (case of USA) or post-Fordism (UK and India), economic efficiency has been found as the overarching objective of management and ‘control’ as its preoccupation (Bolton, 2000a, 2000b, 2004; Cooke, 2006a, 2006b). Control dialectics were limited to modes and circuits of control or direct and indirect means of control (Friedman, 1977; Storey, 1985). Institutional care work (Daly, 2001; Duffy, 2005; England, 2005; Meyer, 2000; Razavi & Staab, 2010) in private healthcare organizations in India, especially nursing is gendered and racialized (Healey, 2013; Nair, 2011, 2012). The present study analyzes the role of social institutions in organizing nursing work in the context of Taylorist and Fordist modes of work management in healthcare organizations. Nursing as a holistic caregiving work, when subjected to processes of control, fragmentation and deskilling, results in sub-optimal care outcomes. Control operates through the structures and/or institutions created by the management to sustain unequal power relations within workers and between the workers and management. Therefore, mechanisms of operating control form an important aspect of management’s prerogative and functions. This article intends to look in how nursing is organized in private healthcare and what are the management’s rationales behind it, locating it within the framework of scientific management techniques of work design. The mode of work organization is analyzed through the lens of Weberian power structure and critical Marxist’s concepts of work alienation and subjugation.

The article is organized as follows. The following section discusses theoretical backdrop of the study, features of Taylorist work design, and its adoption in organizing service work. The next section discusses study settings and the methodology used for the study. Study findings—mode of work organization of nurses based on the four features—skill and education, ethnicity, requirements and hierarchies—are explained in the subsequent section. After a discussion, the comments on the study findings are summarized in the conclusion.

Mode of Work Organization in Services

Work organization¹ can be referred to as the gamut of social, technical and bureaucratic relations governing the factors of production engaged in producing goods and services (Chave, 1983; Hodson & Sullivan, 2008; Watson, 2012). After industrial reforms, principles of work designed by Fayol (1949) and Taylor (1911) became important modes of achieving higher productivity, efficiency and profitability. Scientific management included both Taylor’s principles of technical management as well as Fayol’s administrative strategies. It revolved around securing higher efficiency via rationalized division and mechanization of tasks, separating planning from execution, reduction in skill requirements, better monitoring over workers and incentive payments to intensify work efforts (Watson, 2012). Application of Taylorist modes required the organization to adopt rational and bureaucratic structures, in addition to a class of managers whose functions included forecasting, coordinating, planning, commanding and controlling the work of various parts and sub-parts of the organization (Weber, 1958). As a result, hierarchies, based upon power and authorities were built in order to facilitate the work of the management (Crowley, Tope, Lindsey, Joyce, & Hodson, 2010; Weber, 1958). In the latter half of the twentieth century, the assembly line of production for mass consumption under the Fordist and post-Fordist regimes necessitated management to plan and supervise at every level, to raise work intensity and reduce autonomy of the worker. These processes included adoption of lean production practices, TQM, knowledge management practices in the production designs in both industrial manufacturing and services, which were more neo-Taylorist than post-Fordist, because of their striking similarities with the original Taylorist processes (Crowley et al., 2010).

Taylorist principles were critiqued by Marxist writers based on the effect it had on the workers’ skill and autonomy. Application of scientific methods of organizing work following technology and automation in industrial workplaces led to sub-division and fragmentation in work, resulting in routinizing, mechanizing, homogenizing and deskilling the workers (Armstrong, 1989; Braverman, 1974; Edwards, 1979; Friedman, 1977; Gordon, Edwards, & Reich, 1982; Littler, 1982; Littler & Salaman, 1982; Storey, 1985; Watson, 2012). Capitalist employers had reduced needs for human skills and ingenuity at work (Watson, 2012). The central function of the management revolved only around creating hierarchies that served as mode of control over labour, ensuring that workers could no longer utilize their creative faculties and just become appendages to machine. Work was organized in a way that eventually led to the alienation of workers from the product of their labour (Hodson, 2001; Hodson & Sullivan, 2008; Seeman, 1959; Spencer, 2000).

In the service sector, work organization involved training, soft skills, emotional and aesthetics along with manual and intellectual capacities of the worker (Bell, 1974; Warhurst & Thompson, 1998). Allen and du Gay (1994) and Bryman (2004) view that most of the modern services such as the ones requiring face-to-face interactions involve interpersonal management, therefore, distinct modes of work organization. On the other hand, Beynon (1992), Poynter (2000) and Ritzer (1998) argued that modes of work organization in some services such as those of back-office jobs are subjected to bureaucratic and Fordist modes of work organization, in the same way as that of manufacturing. However, it is important to note that work in most service sectors is complex and necessitates workers to use their own judgements, discretion and disposition. Expanding service economy opens up opportunities for both men and women in services where organization of work involves subjectivities such as gender, race, ethnicity and class (Acker, 1992, 2006). There is an increasing preference of organizations to employ workers belonging to a particular socio-economic category that are found to play important roles in the institutionalization of power and creation of vertical and horizontal structures and substructures to sustain inequalities at work (Acker, 2006; Duffy, 2005; Glenn, 1992; McBride, Hebson, & Holgate, 2015; Rakovski & Price-Glenn, 2010).

Why This Study?

The study is undertaken in a non-metropolitan city of Siliguri, in eastern part of India. Siliguri has been witnessing limited progress in state-assisted² healthcare. Rapid expansion in private healthcare is facilitated by the availability of cheap labour along with the presence and financial inputs of doctor-entrepreneurs and corporate healthcare chains with support from banks and financial institutions. The city has the repute of being the healthcare hub of the east and north-eastern part of the country. The private health sector,³ 20 years ago, was dominated by few maternity-based nursing homes owned by doctors; technical and bureaucratic changes in the past 8–9 years have facilitated the transition towards superspeciality and multispeciality clinics. The investments in latest technologies and use of information sciences are evident in laboratory, operation theatre (OT) and logistics management. Bureaucratic changes are observed in the presence of integrated hospital management systems. This has been followed by increase in scrutiny and monitoring by state bodies regarding the fulfilment of norms of treatment and quality control of equipment and medical services provided by the organization. This, along with an increase in cost of services, has also created a large medical market in Siliguri, catering to healthcare requirements of patients across the north-eastern states, rural counterparts of northern Bengal, neighbouring states of Bihar and even Bangladesh. On the basis of the number of beds, registered nursing homes and corporate hospitals in Siliguri are classified as—less than 30, between 30 and 100, and more than 100 (see Table 1). The nursing homes are found to be dominated by the less than 30 bedded nursing homes. There are 18 nursing homes in this category. The number of large-bedded corporate hospitals is rising with further entry of corporate healthcare chains. In this study, nursing homes and corporate hospitals providing superspeciality or multispeciality healthcare services are referred to as ‘superspeciality hospitals’, as opposed to ‘nursing homes’, which provide services in one or more departments and run diagnostic centres. Superspeciality hospitals have a hierarchical structure and the human resource (HR)⁴ department looks after labour and recruitment affairs. They also provide a host of specialized medical services. This phase of restructuring and corporatization following technological insertion in private healthcare in Siliguri has led to the reorganization of nursing work in hospitals. This inevitably has affected the work of nurses, comprising a significant section of the total staff strength (Nair et al., 2016, p. 9).

Table 1.

Numbers of Nursing Homes in Siliguri Based on the Bed Strength

Number of Beds	Bed Strength
Less than 30 beds	18
Between 31 and 100 beds	16
More than 101 beds	4
Total	38

Source: CMOH, District Darjeeling (2016).

Research Methodology

The study uses a mixed methods research design. Quantitative data pertaining to socio-demographic and economic characteristics is compared with qualitative data to explore in depth, the work organization and labour outcomes at not only the site of production (workplace) but also beyond it. Of the 38 registered nursing homes and superspeciality hospitals, the management of 10 were approached with official documents of whom 6 participated in the interview process (see Table 2).

Table 2.

Profile of Organizations Constituting Workplaces of Nurses

Status of Registration	Name of the Organization	Bed Strength	Nurses Interviewed
Registered	C Nursing Home	60	11
Unregistered	K Nursing Home	NA	3
Unregistered	L Nursing Home	NA	1
Registered	J Nursing Home	50	3
Registered	E Nursing Home and Polyclinic Pvt. Ltd.	64	9
Registered	H Nursing Home	10	10
Registered	A Superspeciality Hospital	150	2
Registered	G Nursing Home	48	5
Registered	M Hospitals	60	4
Registered	I Nursing Home	45	1
Registered	N Nursing Home	65	1
Unregistered*	O Nursing Home	NA	3
Unregistered*	U Nursing Home	NA	1
Registered	Q Nursing Home	15	4
Registered	F Hospitals	90	1
Registered	B Superspeciality Hospital	140	1
			60

Source: Fieldwork.

Notes: *The names of the establishments were missing from the Department of Health and Family Welfare (CMOH, District Darjeeling 2016). Hence, the details pertaining to nurses were not available.

As prior information and documentation on the structures of nursing homes are not available (Baru et al., 2002; Nandraj, 1994, 2012), an unstructured interview schedule was prepared. It contained questions on how hierarchies are constructed, and the modes and channels of recruitment and qualification criteria for skilled, semi-skilled and unskilled workers across the different workspaces of nurses. Wards, OT and intensive care unit (ICU) are the three primary workspaces of nurses (see Table 3). On each visit, meeting with the management lasted for about 45 minutes duration, where details about employment on current workers, development of private healthcare in the city and changes in composition of nursing workers over time were discussed.

Table 3.

Professional and Workspace Profiles of Nurses

		Professional Profiles of the respondents
		Matron	Senior Sister/ Ward-In-Charge	Senior Sister	OT Asst.	Semi-Senior	Junior	Trainee	Total
Workspace	Matron	1							1
	Female Ward		1	3		4			8
	General/ Surgical Ward			10		10	7	7	34
	Burn Ward						1		1
	Paediatric Ward						1		1
	Neuro Ward						1		1
	OT			5	1				6
	ICU			2			1	1	4
	NICU-PICU			1			1		2
	Step-Down/ Recovery		1	1					2
	Total	1	2	22	1	14	12	8	60

Source: fieldwork

Workers were sampled using snowball methods. In-depth qualitative interviews using semi-structured and unstructured questionnaires were conducted with workers across 16 workplaces. This was to understand whether experiences of work were similar or deviant across different structures (nursing homes or corporate hospital), bed-sizes and natures (registered or unregistered). Obtaining permission to access workers within organizations was challenging (Creswell, 2009). The challenges pertained to convincing individuals to trust the researcher and fully participate in the study (Creswell, 2009). Another consideration was the question of eliciting free and unbiased response from workers when the study was conducted at the workplace level (Creswell, 2009). Limiting the data collection only to the workplace level made it difficult to capture diverse and hidden perspectives as participants felt threatened to open up fully. These factors played an important role in conducting the study across the workplaces of nurses and also beyond the workplace to the living spaces (rented houses). Questions were translated in local languages to facilitate the interview process. Anonymity of participants and the workplaces was maintained by changing names of the hospitals and the workers, without tampering with their identity. The management had instructed workers to abstain from talking to ‘outsiders’, therefore they were reluctant to allow recording of interviews. Hence, field notes were meticulously prepared on a daily basis and measures were taken to prevent leakage of data. Using manual coding, themes were prepared and analyzed. The codes pertaining to the mode of work organization were developed by referring to studies on work organization in nursing and labour process literature (Burawoy, 1979; Davies, 1990; Hearn & Parkin, 1987; Hochschild, 2003). Perspectives of management and workers over modes of work organization were compared and contrasted for better analysis.

A brief professional profile of the nurses has been presented in Table 4. There are 60 nurses spread across seven hierarchies in nine workspaces. Majority of the nurses (56%) interviewed in the study belonged to the age group of 21–30 years, of which 75 per cent were unmarried and 21 per cent married. Young unmarried/single women were preferred over married women or those with children in nursing work. Women from two ethnic communities—Nepali⁵ and Adivasi⁶ (36% and 35%, respectively) overpowered the Bengali⁷ (see Table 4). The sample of nurses included women from two religious backgrounds—Hindu (63%) and Christian (37%). The Christian women comprise mainly Adivasi women, hailing from tea estates in Darjeeling hills and Dooars.⁸ An overwhelming percentage of women were from the Scheduled Tribe category (56% indicating dominance of women from ethnic communities; Adivasi women and women from Nepali ethnic groups. Professionally qualified workers constituted only 11 per cent. Around 28 per cent had learnt work informally on-job, rising from junior, semi-senior and, then, senior nursing positions. Over the phase of restructuring and corporatization, there was a rising trend of recruiting workers through agents and labour contractors who ran informal training workshops in towns bordering the tea gardens. In the sample, their percentage was seen to be dominating (60%). On entering the nursing home/superspeciality hospital as a trainee, which is entry level for workers without formal qualification, workers are not given any payment. In two nursing homes out of the 16 establishments, however, workers were given a monthly stipend of less than ₹500. At the junior level, workers are given a salary ranging from ₹1,000 to ₹1,500. At the next level, that of a semi-senior nurse, salary range from ₹2,500 to ₹2,800 depending on the managements’ requirement. In the event of change of workplace, salary differs only marginally. It generally takes a time period of 4–5 years for a semi-senior to rise to the senior nursing position. During this time, her progress is closely monitored by the matron and accordingly she is referred for the senior position. However, there might be significant pay differences among nurses working in the senior positions across nursing homes. For the senior nurses who have a diploma in General Nursing Midwifery GNM, the salary begins with ₹8,000 per month.

Table 4.

Socio-demographic Profile of Nurses

Socio-demographic Profiles	Range	Frequency	Percentage
Age	Less than 20	13	21.67
	21–30	34	56.67
	31–40	7	11.67
	41–50	2	3.33
	51–60	4	6.67
	Total	60	100
Marital status	Divorced	1	1.67
	Married	13	21.67
	Unmarried	45	75
	Widowed	1	1.67
	Total	60	100
Ethnicity	Bengali	9	15
	Bihari	1	1.67
	Nepali	22	36.67
	Rajbansi	7	11.67
	Adivasi	21	35
	Total	60	100
Religion	Christian	22	36.67
	Hindu	38	63.33
	Total	60	100
Caste	Gen	14	23.33
	OBC	2	3.33
	SC	10	16.67
	ST	34	56.67
	Total	60	100
Education	Class I–VIII	4	6.67
	IX–X	18	30
	XI–XII	27	45
	Pursuing Graduation	4	6.67
	ANM	3	5
	GNM	3	5
	BSc (Nursing)	1	1.67
	Total	60	100
Type of Training Institutions	Formal	7	11.67
	Non-formal workshops	36	60.03
	On-job	17	28.3
	Total	60	100

Source: Fieldwork.

Organizing Nurses’ Work in Siliguri

Nurses’ work in the private nursing homes in Siliguri is organized on the basis of skills, ethnicity and hierarchies. Each of these has been explained here.

Education and Skill

The trend of employing nurses on an informal basis was not a new phenomenon in the context of the private health sector in India. Private health establishments have always depended on nurses who were trained by doctors at the hospitals at OTs and wards. However, following technological and bureaucratic changes, there has been higher demand for trained workers, impacting their recruitment patterns and roles in the workplace. Registered nurse (RN)⁹ having accredited BSc (Nursing) or graduate diploma in nursing (GNM) has the required knowledge and expertise and is most suitable to work. However, employing greater numbers of qualified personnel imply further rise in labour costs as they have to be paid higher salaries and social security benefits. The work inside the hospitals is therefore organized into a mix of skills consisting of RNs and the informal nurses.¹⁰ RNs, numbering a few in each hospital, are found mostly in administration as ward/OT/ICU-in-charges. Major share of work including administering drug, injections, medicine doses, coordinating and reporting with the resident medical officer (RMO) and undertaking direct care of patients is done by the informal nurses. Organizing the work in this way reduces investments in care as the organization does not have to pay high wages to informal nurses. From the management’s point of view, this mode is justified as the urgent tasks of documentation, coordination and cure-oriented tasks are entrusted with the formally qualified workers while those tasks requiring no formal qualification such as direct caring can be relegated to informal nurses.

Ethnicity

Nursing in the present context exhibit various intersectionalities or interlocking of gender with race, ethnicity and class that impact the formation of hierarchies at the workplace. Three different ethnicities (Bengali, Nepali and Adivasi) make up nursing workers. This phenomenon has followed restructuring and corporatization. Earlier, doctor-entrepreneurs had no need of expressing ‘preference’¹¹ or ‘choice’ for different workers as it was supply led. Mostly destitute women, local or migrant, who had lost the male earning members, approached the doctor-entrepreneurs. While setting up nursing homes, doctor-entrepreneurs required workers who could be trained and taught work as per requirements and would stay with the institution over a considerable period of time. These women were mostly Bengali and came from the rural districts across North Bengal as well as Siliguri; a few were Nepali. Following structural changes, a rising demand for workers was met by the inflow of migrant workers mainly from Nepali and Adivasi ethnicities. Nepali women joined work through word-of-mouth and networking with existing Nepali workers in nursing homes. These women learnt work at their workplaces and were trained by seniors from the Nepali community. The Adivasi women were recruited through agents and labour suppliers running small unregistered workshops or training centres. These women have done home nursing or preliminary first-aid classes before being brought to nursing homes for work.

Presence of women from diverse ethnicities resulted in organizing work along racial and ethnic attributes. The preference of the management of nursing home C for workers across the three communities has varied over time. When the doctor-entrepreneur started the nursing home, she was approached by Bengali women. Eventually, however, there occurred a greater supply of Nepali women due to networking, alongside the existing Bengali women. Soon, the Nepali women because of their hard work and submissive nature became indispensable part of her nursing home. However, after working for 2 or 3 years, some of them began demanding higher wages. These aspects were disliked by her. Over time, due to the presence of workshops and training centres, Adivasi women came for work who were preferred over both Nepali and Bengali workers. The reasons for preference are attached to the personal traits and qualities of these workers—docility, timidity, obedience, submissiveness along with intelligence, ability to grasp quickly, efficiency and loyalty to the organization. However, among other characteristics directly related to efficiency, such as intelligence, qualification, formal or acquired skills; loyalty, obedience, meekness and submissiveness determine preference. These aspects of ‘preference’ were reiterated by managements at nursing homes G and F.

I like to recruit adivasi women in my nursing home. Adivasi girls are timid and whatever duties are assigned to them, they perform without any qualms. It is easier to control them as they are disciplined, obedient and can speak both in Hindi and English. (Doctor-entrepreneur at nursing home C).

The Adivasi women’s economic conditions at place of origin have impacted their behaviour at workplace. Adivasi women hail from tea estates and constitute the fifth or sixth generation of migrated workers (Bhowmik, 1981; Xaxa, 1997). They lack bargaining power over basic rights and entitlements at workplaces and can be easily controlled. They can never raise voices if they are ill-treated or discriminated due to their skin colour, look, social and economic backgrounds. The work experience, however, is neither trusted upon nor recognized. They are kept under observation of senior nurses and are silenced every now and then. Nepali women are kept on work due to their physical features. The management at E stressed that age, fair skin complexion, sense of dressing and make-up, apart from their capacity for hard work, ability to survive at low wages and pleasant and friendly nature worked in their favour. Workers who satisfy management with their meekness and obedience are quickly promoted to senior posts. However, not all Nepali women are oblivious of the fact that they are being paid very low. The doctor-entrepreneur at C expressed how living in the city is making them aware about the compensation, which is motivating some of them to demand higher salaries. The management is therefore keen on recruiting more of Adivasi women (compared to Nepali women) who have till now never demanded anything. Such recruitment patterns can be validated with quantitative data, illustrating how workers’ position on the hierarchy is determined by their ethnicity and place of origins. Table 5 points to decreasing participation of both local and migrant Bengali women at the entry levels. This is evident in the presence of one worker each at the levels of trainee and junior and two workers at semi-senior levels (all four have migrated from Cooch Behar). On the other hand, there are five senior Bengali nurses of whom four are locals from Siliguri. These women consist of one GNM nurse and the remaining four consists of those who have risen to the post of senior nurses by being associated with the nursing home over a considerable period of time. On the other hand, Adivasi women from Dooars (tea estates) are high at the levels of trainee (4) and junior (11), compared to the senior level (2). This re-establishes the preference patterns of management in favour of Adivasi workers. Nepali women are comparatively more in numbers as senior nurses, ward-in-charges and semi-senior nurses. Both ward-in-charges are migrants from Nepal. Prevalence of more Nepali women compared to Bengali women at senior positions also point to decreasing participation of the latter in nursing labour market as stated by the management at C. Apart from senior positions, Nepali women are also found in greater numbers in the intermediate positions such as semi-senior nurses (5).

Table 5.

Cross-Tabulation Between Position in the Hierarchy, Ethnicity and Place of Origin

Designation/Ethnicity	Place of Origin
Designation/Ethnicity	Alipurduar	Cooch Behar	Darjeeling	Dooars	Jalpaiguri	Nepal	Sikkim	Siliguri	Grand Total
OT Asst.		1							1
Rajbansi		1							1
Junior		2		10					12
Adivasi				10					10
Bengali		1							1
Rajbansi		1							1
Matron			1						1
Nepali			1						1
Semi-senior nurse	1	4	5	3			1		14
Adivasi				2					2
Bengali		2							2
Bihari							1		1
Nepali			5	1					6
Rajbansi	1	2							3
Senior nurse	2		9	5	1		1	4	22
Adivasi				4					4
Bengali	1							4	5
Nepali	1		9	1	1		1		13
Trainee		4		4					8
Adivasi		1		4					5
Bengali		1							1
Rajbansi		2							2
Ward incharge						2			2
Nepali						2			2
Grand total	3	11	15	22	1	2	2	4	60

Source: Fieldwork.

Recruitment and Promotion on Job and the Hierarchies

Mode of organizing includes setting the requirements for recruitment and promotion on job. This is important as it helps to construct hierarchies and defining roles of workers in accordance with their work experiences and other attributes. Nursing homes maintain that junior nurses need to have a minimum of 2 years of experience. A semi-senior nurse requires between 2 and 4 years of experience while a senior nurse should have minimum experience ranging between 4 and 5 years. Nurses at the OT are required to undergo a 3-month training period where they work under the supervision of senior OT nurses. However, the required number of years of work need not be the same across all nursing homes. In nursing home F, the trainee level is sub-classified into three layers on the basis of years of experience. Level 1 consists of those who have less than a year’s training; level 2 consists of workers having between 1 and 2 years while level 3 implies workers currently in their third year of training. After completing 3 years, the trainee is given certificate and promoted to the post of junior nurse. However, for sustaining on the job, personal attributes of the workers such as obedience, dexterity and docility are accorded primacy over work experience and acquired skills.

The hierarchies play important roles in delegating, distributing and organizing work, facilitating co-ordination, monitoring and supervising the workers at all levels. Hierarchies are important means of bureaucratic organization of work. Constructions of nursing hierarchies differ across the size of the nursing home and numbers of nurses. Nursing hierarchies in the corporate structure of superspeciality hospitals A and B are illustrated through Figure 1. The structure is elaborate in corporate hospitals with a separation of the nursing administration and nursing staff. The nursing administration is headed by the nursing superintendent (NS). She is followed by the deputy and assistant nursing superintendent (DNS and ANS). Below them are the respective ward-in-charges. Nursing staff is organized as allocation¹² nurses. Ward-in-charges are entrusted with decision-making jobs while general duty assistants in the wards supervise trainees, monitor work done by semi-seniors and juniors and document technical errors and omissions, apart from patient care. At the OT, there are OT technicians, circulating nurses and housekeeping personnel (scrub nurses), all working under the supervision of OT in-charge. Skill and preferences of workers and their past working experiences are taken into consideration while placing nurses across ward/OT/ICU. However, the management may apply discretion in deciding the workspace depending on the number of patients, type of caring requirements, workload and availability of other support services, and nurses have to follow the orders. In emergency, the semi-senior nurses are asked to alternate between OT and wards without questioning. Figure 2 illustrates the nursing hierarchy inside nursing homes J and E. The matron or nursing superintendent is at the top of the hierarchy. There is less strict demarcation between nursing administration and staff nurses. The matron is entrusted to organize, coordinate and supervise tasks of seniors, semi-seniors and junior nurses and is responsible for all the administrative work. In contrast to the upper portion of the hierarchy where nurses are entrusted more administrative and supervisory roles, workers such as trainees, juniors and ayahs do most of the care component of work.

Figure 1.

Source: Fieldwork.

Figure 2.

Source: Fieldwork.

Discussion

A Critique of Power

In the rational bureaucratic structure of organizations, hierarchies act as channels of power, authority and control as it helps implementing rules, laws and regulations (Bhowmik, 2012; Weber, 1958). Based on the fragmentation of tasks, hierarchies of both vertical and horizontal power relationships are created for profitability, efficiency and quality. The mode of hierarchical work organization within nursing homes and superspeciality hospitals have a close connection with extending power and control over workers. The nature of power is more bureaucratic in superspeciality hospitals, compared to the nursing homes where the power is more patriarchal-paternalistic in nature, nevertheless, both derive their legitimacy and authority from the management. In discussing the modalities of power, it is important to highlight the role played by nursing superintendents in superspeciality hospitals and matrons in nursing home who symbolize how the centralized power of the organization is diffused through the agents or lower-level management. They are close to the owner and management and relations of trust and favouritism are built with them so that they function in the best interests of the management. They represent lower management, the foreman or supervisor who plays an important role in forwarding the immediate goals of the management in controlling and monitoring the daily activities of the workers. The authorities vested in them signify bureaucratization of the structure of control over workers (Kelly, 1978; Littler, 1978).

The matron plays an important role in facilitating the process of subordination and control over workers. Whoever rises to the apex of the nursing hierarchy is the prerogative of the management. Workers who have been associated with the organization over a considerable span of time are considered for the matron’s job. The role of the matron is vital in maintaining confidentiality of information, deciding promotion, wage hikes and upgradation of junior staff. Formal qualification or skills are not considered necessary. In two nursing homes, it was found that the matron did not have any such prerequisites for the post held by her. Nevertheless, she was taking decision on the line of treatment in addition to managerial and supervisory ones. In duty dispensation, which include organizing tasks in an efficient manner, the matron or nursing administration is accorded required amount of functional autonomy. According to the matron at nursing home F, for timely performance of duties, there is a need for exercising strict control and supervision over the work of all cadres of nurses, ensuring that every aspect of work is done in a coordinated manner, in line with the requirements of the organization. In the event of a shortage of staff during an emergency, the trainees and juniors are ordered by the matron to report to duty no matter if it is in the middle of night, rest days or immediately after a series of night shifts.

Although greater parts of the functions of the matron have to do with ordering, commanding and controlling, matrons understand that it is not always possible to thrust work on the nurses. At times, it is important to modify the strategy and in place of coercive ones, measures such as ‘evoking consent’ (Burawoy, 1979) are more effective. The reasons are concerned with both the structure of hierarchy and the nature of the work. The elaborate hierarchies need effective coordination and consent of different cadres of nurses belonging to different socio-economic backgrounds. To manage diverse groups of workers, coercion does not always work. Consent is vital for the maintenance of peace and discipline considering the tasks, which might be of utmost urgency in nature and are concerned with people’s lives and well-being. Maintaining social relations and making workers conform to workplace norms depends upon evoking cooperation from workers on matters of care planning and execution of tasks. Therefore, a combination of coercion and consent is used to elicit the required behaviour from workers. Consent is generated by making workers feel that while organizing tasks, their comfort and availability is taken into account. This is mainly to inculcate an environment of harmony and mutual dependence at the workplace. Workers on being given this facility do not hesitate to do double duties stretching continuously up to 12–16 hours, as and when required, and not always accompanied with overtime payment. Some of the junior nurses require leaves for visiting homes once every 15 days to bring food and other eatables. Later on, most of these semi-seniors and juniors are made to work for extra hours without sufficient overtime to make up for the leaves taken. Additionally, juniors remain obligated to carry out any errands given to them. Therefore, while coercion is used as a daily mechanism to subordinate workers, consent is used to extract additional work, without making additional payments.

Weber (1958) suggested that in the rational bureaucratic structure of the organization, the people who represented the top level of the hierarchy needed to be impersonal and unbiased in the discharge of duties. This would enhance the productivity and efficiency of the organization. However, the social composition of nursing workers at various levels of hierarchy indicates that gender, ethnicity and class influence not only the recruitment patterns but also positions within the hierarchy (Duffy, 2005; Glenn, 1992; McBride et al., 2015; Rakovski & Price-Glenn, 2010). Even in aspects of survival at the workplace, personal relations play a greater role compared to years of work, and this indicates the presence of bias. This affects the quality of care as workers who perform well are not rewarded accordingly, resulting in frustration among them.

Scientific Management in Nursing

Nursing in the era of neoliberalism involves co-existence of several power relations between doctors, management, patients and their families. Nursing is a feminized profession in India. However, factors like the religion, caste and class are also found to impact work (Gill, 2016; Healey, 2013). The first mode of organization of work in hospitals in formed on sexual lines. In the clinical hierarchy within healthcare organizations, nurses, predominantly females, share a subordinate status vis-à-vis the management and doctors (Davies, 1995). Within this gendered work of caring, mode of organizing work hints at the adoption of Taylorist work processes revealed through fragmentation of tasks, construction of elaborate hierarchies, centralization of power in the hands of the management and continuing emphasis on the concept of efficiency.

Taylorism as a form of work organization can be analyzed in terms of division of labour, structures of control over task performance and employment relationships (Kelly, 1978; Littler, 1978). Division of labour entails fragmenting the work, preventing workers from organizing their own work and minimizing the requirements for skilled workers. Bureaucratizing the structures of control is an important step for methodically separating planning from execution and also monitoring workers (Littler, 1978). All of these processes are integral parts of Taylorism, which are directed at raising efficiency, quality, standards and productivity, and work intensity. Efficiency, thus, rests upon the performance of a large number of tasks in a timely and specialized manner. It requires the employment of the skilled and qualified worker for preservation of quality and standards of the service rendered by the organization. It has been pointed out by Lloyd and Seifert (1995) that the quality of nursing care enhances with the employment of qualified nursing staff.

The idea of efficiency is inherently flawed. Although the logic of organizing nursing work is claimed to rest upon the delivery of quality nursing care, private healthcare in India has never employed qualified nurses. This is the reason why looming shortages in the number of skilled nurses in India (Gill, 2016) has never interfered with the expansion of private healthcare. The organization of work is not designed on the intellectual requirements of the nursing profession, nor is the remuneration of workers determined by the incentive payment mechanism (Littler, 1978). Although the most important factor affecting size of the pay need to be efficiency of the worker, relationship with the management, according to workers, is given more importance. Management in private healthcare employs informal nurses, compromising with the quality of care services rendered by the organization (Rao, 2012). Although it is also not unaware that the dearth of trained nurses interferes with the quality of care provided by hospitals, it desists from investing in skill formation of labour. In majority of the nursing homes, it was found that there is an absence of format for training the new workers. Most of them learn by observing the work of their seniors and are asked to follow orders. Trainees thus have limited understandings of why the particular line of treatment is being followed. There are high attrition rates of junior and semi-senior workers who change workplaces, one of the reasons being dissatisfaction from prevailing low wages. This limits the amount of skill that can be acquired over time and through experience, and development of social relations by working in a fixed workplace and workspace. A few corporate hospitals organize annual orientation and training programmes for senior nurses who are less likely to change workplaces. These orientation programmes have more to do with disciplining workers than skill development and trainings in core nursing areas. The ability of workers to plan and organize their tasks is further limited when more than years of experience, skill and dexterity acquired over time, personal relations are given more importance for sustaining on job.

Efficiency, according to Taylorism, necessitates fragmentation or division of a single task into several parts. Nursing constitutes holistic care work where demarcation between care and cure is not achievable in practice. However, fragmentation of tasks into ‘care’ and ‘cure’ according to the management in superspeciality hospital A is rational, as qualified nurses are required to centre themselves only in and around patient cure. ‘Cure’ work revolves around task management, which according to management needs formal education and is the most important part of nurse’s work. This theory put forward by the management has problems in conceptualizing what constitutes the nurses’ domain of work. Management accords primacy of ‘cure’ over ‘care’ as the original work of nurses. Even this concept of ‘cure’ is not concerned with technical knowledge of the patient’s condition or line of treatment but managerial tasks such as coordination, documentation, supervision and administration. Management requires qualified nurses to function on their behalf and manage and co-ordinate the work of informal nurses. Moreover, although management claims that demarcation and role definition is required for efficient task management, it is not followed. Nurses across both nursing homes and superspeciality hospitals constitute admixture of few RNs and mostly informal nurses. There are little differences in roles and responsibilities among these two groups and their assigned responsibilities have little congruence with their skills or education levels. In several instances, it was found that informal nurses were working as ward/OT/ICU in-charges. Under the new structure, ward/OT/ICU in-charges are expected to have sound knowledge of medicines and must be able to take decisions regarding patient cure and care. It is unlikely that the informal nurses will be able to fulfil these criteria because of their lack of knowledge on medicines and lines of treatment. Thus, fragmentation of tasks is not accompanied by distribution of tasks as per specialization. All nurses, irrespective of their levels and areas of expertise are required to perform coordinated tasks not only among different hierarchies of nurses but also with different groups of clinical manpower. The absence of defined and demarcated roles between RNs and informal nurses is unlike the practices followed in USA and UK, where RNs are differentiated from nursing aides based on qualifications and assigned roles, commensurate with their formally acquired or informally gained skills and qualifications. The role mixes lead to greater informality, deskilling and de-professionalization of nursing in an increasingly formal workspace.

The Marxist Critique

Marxist and neo-Marxist scholars, critiquing scientific mode of work organization (Hodson & Sullivan, 2008; Kelly, 1978; Littler, 1978; Wood, 1987), emphasized on how its adoption led to control and alienation of workers in the process of achieving higher economic efficiency. Aspects of control and alienation are contextualized with the labour process in nursing in private healthcare. Instruments of control include social attributes of workers such as origin, ethnicity, as well as their personal natures such as obedience and submissiveness. They help to control behavior at workplace. Recruitment is based on ethnicity. Adivasi women are preferred over Nepali and Bengali women as they are docile and with their incorporation, tasks are managed efficiently. Carrying out orders of the senior nurses and doctors unquestioningly constitute a central feature of an ideal worker in the organization. The orders can range from cleaning floor to laundry work or bringing water from municipal taps, which do not constitute core activities of the nurse. When these workers perform work of other staff members, the cost of employing sweepers and laundry workers reduces. Additionally, with alienation of workers from their core learning, skilling is limited that helps to perpetuate the system of informal and preference-based recruitment, low wages and subjugation of workers. The present generations of Nepali and Bengali women question about these labour practices and demand higher wages, which is a threat to the order established by the management; therefore, they are not preferred.

Alienation manifests itself from the subjective experiences of work, including workers’ sense of association or dissociation from the workplace and feeling of belongingness to a group/class (Hodson, 2001; Hodson & Sullivan, 2008; Seeman, 1959; Spencer, 2000). The concept was used in relation to women’s experiences in care work (Hochschild, 2003; Theodosius, 2008). However, more than emotional estrangement, it is the social isolation that characterizes experience at work. Individualizing the worker is the strategy of the management and when differences between workers and management arise, it is solved at individual levels. Another strategy is to silence the particular worker by incessant threats of job loss.

there is no need and use of discussing among yourselves; if you have any problems come to us and we will see if the issue can be resolved. (Doctor-entrepreneur at C)

Mode of work organization stresses on fragmenting workers along with divided tasks. Fragmentation based on skill, hierarchies and ethnicities sustain the antagonism among the workers, alienate them from each other, and, thus, prevent class consciousness. Nurses from different ethnicities find it is difficult to unify despite having common problems, struggles and aspirations. The fellow feeling is prevented as workers from one ethnicity consider ‘the others’ as opponents and competitors. This was evident from the views that the nurses of Bengali and Nepali communities hold about each other. Workers from Bengali community believe that Nepali women get work not because of their hard work but due to the ways they behave and carry themselves at the workplace. Nepali women adopt means to gratify males, including doctors, managers and even patients. Nepali women are taking away jobs from Bengalis. On the other hand, Nepali women believe management when they use words such as escapist, shirker and insincere in reference to Bengali nurses. These feelings of disrespect, suspicion and antagonism is infused by the management.

Conclusions

Comparing nursing labour processes in the context of market reforms in the UK and USA with that of India, it is not an exaggeration to mention that organization of nursing in private healthcare India has followed their patterns, originating in Taylorism. Application of post-Fordist techniques of work organization in the form of TQM is limited to India’s corporate healthcare industries, which are concentrated in the metropolitan cities. Private healthcare, however, covers a vast range of organizations differentiated by size, structures, nature of services and amount of investments. Modes of work organization are therefore neither uniform nor standardized. Although the common goals of management across private health organizations are cost minimization, profit maximization and efficiency, the strategies differ. The mode of work in the present context are mostly Taylorist than Fordist, however, it is not limited to either of the two, because of the roles played by social institution such as origin and ethnicity in organizing work.

The idea of efficiency in private healthcare, derived from Taylorism is visible more at the level of ideology and consciousness of the management than in actual practice (Wood, 1987; Littler, 1978; Kelly, 1978). Therefore, more importance is given on rapid accumulation¹³ and cost savings rather than efficiency and quality. Concepts of efficiency, fragmentation, division and specialization of work in the context of nurses’ work are also misconstrued. Nature of nursing is different from the industrial work. Even within the category of services, nursing service requires a lot of individuality and discretion over the amount of care to be delivered, genuine feelings and empathy for those in need of care (Hochschild, 2003; Theodosius, 2008). Workers need competence to understand the holistic nature of work requiring both care and cure skills. Nurses thus need flexibility over the amount of emotions they deliver through their work. When nursing is subjected to routinization and deskilling processes in ways similar to those of factory work, it leads to deterioration in quality of care. In the present context, private healthcare is little concerned over preserving the care quality provided by the organization, it is the cure and treatment that is accorded significance over care. Elaborate hierarchies in the organization not only facilitate control and monitoring over workers, it also enables the process of labour cost saving as workers are made to work for extra hours without being paid for overtime. Fragmentation between care and supervisory roles of the nurse leads to further deterioration in care quality as it leads to problems regarding role specification where responsibilities are often not in consonance with qualifications and expertise of the nurse. However, more than other factors, it is the employment of low-quality untrained and semi-skilled workers that interfere with the quality of care.

In the Indian context, while government hospitals run on formally skilled and qualified nurses, the private sector uses low cost semi-skilled and unskilled workers, often belonging to marginalized and backward communities. From the labour point of view, nursing in India has always been associated with stigma and the participation of women from particular social and economic backgrounds (Healey, 2013; Nair, 2012; Raghavachari, 1990). Hence, the role of social institutions in nursing is not a new finding in the study. The present study contributes in understanding how the social institutions (women at the intersections of class and ethnicity) are used by the management in private healthcare to design work and discipline, control and alienate workers at the workplace. Majority of these workers have no formal qualification and their labour power consists of manual and emotional capacity to work against a given wage rate. Their skill comprises of the work experience gathered over time by working in organizations and learning through experiences and observations. As migrants from the socially marginalized ethnic communities, it is their workplace from where they learn skills for obtaining livelihood. This limits the ability to bargain for higher wages in a patriarchal–paternalist workplace. They constitute the emotional proletariat in nursing with limited bargaining powers (Macdonald & Merrill, 2009). Although they constitute a uniform class, the fellow-feeling and class consciousness is limited as they are divided by hierarchies and ethnicities. Management’s intentions lie in curbing protests and resistance from workers. The management is guided solely by motives of higher profits; fragmenting, individualizing and promoting antagonism between workers belonging to different ethnicities. Thus, work organization follows ways that reduce and eliminate chances of conflicts between forces (bourgeoise management and proletariat worker) and means of production (the care skills and labour power) by creating an alienated and subjugated labour force, so as to keep the capitalist in perpetual control over the labour process. Thus, increasingly, important roles played by subjectivities and social institutions such as race, class and ethnicities further the understandings pertaining to management’s mode of work organization in informal care work in formal institutions. This study highlights how Taylorist principles are reconceptualized and merged with informal social institutions in fulfilling management’s goals of higher accumulation in service industries.

Footnotes

Acknowledgements

The author is thankful to Prof. Virginius Xaxa and Dr. Christa Wichterich for their comments on the initial drafts of the article. The author thanks the anonymous referees for their invaluable comments on the article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author received scholarship from ICDD for the conduct of the study.

Notes

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