Ameliorating Workplace Harassment among Direct Caregivers in Canada’s Healthcare System: A Theatre-Based Intervention

Abstract

The article reports on a theatre-based intervention designed to address workplace harassment among direct caregivers in Canada. The study is part of a larger analytical project that relies on labour process theory and critical realist evaluation methodology to understand what interventions work, how, for whom, and under what circumstances. Using Theatre of the Oppressed techniques, the reported intervention addresses workplace harassment by challenging the normative codes governing social interactions in participants’ workplaces. The study’s analysis indicates that the intervention’s Theatre of the Oppressed activities energized the participating caregivers to imagine, enact and collectively assess new social interactions. The caregivers developed strategies to resist the oppressive relations of their employment and became competent contesters of dominant discourses circulating in their workplaces. The solidarity developed through the bodily sculptures and enacted scenarios elicited participants’ deliberative exchange about workplace harassment and awakened a collective will to carry their revelations back to their workplaces.

Keywords

Canada’s healthcare system critical realist evaluation direct caregivers labour process theory theatre-based intervention Theatre of the Oppressed workplace harassment

Introduction

Workplace harassment is identified with considerable negative consequences for both organizations and individuals (Deery et al., 2011; Hoel et al., 2004a; McTernan et al., 2013). Notwithstanding costs to persons and organizations, agreement on the causes of harassment remains outstanding and competing or contradictory explanations have led to a wide array of interventions by governments, unions and employers/managers in public as well as private sector workplaces.

The purpose of this article is to introduce a harassment intervention not found in our review of the relevant literature (Carr et al., 2017; Quinlan et al., 2014, 2019). Rooted in the philosophy and embodied activities of the Theatre of the Oppressed (TO), the intervention addresses workplace harassment among healthcare workers in a western Canadian province by disrupting hegemonic values and beliefs and challenging the normative codes governing social interactions in the workplace. Our analysis suggests that the solidarity achieved from the theatre-based intervention effectively subordinates the status quo to new communicative dynamics in the participants’ workplaces.

The study is part of a larger analytical project evaluating harassment interventions, a project that relies on critical realist evaluation methodology to understand what interventions work, how, for whom and under what circumstances (Pawson and Tilley, 1997; Porter and O’Halloran, 2012). Before launching the larger project, a scoping review of interventions in healthcare workplaces was completed with findings indicating that interventions grounded in participatory principles hold the most potential for producing positive outcomes (Quinlan et al., 2014). A synthesis of relevant literature was also undertaken to identify the contexts, mechanisms and outcomes of harassment interventions in workplaces that extend beyond the healthcare sector (Carr et al., 2017; Quinlan et al., 2019). The synthesis results (Quinlan et al., 2019) depart from the literature’s dominant psychological explanations for the effectiveness of interventions. Although individual personality traits play a role in explaining harassment, our focus is on organizational and social structures that have been implicated in the frequency, intensity and perpetuation of workplace harassment (Crowley, 2014; Leiter et al., 2011; Roscigno et al., 2009).

Labour process theory (LPT), a theoretical pillar of our analytical project, stands in contrast to the psychological theories of workplace harassment by considering the impact of a convergence of historical trends that affect the organization of paid work under contemporary capitalism (Beale and Hoel, 2011; Hoel and Beale, 2006). This understanding of harassment affirms that perpetrators need not be individuals, but can be procedures governing the organization of work and the related social interactions. LPT suggests that not all interventions to address harassment are ill-fated; rather, they are constrained by the particular conditions of the employment relationship within the capitalist mode of production.

The overarching question driving our study is how did the particular conditions of the employment relationship for the healthcare workers impinge on the theatre-based intervention and with what consequences? The analysis shows that participants of the theatre-based intervention develop collective strategies to resist oppressive relations of employment despite the hyper-rationalization of their healthcare workplace, which trumps cost efficiencies over other organizational mandates, often at the expense of workers’ social interactions with each other. The article argues that the solidarity within the group of participants achieved through the TO activities provides a significant buffer against the contextual conditions of their employment relationship, allowing them to explore new definitions of harassment and constitute new norms and identities in the protected space of the workshops. The article proceeds by sketching the underpinning theory before turning to a description of the intervention and then the findings.

Labour process theory

LPT takes its inspiration from Marx’s (1887) historical materialism with its premise that human societies are differentiated by the nature of work performed by humans to produce the means of their subsistence and the social relations embedded in those forms of production. Harry Braverman’s (1974) LPT contemporizes Marx’s analysis of the structural antagonism within the relationship between employers and employees, arising from the exploitation of labour for profit under the present-day capitalist mode of production. More recently, LPT scholars have responded to the changing nature and conditions of work, including knowledge, emotional, aesthetic and team-based forms of labour (Thompson and Vincent, 2010). Despite its new forms, labour remains an indeterminate element of capitalist production. Since labour power is embodied within workers, it therefore needs to be extracted from workers in bargains that exchange wages for the capacity to work, not the work itself. In the face of the changing conditions of work, new, more sophisticated techniques of extracting workers’ labour power have emerged. Some techniques of managerial control adopt a more coercive face, others rely on ‘soft’ human resources regimes and delegation of self-organization (e.g. team-based work).

Lean is one such control strategy that accentuates the principles of Taylorism with its emphasis on cost-cutting, efficiency and standardization (Janoski, 2015). Derived from the Toyota automobile company’s production line system, Lean’s assumed transferability from the manufacturing to service sector, and from the private to public sphere, is only one of its difficulties (Dunsford and Reimer, 2017; Radnor et al., 2012). Other research confirms that, although there is potential for positive outcomes from Lean if it is combined with strong independent worker representation, generally Lean leads to an intensification of work and management-by-stress (Thompson, 2016). The findings suggest that an understanding of Lean needs to be rooted in an analysis of capitalist labour process and shop-floor resistance and accommodation (Zhang, 2015).

Understood within the frame of LPT, workplace harassment is congruent with any of these strategies of control, such that perpetrators of harassment need not be individuals, but can be procedures governing the organization of work and the social interactions evoked as a consequence. LPT challenges the notion that it is in the interests of employers to eliminate harassment and the even stronger assumption that employers have the ability or desire to eliminate it, despite the fact that harassment undercuts profits because of staff turnover, sick benefits and other disruptions to the productive processes.

The study’s intervention

The study’s intervention takes inspiration from Boalian TO (Boal, 2000, 2002). Grounded in Marxist theory and Brecht’s political aesthetic, TO aims to empower collectives to become protagonists in their own lives by recognizing both agenetic and structural dimensions of the social problem under investigation. In TO, participants develop scenarios that reflect the underlying stories of their everyday lived experience. Endorsed by UNESCO as a tool for generating social change, TO has been adopted in over 70 countries (UNESCO, 1997) to confront a diversity of injustices including sexual violence (Christensen, 2013), environmental degradation (Sullivan and Parras, 2008) and abuse of patients by healthcare workers (Swahnberg and Bertero, 2012).

TO was specifically chosen for the intervention because of its premise that social problems, such as workplace harassment, are experienced individually but have structural antecedents (Boal, 2000). The premise directly aligns with the LPT formulation of workplace harassment outlined above. In TO, the creative capacities of participants are deliberately ignited so they might recognize their shared interests, envision alternative social orders and address identified barriers collectively. In this way, TO reaches beyond the therapeutic aims and outcomes of psychodrama (Moreno, 1947). Although individual TO participants can experience therapeutic benefits that enrich their repertoire of responses, collective benefits are the aim.

The study’s intervention consisted of two-day workshops in the spring of 2016 with three types of direct caregivers employed by two of the province’s health regions: registered nurses (RNs), licensed practical nurses (LPNs) and healthcare aides, known as Continuing Care Assistants (CCAs). The first set of workshops was held with a combined group of 18 LPNs and CCAs; a week later the second set was held with 11 RNs. The majority of participants were women working in different hospitals, long-term care homes, or home-care regions with work experience ranging from 3 months to 41 years (see online Appendix A for demographic characteristics).

The workshops were held away from the workplace in a church hall with meals and overnight accommodation for out-of-town participants provided by the study. The workshops were facilitated by Jiwon Chung, an internationally recognized expert in TO. Firmly rooted in Marxist theory, Chung uses TO to challenge, resist and transform systemic oppression and to redress large-scale historical atrocity and injustice. His work with community groups addresses a range of social issues including homelessness, trafficking, racism and incarceration. To his facilitation of the workshops, Chung brought a critical, theoretically informed understanding of the conditions of work in healthcare and other public sector workplaces under the grip of neoliberal ideology. The workshop’s particular activities – including Rainbow of Desire, Labour dances, Image Theatre and Forum Theatre (Boal, 2002) – were chosen to develop solidarity within the group and highlight the structural conditions of participants’ work. Throughout the workshops, participants’ stories of their experiences with harassment were solicited and chosen on the basis of the degree to which they resonated with others. The generated sculptures and scenarios, based on the experiences, served as theatrical models for the group to interrogate the structural dimensions of harassment, with group members playing characters (recognized by their institutional role rather than name) in incidents not necessarily of their own direct experience but within the realm of the group’s collective set of experiences.

Prior to launch of the theatre-based intervention, ethics approval was obtained from the Research Ethics Board at the first author’s university and operational approval was obtained from the participants’ employers. Following the workshops, semi-structured interviews were conducted with volunteering participants (six RNs and five LPNs/CCAs). The workshop participants were recruited via posters placed in their workplaces. The three groups of caregivers were chosen because, as the study’s guiding theory would suggest, their position in the occupational hierarchy would make them particularly vulnerable to workplace harassment. However, experience of harassment was not a qualifying requirement for recruitment; instead, the inclusion criteria, in accordance with TO procedures, aimed to enlist care workers who were concerned about harassment as a problem in their workplaces and were willing to explore potential solutions. The interviews were conducted 6–8 months following the workshops to better capture sustained outcomes of the intervention. In line with critical realist evaluation methodology, the interview questions focused on the intervention context, mechanisms and outcomes. After verbatim transcription and accuracy checks were completed, guidelines for thematically analysing the interview data were applied (Lincoln and Guba, 1985). Discrepancies and contradictions identified in the data were explicitly used to enrich the analysis by revising categories and collapsing thematic categories and clusters. The workshop field notes were then integrated to safeguard against an over-determination of the transformative potential of the intervention. Pseudonyms for the participants are used in the analysis reported here.

Findings

As CCAs, LPNs and RNs, the participants worked as the foot-soldiers of acute and end-of-life care, feeding, toileting, dressing, medicating and comforting patients in hospitals, nursing homes and individuals’ residences. As Rose (CCA) described, ‘We listen is what we do. I don’t judge, I just listen and let the patient talk, because sometimes that’s just what they need.’ The participants’ descriptions of their work correspond with scholarly characterizations of care-work as requiring continuous practical and ethical decision-making to respond to the inherent unpredictability in patients’ fluctuating levels of care needs (Lopez, 2006). Care-work is largely devalued due to its gender assignment (England, 2005) and in workplaces where the logic of efficiency prevails over the ethic of care, the processes that help secure the necessary mutual understanding between care workers are pre-empted. In downsized, under-staffed ‘lean’ workplaces, care-work is made more onerous and destabilized social relations among care workers become one of the most insidious consequences (Quinlan et al., 2019).

When harassment is superimposed onto this already challenging work, it contributes to the debilitating effects well documented in harassment studies, including depression, anxiety, sleep disorders, to name a few (Hoel et al., 2004b; McTernan et al., 2013). Although recruitment to the study did not require it, most of our study participants disclosed that they had encountered harassment in the workplace, either as a witness or a target. Remarking on its ubiquity, Liza (RN) said, ‘Most of us had stories. So, it’s not like it is just happening in little pockets. It’s happening everywhere.’ Barbara (RN) concurred: ‘It stuck out to me that we were all from different areas, and different stages in our career, and we had all noticed bullying happening. Yet, most of us hadn’t reported it.’ These findings accord with research that indicates that few targets report harassment and that prevalence rates of workplace harassment tend to be higher in healthcare than most other sectors (Laschinger et al., 2010; Lewis, 2006).

The timing of the study’s intervention coincided with the rising tide of Lean in the participants’ workplaces. Similar to other Lean healthcare workplaces, the study’s participants described a coercive managerial regime that values efficiency over social relations (Waring and Bishop, 2010). Despite this context of deepening managerial jurisdiction that rewards compliance and erodes workers’ control over the labour process, the study’s intervention did produce beneficial outcomes. The analysis of the interviews, conducted eight months after the workshops, indicates that participants formed collective strategies of resistance as alternatives to co-worker to co-worker harassment and supported their fellow workers in their pursuit of existing avenues of redress. These two consequences of the intervention are elaborated in a subsequent section. The article first addresses the initial part of the research question (i.e. aspects of the employment relationship) with a description of Lean, as understood by the participants.

Lean management regime

Lean was introduced to the province’s healthcare system a decade ago. Its widespread adoption has since slowed with criticisms becoming increasingly vigorous. Independent evaluations of Lean have revealed inadequate resourcing of the necessary support systems, reduced worker satisfaction, and high costs, particularly the salaries for those in leadership positions (Moraros et al., 2016; Rotter et al., 2014). These findings indicate Lean has peaked in its life cycle (McCann et al., 2015).

Lean was described by our participants as creating constant change in the workplace and an accompanying uncomfortable degree of uncertainty. More than one participant complained of the ‘revolving door’ of staff, positions that stay vacant for a number of years, and the insufficient or confusing information provided by management. The continual ‘churn’, combined with budget pressures, inflate managerial control and open a portal for threats of job loss. ‘The manager is telling us that if we don’t do this, we are going to lose our jobs’ (Liza). Such threats are not hollow as waves of layoffs throughout many of the province’s health regions continue with alarming regularity (CBC, 2016; Charlton, 2016; Menz, 2016).

Shortages of staff plague the healthcare sector in the province and country as a whole (Canadian Institute for Health Information (CIHI), 2007; Craig, 2015). Shortages, particularly among RNs, are especially problematic in the rural areas (Kulig et al., 2013; White-Crummey, 2017). The shortage of staff and resulting overwork impinge on the social relations between workers. The study’s participants recounted occasions of reaching out to co-workers to share experiences in an elevator, over a patient’s bed, or in equipment rooms, with necessarily circumscribed responses to highly personal disclosures. ‘I’m sorry that happened to you’ is frequently all that time permits. Subsequent encounters occur under equally constraining circumstances or never at all because one or both had left the workplace.

Prior to the introduction of Lean, the home-care workers met in ‘huddles’ at the beginning of each shift where they collected their schedules of home visits for the day, a venue for exchange of information and development of social relationships. However, the huddles were disbanded on the grounds that daily mingling was considered inefficient. Angela (CCA in home care) describes ‘a divide-and-conquer thing . . . We don’t feel that we’re united as a group anymore. And we think that’s by design. Divide-and-conquer . . . people are feeling very isolated.’ Reflecting on the changes in social relations prior to the Lean implementation, participants drew sharp contrasts between the top-down communication style of Lean managers and the collegial, mutually respectful, management–staff relationships of ‘the good old days’.

Another effect of the cost-saving priorities has been the ‘turf war’ between LPNs and RNs (CBC, 2014; Leo, 2014). With LPNs considered to be more ‘cost-effective’ (i.e. lower wages), they have replaced the RNs with an expanded scope of practice, allowing long-term care facilities to be staffed exclusively by LPNs. Consequently, cross-fire between the unions and professional associations has ensued. A participating RN commented that ongoing strife was another ‘divide-and-conquer’ strategy invoked by management: ‘As long as we are fighting one another then they don’t have to deal with what the real issues are’ (Liza).

The link between harassment and the consequences of Lean’s primary preoccupation with reducing costs did not escape others:

It’s all about the bottom line . . . [but] there needs to be some care for the employees too, and I think if there was a little bit more attention to that there might be a little bit less harassment, even between co-workers. That really hurts when people [managers] are trying to save money on the backs of mental health and morale of their employees. (Angela)

In the province’s healthcare system, middle managers are responsible for adhering to the Lean principles of reducing costs and overseeing patient safety, while mediating conflict between subordinate care workers. The contradictions embedded in middle-managerial roles are accentuated by middle-managers’ membership in the same union as employees they may be required to take punitive action against. Mary (LPN) describes her time seconded to a middle-management position and reporting harassment perpetrated by a subordinate:

It isn’t an easy position to be in at all. I have had to report employees to the union. I have to file reports. You have to think, ok, I’m going to get backlash here. You get stabbed in the back and that person starts bleep, bleep, bleep. If you don’t have that management support, for me it can get really ugly and you feel like the lone person on the other side of that door [from the subordinate she is reporting]. But, I do what’s right. I follow what I need to follow for the rights of the patient.

On the one hand, Mary’s job as a middle manager was to ensure that Lean goals are met, yet on the other she was a wage earner like those she disciplined, sharing interests in higher wages and better conditions of work.

The persistent staff shortages exacerbate existing stressors on middle managers such as Mary, who are often pushed to adjudicate conflict-laden interactions while maintaining a façade of amicable interpersonal relationships between management and workers. Set within the organizational chaos induced by the labour crunches, and pressures on their own time, it is not surprising that managers easily disregard complaints raised by their subordinates or adopt dictatorial approaches even when they might not wish to do so.

Participants reported that harassment complaints in the participants’ workplaces are also funnelled through Human Resources (HR) staff. Pamela’s (RN) attempt to report harassment to HR staff was less than satisfying:

When I first told my manager, my manager actually said I should consider submitting a police report and consider filing charges. Then when I talked to Human Resources, that was backtracked on. And they said: ‘Well no, we prefer to deal with this internally before we take those steps. If we need to take those steps, we will let you know.’

The responsibilities of HR staff typically include protecting the reputation of the organization from mishandled incidences of harassment coming to the public’s attention through litigation and media coverage. When the responsibilities also include settling harassment complaints, the inevitable conflictual position of the HR staff can result in short shrift given to investigations and adjudications of complaints.

Formalized procedures to attend to harassment were introduced as a result of provincial legislation (Legislative Assembly of Saskatchewan, 2007), including a ‘Critical Incident Line’ for employees to report workplace harassment to a centralized office by telephone, and conflict resolution sessions led by managers. Participants revealed feeling isolated and left alone to figure out how to report incidents of harassment with very little information provided. Pamela railed, ‘There is so much confusion about what to do . . . it almost seemed some of the policies are used against you in the workplace as opposed to trying to ameliorate any situation’.

The conflict resolution sessions also lacked credibility among the participants. Angela described one such session in her workplace:

It was ironic that, about a month ago, suddenly this manager wanted to have a . . . well, she led a conflict resolution session. We only had an hour and it was at the end of our workday, and I thought that someone totally neutral was going to run the session. No. It was run by the manager and she’s the problem. So how the heck can you have anything meaningful. We all tried to play the game but were all sitting there feeling incredibly uncomfortable, and thinking, ‘Wow, how ironic is this? And what’s going on with the hypocrisy here that she’s running this.’ Nobody was going to speak up and say, ‘You’re the problem’. We tried to do the best we could, but what can you do in an hour? [. . .] It just looked like they were going through the motions to make it look like they were doing something.

The manager’s attempt to address harassment was divorced from a genuine promotion of workers’ dignity and an attempt to develop new norms for the communicative interactions in the workplace. Instead, the session was a means of adhering to the legislative requirements while downloading the responsibility for workplace interactions onto employees by requiring them to monitor their own behaviour. When workers are forced to participate in disingenuous initiatives such as the session Angela described, the result is all too often an amplified alienation of the employees involved, with social interactions a mere veneer devoid of authentic emotions.

As LPT suggests, not all harassment interventions are thwarted by the contextual conditions of the employment relationship, merely that their outcomes are circumscribed by those conditions. The above description of the participants’ Lean workplaces would suggest that the social relations within those workplaces were so fractured that it would be unlikely that the participants could be activated to collectively resist the oppressive relations of their employment. Indeed, the study’s 18-month recruitment period can be interpreted as participants’ indifference to, and/or incapacity for, unity with their fellow workers. However, as the discussion in the two sections below illustrates, the participants upon returning to their workplaces did in fact support their fellow workers to pursue available avenues of redress and develop strategies of resistance as alternatives to the ongoing harassment. In charting these agentic responses to a repressive managerial regime, the article now turns to the second part of the research question: the consequences of the intervention.

Supports for targets to pursue formal avenues of redress

Most of the study’s participants were dissatisfied with the management-initiated complaint procedures and union grievance procedures. The shared disenchantment with the available procedures was best articulated by Barbara: ‘There’s really no point in doing it [filing a complaint] because it seems really cumbersome and a lot of work and in the end it usually doesn’t even work to your favour, and in fact it’ll increase your stress levels’. Instead of formal procedures, she invested her confidence in her co-workers: ‘I think that sometimes you just have to rely on your co-workers, and you’re lucky if you have a place where you work where people support you’. Several denounced the available formal procedures for protecting the managers instead of disciplining them for the harassment they inflict on subordinates, and the union for its complicity. Others spoke of institutional inaction in the face of a growing volume of complaints, attributing the inaction to an overburdened staff receiving the complaints and deficient skills to respond respectfully and professionally to the complaints.

However, there were two notable cases of participants supporting their fellow workers in the pursuit of redress as a result of the workshops. Olive (CCA) sketched a change in her approach to conducting her duties as a shop steward and representing fellow union members: ‘Now I’m more verbal to how I feel. I have the courage to speak up if I have to.’ Before the workshop, she felt too intimidated by managers to support co-workers who were contending with collective agreement violations. In management–union meetings, she had been silent, unable to point out deviations from the agenda or challenge managers’ hoarding of relevant information before, and during, the meetings. Now, as she reported, she directs the discussion in the meetings when it is becoming unproductive for the union member and provides managers access to only the information to which she feels they are entitled: ‘I have more feeling . . . that I can support that person. That I can stand behind that person.’

Another shop steward, emboldened to act in the interests of the union and its members, described her experience of intervening on behalf of her co-worker: ‘When I’m in a meeting with a manager, I’ll say, “You know, she’s trying to express how she feels. Let her. Let her express her feelings.” I’m more likely to do that now, whereas before I wouldn’t have probably voiced any . . . I would have just done my notes’ (Natalie, CCA). According to her recounting, Natalie is now able to regularly advise her fellow workers about how to respond to managers who are treating them unfairly. She cited as a source of pride her advice to a fellow worker who was being called at home by his manager almost immediately after finishing his shifts with a demand to return for another unscheduled shift: ‘I did tell him that that’s harassment. She doesn’t have any business calling him, especially right after a night shift. I said, just tell her, “You know, can this wait for the next few days until I’m in? Or, maybe you want to pay me for this call.” That stopped it. No more phone calls [laughs].’

It is noteworthy that both Olive and Natalie were union shop stewards. Perhaps because these participants were already schooled in the benefits and strategies of solidaristic actions, they were more predisposed to supporting their fellow workers pursuing resolution and redress through the available procedures. Although comparative measures are beyond the scope of the study, it is possible that these two participants garnered greater benefit from the activities in the study’s workshops, which were specifically designed to develop solidarity and contribute to a heightened sense of agency.

Collective strategies of resistance as alternatives to co-worker to co-worker harassment

During the workshops, legalistic definitions of harassment were reassessed via the embodied activities. These newly forged understandings of harassment accompanied a capacity for new patterns of social action for the participants returning to their workplaces. Referring to the activity of body sculpting, Liza remarked that it ‘allowed us to see what harassment looks like rather than just talking about it’. Rose observed, ‘It was very beneficial; it really defined the harassment for me. I mean, before I might have thought, “Oh really, that’s fairly minor”. But to that individual, it of course isn’t. Something that might seem little to me or trivial to me, isn’t.’

From these new understandings of harassment, participants formulated new social identities that included a sense of competency to think and speak about it, a position previously attributed to management, psychologists and other ‘experts’. Natalie affirmed that back in her workplace, she is now ‘more willing to say, “you know, this is starting to feel a little bit like harassment”, or “that’s not acceptable”, or “can we approach this in a different manner?”’. Jessica (RN) considers herself to be ‘part of a solution rather than part of a problem’ by joining with her fellow nurses when necessary to assert, ‘No, we’re not doing that to each other; we’re not participating in this’.

In the workshops, links were made between harassment and the structural dimensions of the healthcare system. For instance, their own common practice of initiating new workers ‘by fire’ was recognized as a response to oppressive work regimes. With new insights garnered during the workshops, the practice of overloading new recruits with more work than could reasonably be expected of even seasoned workers was identified as harassment. Natalie reported that her awareness of the unjust targeting of new workers led her to understand that in response to the harassment, new recruits often exit the job, which exacerbates the chronic short-staffing and contributes to overwork for those on the job. In her follow-up interview, Natalie described situations in which she now takes action to reverse the domino effect of this phenomenon by interceding on behalf of persecuted greenhorns, informing the perpetrators and fellow workers that their targets were in fact ‘doing a really good job here and we just have to find some time management, because they’re new’. Her use of the ‘we’ indicates that the problem of overwork is a shared concern and time-management solutions are to be shouldered by fellow caregivers. She further advised that any solutions they devised would not include overloading new workers.

In her follow-up interview, Mary recounted the way in which she and another participant developed collective strategies to respond to harassment back in the workplace:

An LPN was at the workshop with me. And you know, we talked a little bit more together. So we talked about bullying, we talked about harassment, how we need to stand up and say, ‘No, this is unacceptable’. Yeah, so there has been those coaching sessions and those conversations. Talking about bullying and harassment and advising that member where to report and get support.

The participants returning to the same workplace with Olive now act as checks for one another to stop the unjust treatment of new workers. They regularly remind each other of their experiences when they were first on the ward, especially when they notice their own backsliding into well-worn patterns of interaction with new workers. Their interactions with new staff have also influenced other workers who did not participate in the workshops. After recounting an incident involving a newly hired worker, Olive was gratified to ‘see all the others that wanted to help her, and it wasn’t just two of us. It was other co-workers too. It was awesome to see. There was so much help for her and hugs, and “you going to be okay? We’re here for you!”’

Furthermore, the workshops produced insights about the professional hierarchy in the healthcare system. As Carrie (RN) described, physicians work laterally to the system as independent entrepreneurs and the Senior Medical Officers are ‘sheriffs with no gun’, responsible for the physicians but without authority. Suspending physicians’ hospital privileges is one gun that is seldom used because of the anticipated public outcry from already under-served communities, all of which leaves RNs with little recourse to deal with harassment from physicians. Once she returned to the workplace, Carrie was inspired to coach her fellow RNs in strategies to resist harassment:

I talked to the nurses who were treated inappropriately by a physician. We explored some strategies about what we might do differently next time. They were feeling very uneasy and upset by what had happened. I tried to reassure them. I said, ‘Maybe you could have done things different in hindsight, but what you did was still okay, and it’s okay if you’re not doing things perfectly all the time’.

Although Carrie’s coaching did not lead the RNs to file formal complaints, her confirmation that they were in fact good nurses, and that the treatment they received from the physician was indeed inappropriate, might well contribute to their confidence to file a complaint in the future. Evident from her narrative is Carrie’s dedication to building a cohesive group of nurses who operate as a team to support each other to confront harassment from physicians and other workplace challenges.

It could be speculated that had the terms and conditions of the employment relationship for the study’s participants been otherwise, had Lean never been implemented or already gone out of fashion, along with all the accompanying ill effects on the social infrastructure among the caregivers, perhaps more monumental outcomes of the intervention might have been achieved. However, given the structural conditions of their employment, the fact that participants did develop some strategies to resist the oppressive employment relations needs an accounting. It is this accounting to which the article now turns.

Discussion

Interventions directed at reducing harassment need to inculcate new communicative practices among workers. Given the institutional power dynamics dominating workplaces and the larger economic and social order of contemporary capitalism, the agentic potential would seem slim for intervention participants to make truly authentic contributions to the development of those new communicative practices. Indeed, LPT theorists have pointed to a deepening and broadening of managerial controls in both goods-producing and the new service and knowledge industries (Thompson and Vincent, 2010). As the means of overcoming the inherent indeterminancy of labour, techniques of managerial control differ by context. In many contemporary healthcare settings in the UK and the US, Lean management is a common control regime. The study’s findings regarding the implementation of Lean in the jurisdiction of the study’s site supports LPT’s portrayal of its dark side (Thompson and Smith, 2009), as well as corroborating other research that casts doubt on the transferability of Lean into healthcare (Joosten et al., 2009).

How then would it ever be possible for healthcare workers to resist the oppressive working conditions of Lean and create new patterns of interaction? The neglect of workers’ agency in Braverman’s LPT is a well-rehearsed criticism of the theory (Knights and Willmott, 1989; Willmott, 1990). The ‘new’ LPT addresses the ‘missing subject’ and the influence of discourse and workers’ resistance, subjectivities and identities in work systems (e.g. Ackroyd and Thompson, 1999; Marks and Thompson, 2010). By taking up questions of subjectivity, we can understand, without losing sight of the structural antagonisms inherent in the capitalist employment relationship, how work organization is produced and reproduced in the everyday accomplishments of social interaction (O’Doherty and Willmott, 2001). It is in this vein of the new LPT that the article offers the following analysis of the TO workshops as sites for collective reflection and creative responses to the coercive effects of Lean. In keeping with the emancipatory aims of TO, the intervention was designed to encourage participants to self-consciously interpret the existing social arrangements in their workplaces in order to resist the dominant social order. By demonstrating the alignment between the revolutionary intent of TO and Braverman’s declared aim to subvert the ideologies of capitalist employment relations, the article reclaims the underplayed radicalism of LPT, as advocated by Spencer (2000).

The workshops

The workshop activities included the development of scenarios from participants’ lived experience of harassment, substituting first names for job titles to anonymize. The aim of the scenarios was not to portray ‘good’ guys and ‘bad’ guys, but to illustrate harassment as a behavioural manifestation of relations of power and to investigate what prevents well-intentioned people from changing the structural conditions that give rise to the harassment.

Using their bodies, participants enacted their lived experiences to awaken a critical consciousness and render the status quo visible. The enactments became collectivized social experiments in which alternative scripts, characterizations and outcomes were investigated. Hegemonic narratives associated with workplace harassment were revealed and interrogated via the aesthetic language of theatre. The discussions arising from the theatrical reconstructions gave group members control over the social construction of meaning, their identities and the development of a ‘moral community’.

Using the aesthetic language of theatre, participants stepped outside themselves and into the role of ‘the other’. They took on aspects of another’s reality and looked at themselves through the eyes of others, all the while remaining themselves. Knowledge of other subjectivities was gained as participants ‘returned’ to themselves and participants reconstituted their selfhoods accordingly. As Jessica reflected on her experience:

He [the facilitator] got the participants in our workshop to take certain aspects of that nurse that I was having this conflict with. He got several of the participants to act out certain elements of her. I think there were eight of them. A really bad headache, I’m busy, I’m very tired, I don’t feel well, too many people at me at once . . . Each person acted out, I mean acted out, not just verbalized, but acted out an element of her state. And he asked me, ‘Which one is it?’, and I said, ‘All of it. That’s all of what’s going on with her.’ And that was very profound for me. The acting was so alive. It was just like going to a movie and you get really into it. It’s just like that. Learning happens on a tremendously deep, subconscious level.

By embodying participants’ subjectivities, the TO activities aligned with the ‘new’ LPT to provide a way of understanding the constructed, contingent nature of social relations through which meanings are negotiated, while staying rooted in the material dynamics of the structural antagonisms of the capitalist employment relationship (O’Doherty and Willmott, 2001).

The bodily ‘sculptures’ and scenarios required no theatrical ‘talent’ or training and their interpretation was left open to negotiation without demanding specialized knowledge, as the esoteric, ‘high’ art forms may do. The only expertise required was the participants’ intimate knowledge of their own work lives to first formulate the scenarios, then to assess the assumptions implied in the scenarios during the follow-up discussions. Under the facilitator’s sensitive guidance, participants revealed the details of their experiences, chose group members to ‘play’ characters in incidents drawn from their work experience, and creatively shaped new dramatic actions, meanings and outcomes. Solidarities were forged in the course of the ensuing ‘sympathetic co-experiencing’ (Bakhtin, 1986). In the study’s follow-up interviews, Rose reported her experience of being the protagonist in a scenario enacted in the workshop:

You just felt more open and at ease. It [the scenario] did bring up a lot of emotions, a lot of memory. I did come to tears just talking about it and sharing the experience. At the end of the day, I just knew I wasn’t alone. It just got to be more open, and you got to feel more safe and secure and relaxed.

The embodied nature of the activities was crucial to the comradeship that developed: ‘Maybe it was a little bit intimidating sashaying across a floor in front of a bunch of people you don’t know, but there’s also a safety in that too’ (Carrie). The participants reported that the connective effects of the workshops persisted over subsequent months: ‘It was a good feeling to come out of it [the workshop] knowing there were other people who were kind of in the same boat who were all trying to make the workplace a little bit better’ (Pamela). The solidarity Debbie (CCA) felt with the others helped to validate her experience of harassment: ‘You realized it happened to others and you felt like what you went through had meaning, because someone else struggled, too. It felt to me like we were a team.’ Referring to the intervention as a programme, Olive declared, ‘This program is . . . hmm . . . an eye-opener. I really believe, no, I know, I’m not alone. I felt like a tower.’

Conclusion

To examine a theatre-based intervention addressing workplace harassment in Canada’s restructured healthcare system, the article employs critical realist evaluation, a methodology with an ontology that accords with LPT’s realist and materialist perspectives. The results indicate that theatre-based activities energized the participating caregivers to become competent contesters of dominant discourses circulating in their workplaces despite the coercive managerial regime of Lean. Study participants were able to imagine, enact and collectively assess new social arrangements. The enduring solidarity achieved from the intervention was a cushion against the managerial regime, allowing them to create new patterns of interaction. The communicative infrastructure developed through the bodily sculptures and enacted scenarios elicited participants’ free exchange of deliberations about harassment as a shared concern and awakened a collective will to carry the revelations of their newly founded ‘knowings’ back to their workplaces. The evidence calls for further empirical testing of the same intervention with different types of workers as a next step in a critical realist evaluation of the intervention. In accordance with Critical Realist Evaluations’ incremental approach to evaluation, further testing of the intervention is suggested with groups of workers specifically chosen for readily made comparisons to the study’s results (e.g. other public sector workers such as education workers and private sector healthcare workers).

Supplemental Material

WES867279_-_sup_mat – Supplemental material for Ameliorating Workplace Harassment among Direct Caregivers in Canada’s Healthcare System: A Theatre-Based Intervention

Supplemental material, WES867279_-_sup_mat for Ameliorating Workplace Harassment among Direct Caregivers in Canada’s Healthcare System: A Theatre-Based Intervention by Elizabeth Quinlan, Susan Robertson, Ann-Marie Urban, Isobel M Findlay and Beth Bilson in Work, Employment and Society

Footnotes

Acknowledgements

We thank our collaborating labour unions and professional associations: Service Employees International Union West, Canadian Union of Public Employees, Saskatchewan Association of Licensed Practical Nurses, Saskatchewan Union of Nurses, Saskatchewan Registered Nurses Association.

Funding

The research is funded by a Canadian Institute of Health Research Operating Grant.

Elizabeth Quinlan is an Associate Professor in the Department of Sociology at the University of Saskatchewan, Canada. She publishes on workplace harassment, caring labour and gender relations.

Susan Robertson is a Research Associate and Lecturer in the Department of Sociology, University of Saskatchewan with research interests in the area of critical social theory and arts-based knowledge production and translation methodologies.

Ann-Marie Urban is an RN, RPN and Associate Professor in the Faculty of Nursing, University of Regina, Canada. Her research focuses on understanding what influences nurses and their work as well as nurses’ physical and mental health.

Isobel M Findlay is Professor Emerita, Edwards School of Business, and University Co-Director, Community-University Institute for Social Research, University of Saskatchewan, Canada. She has published widely on business communications, cooperative studies, Indigenous entrepreneurship, and law and culture. Using a gender lens and Indigenizing concepts, her research interests are in communications, cultures, and communities, diversity in the workplace, partnerships and governance, performance indicators and reporting standards.

Beth Bilson is a Professor in the College of Law, University of Saskatchewan, Canada. Her research interests are in administrative, labour and employment law and legal history. She is currently on secondment to the position of University Secretary, University of Saskatchewan.

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