Introduction

In the last three decades, French New Public Management (NPM) reforms represented a substantial change in the principles underpinning French public hospitals’ budgeting and have introduced a management by objectives approach by emphasizing the rise of performance targets such as patient volume (Simonet, 2015). As a consequence, the public good served by the public health sector has been challenged by the rise of tensions related to increasing pressures to accelerate the pace of service delivery. These changes include an emphasis on the quantification of work through quantitative performance indicators which press health professionals to speed-up the patients’ turn-over (Morinière & Georgescu, 2021). These practices are characterized by “performance-oriented objectives” and are driven by the principles of the New Public Management (NPM) which promote the values and the processes of the private sector. Thus, these changes pose new working demands for health professionals to face these expectations of productivity and raise significant questions regarding their current working conditions.

This trend of accelerating the pace has been conceptualized as one of the processes of “social acceleration” by the sociologist Rosa (Rosa, 2015; Rosa et al., 2017). Rosa argues that social acceleration is a constitutive characteristic of capitalist society and identifies three distinct, yet related, processes of social acceleration: ‘technological acceleration’ (i.e. an increase in technological innovations); ‘acceleration of social change’ (i.e. an increase in change of social structures); and ‘acceleration of the pace of life’ (i.e. a rising number of actions per unit of time) (Rosa, 2010; Rosa et al., 2017).

In management contexts, Rosa (2003, p. 291) suggested that the acceleration appears through a “more intense range of accelerated activities into shorter periods of time,” leading to increasing levels of work intensity and time pressure. Indeed, for organizations, as “faster” is associated with “cheaper,” the acceleration of time promises a host of benefits that are compelling, as an organization is considered more productive when it shortens the time it takes to achieve a given amount of work (Lee & Liebenau, 1999; Orlikowski & Yates, 2002). Associated with financial implications, this Western industrialized conception of time enables the commodification of labor, because time is viewed as a scarce resource that should be optimized, saved, budgeted, and organized so that there is no waste of time and, thus, no waste of money (Ancona et al., 2001; Lee & Liebenau, 1999).

However, the acceleration of time comes with risks and poses new questions that business ethics researchers must confront. Indeed, the experience of acceleration can have adverse effects on individuals, who are likely to feel time pressure when targeting performance objectives within ever tighter deadlines (Van Der Lippe, 2007). In this respect, the problem of time allocation and time scarcity may entail an implicit ethical dimension as it involves a constant acceleration of rhythm simply for individuals to stay in the same place (Rosa et al., 2017). Higher levels of stress, turnover, and the risk of burn-out (Kubicek et al., 2013) have been linked to people’s attempts to accelerate (Rosa, 2010). Thus, acceleration has to be evaluated on the basis both of its benefits for organizations, such as creative behavior, productivity, competitiveness, and its dark-side effects on employees, such as, for instance, pressures for unethical behavior (Rostami et al., 2019).

Prior literature has started to shed light on the effects of acceleration within organizations in different contexts (Kubicek et al., 2013; Rostami et al., 2019; Ulferts et al., 2013; Vostal, 2013, 2015, 2016; Ylijoki, 2013). However, some of these studies are quantitative (Kubicek et al., 2013; Rostami et al., 2019; Ulferts et al., 2013) and, the one that are qualitative focus exclusively on the context of academia (Vostal, 2013, 2015, 2016; Ylijoki, 2013). Consequently, to the best of our knowledge, on the one hand, little work in business ethics currently exists on the ethical implications of temporal experiences and, on the other hand, in acceleration studies, authors have just started to identify some of the ethical issues related to the processes of social acceleration within organizations (Rosa, 2003; Vostal, 2015). The current paper takes up this agenda in the context of business ethics to broaden this area of inquiry. Thus, we ask the following question: What are the ethical implications raised by the experience of acceleration for health professionals within healthcare organizations?

To study this issue, we draw on an in-depth case study of a medical unit within a French public hospital. We conducted 240 hours of observations of several meetings from October 2018 to February 2019 and from September 2019 to March 2020. The aim was to observe various actors debating with each other about performance issues. We also carried out 48 semi-structured interviews with actors at different hierarchical levels and in various functions, including nurses, mid-level healthcare managers, physicians, and administrative executives. In addition, in 2017, we conducted a series of phone interviews with 20 directors, with different levels of responsibility, in 20 different public hospitals of various sizes.

By providing empirical evidence of such experiences, we identified four ethical concerns raised by the experience of acceleration: the expected flexibility of directors facing uncertainty; the erosion of the ethic of care; the process of mechanistic dehumanization; and the adverse effects of speed on emotional work and workers’ well-being. This study accordingly provides useful insights into employees’ experiences and offers practical implications for managers who want to protect their employees from these ethical concerns.

This article makes three main contributions to the literature. Firstly, we show how the theory of social acceleration could add to the ethics of care literature (Gilligan, 1982; Held, 2006; Tronto, 1993). While prior studies suggested ethical problems related to the lack of time for health professionals (Kälvemark et al., 2004; Preshaw et al., 2016), however, to date, these studies do not clearly identify the ethical dimensions of acceleration. Secondly, we contribute to the humanistic management literature (Kostera & Pirson, 2016; Pirson, 2017). We discuss the uncertainty faced by the directors in anticipating the future and how it leads to a concentration on short-term issues, giving rise to the omission of profound long-term damages caused by a disregard toward mechanistic forms of dehumanization of health professionals. In this regard, we point out the dark sides of acceleration, which may lead employees into subtle form of exploitation (Hutter et al., 2006; Kellogg et al., 2006; Mariappanadar & Aust, 2017; Michel, 2011). Thirdly, we add to the emotional work literature (Bagdasarov & Connelly, 2013; Henderson, 2001; Karimi et al., 2014; Smith, 2012; Vincent, 2011; Zapf, 2002) by emphasizing the crucial role of acceleration in pushing healthcare workers to increase speed without protecting them from stress and emotional exhaustion. Consequently, our study highlights how the effects of acceleration within healthcare organizations contribute to creating a dehumanizing workplace culture.

We begin by presenting the prior literature on time in modern society, drawing on Rosa’s work to identify the possible ethical concerns associated with acceleration in healthcare organizations. We then present our method and findings, which are discussed in relation to Rosa’s perspective in the final section.

Literature Review

The Problem of Time in Modern Society

Time is traditionally represented through the metaphor of the clock to signal a rhythmicity that can be measured and assessed on continuous, objective, linear, and quantifiable scales (Butler, 1995; Hassard, 1990; Holt & Johnsen, 2019; Reinecke & Ansari, 2014). In this regard, prior research has highlighted that certain aspects of time are associated with synchronization, ordering, sequencing, or timing, while others are associated with control or measurement (Adam, 1990). Thus, accounting and, more specifically, clock-time-based performance measures serve as a potent tool to increase efficiency and standardization processes (Butler, 1995). Indeed, industrial capitalism has promoted an acceleration of time and rhythmicity with quantitative measures and ordered temporal units to avoid the waste of time, transforming time into a valuable and valued commodity (Rosa, 2015).

However, while the conception of quantified time permeates organizing in modern society, the sociological theory of time has developed a more qualitative and inter-subjective concept of time defined as a social construct (Butler, 1995; Hassard, 2001; Holmer-Nadesan, 1997). From this perspective, scholars have stressed the importance of temporal experiences in shaping the temporal organization of the day, defining time as a collective phenomenon (Blue, 2019). Thus, the experience of time depends on the group or organization to which one belongs and may be conceived differently across cultures (Butler, 1995) or even within the same geographic space (Ancona et al., 2001).

Given this dichotomy, some prior literature has also emphasized that time is both subjective and objective. For example, Orlikowski and Yates (2002) introduced the concept of “temporal structuring” to refer to the institutionalization of temporal patterns and the intersubjective nature of time. This conception of time is deployed to comprehend the co-construction of time within organizations and organizational practices (Holt & Johnsen, 2019). Nevertheless, time can be critical when tensions arise from competing temporal demands (Reinecke & Ansari, 2014). By embedding different values and norms, different conceptions of time may create temporal dissonance for individuals as they engage in their own actions and interact with others who do not necessarily share their conceptions of time (Reinecke & Ansari, 2014).

Hartmut Rosa’s Critical Theory of Social Acceleration and Dynamic Stabilization

Western conceptions of progress and development have led to a mode of social reproduction in modern societies that implies a process of “dynamic stabilization” (Rosa et al., 2017). Rosa et al. (2017) used this term to refer to the way in which capitalist economies’ stability hinges on their capacity to grow, expand, and innovate. In this sense, it refers to the way in which society requires (material) growth, (technological) augmentation, and high rates of (cultural) innovation in order to reproduce its structure and to preserve the socioeconomic and political status quo: “Capitalist systems in all varieties resemble a bicycle that gains in stability with the speed of its forward motion, while it easily tips when slowing down or coming to a halt” (Rosa et al., 2017, p. 56). In this regard, dynamic stabilization intrinsically entails a logic of increase, escalation, and speed simply in order to achieve stability, which threatens, in turn, the very stability, sustainability, and viability of modern society (Rosa et al., 2017).

In this context, the processes of social acceleration refer to the temporal structure and time regimes of modern capitalist societies, characterized by the simultaneous appearance of three independent processes of acceleration that mutually reinforce each other in a circular fashion:

… the intentional acceleration of goal-directed processes (technical acceleration, mainly of transport, communication and production), the increasing rate of sociocultural transformation (acceleration of social change) and finally the rising number of episodes of action and/or experience per unit of time (acceleration of [the speed of] life) (Rosa et al., 2017, p. 58).

The first process, also called technological acceleration, refers to the increasing development of transport, communication, and production (Rosa, 2008). The revolution in transport and new technologies has led to an increase in the amount of data processing and information. The second process, acceleration of social change, results from the increasing speed at which structures are changing (Rosa, 2008): “Whereas phenomena of the first category can be described as acceleration processes within society, the phenomena of this second category can be classified as accelerations of society itself” (Rosa, 2008, p. 82). As a result, social change has:

… rendered social constellations and structures as well as patterns of action and orientation unstable and ephemeral. Thus, attitudes and values as well as fashions and lifestyles, social relations and obligations as well as groups, classes, or milieus, social languages as well as forms of practice and habits, are said to change at ever-increasing rates (Rosa, 2008, p. 83).

The third process, acceleration of the pace of life, describes the increase in the number of actions per unit of time due to the increased speed of actions and experiences. As a consequence, “people will feel that time goes by faster than before and they will complain that ‘everything’ goes too fast” (Rosa, 2008, p. 86).

Yet, in the context of the modern workplace, Rosa (2015) pointed out how acceleration appears through increasing levels of work intensity and time pressure. These processes of social acceleration and dynamic stabilization appear to raise ethical concerns as an increasing amount of resources is required to maintain this acceleration, requiring flexible and active employees who care not only for themselves but also for the economic and social reproduction of the organization. Indeed, in the logic of dynamic stabilization, the amount of energy that needs to be invested to maintain acceleration is enormous and increases further every year (Rosa et al., 2017). Subsequently, this leads to an escalatory pace that is difficult to support for individuals who need to run faster and faster each year just to stay in place (Rosa, 2010). They need to remain competitive in the dynamization-spiral, which demands an ever-higher investment of individual energy. However, these individuals can never be sufficiently active and mobile, nor ever show sufficient initiative.

In addition, despite the fact that time may always be divided into shorter units, human action requires time to be executed. Rosa et al. (2017, p. 68) called this relationship with other human beings, including at work, “resonance to the world”, defined as a “non-alienated relationship that is truly significant for the subject; a relationship that speaks to him or her.”. In this sense, the acceleration of the speed of work may lead to a form of alienation that, in turn, may prevents us from “leading a good, autonomous life” and doing what we really want (Rosa, 2010, p. 92). According to Rosa (2010, p. 83), social acceleration “is about to pass certain thresholds beyond which human beings necessarily become alienated not just from their actions, the objects they work and live with nature, the social world and their self, but also from time and space themselves”. In this regard, Rosa et al. (2017) explored the negative consequences of this mode of social reproduction for individuals’ mental health and well-being. These authors highlighted the increase in stress-related disorders, such as burn-out or depression, which may be interpreted as a stress-reaction to the excessive demands placed on individuals.

Ethical Implications Raised by the Experience of Acceleration Within Healthcare Organizations

Although there are no prior studies on the ethics of acceleration, academic research in ethics has begun to consider the ethical concerns raised by time within organizations (Henderson et al., 2008; Hutter et al., 2006; Kubicek et al., 2013). Ethics is defined as “a systematic attempt to make sense of our individual and social moral experience, in such a way as to determine the rules that ought to govern human conduct, the values worth pursuing, and the character traits deserving development in life” (DeGeorge, 2014, p. 13). According to DeGeorge (2014, p. 13):

… to the extent that ethics is concerned with how people ought to act, it has a critical dimension. Given any set of practices, rules, or actions, one can appropriately ask this: Is it ethical? Simply because something is an accepted course of behavior or simply because something is enacted into law does not make it ethically justifiable.

In this regard, business ethics is not something separate from society; it is an integral part of society as it focuses on applying “general ethical principles to particular cases or practices in business” (DeGeorge, 2014, p. 13). In this sense, business ethics “can produce arguments showing that a practice is immoral, but obviously, only those in a position to implement the changes will be able to bring them about” (DeGeorge, 2014, p. 17).

In order to situate our examination of acceleration as a temporal feature for healthcare organizations, we must define the ways in which healthcare institutions have been framed and driven by neoliberal New Public Management (NPM) principles since the 1980s. In this regard, the reduction of public health expenditure has become the dominant political strategy in the last three decades in many Organization for Economic Co-operation and Development (OECD) countries. Healthcare organizations have been increasingly defined as organizations dealing with market principles and are expected to drive economic growth while ensuring the provision of public services. In this regard, many reforms founded on NPM principles have transformed healthcare organizations by stimulating economic growth, a management-by-objectives approach, and performance targets such as patient volume (Simonet, 2015). This market-driven approach has led to intensifying ethical concerns (Morinière & Georgescu, 2021) involving time that may become problematic (McGivern et al., 2018). In particular, we argue that the experience of acceleration within healthcare organizations may involve several interrelated ethical dimensions that have not yet been fully investigated.

First, a significant issue associated with acceleration that we consider to be ethically problematic is related to the ethics of care. An ethics-of-care approach recognizes meaningful interpersonal connectedness, deep relational quality, and human interdependencies as the basis for work in general and for good care delivery in particular (Gilligan, 1982; Held, 2006; Tronto, 1993). In this regard, a growing number of scholars have begun analyzing the importance of the ethics of care in different professional areas (Alacovska & Bissonnette, 2021; Linsley & Slack, 2013; Spiller et al., 2011; Vijayasingham et al., 2018), including nursing (Molterer et al., 2020; Nortvedt et al., 2011). Prior studies have emphasized how durational expectancies, listening time, and relational ethics are significant in care relations (Egede-Nissen et al., 2013; Sellevold et al., 2013; Waterworth, 2003) and can enhance patient satisfaction (Gross et al., 1998).

However, the ethics of care may be threatened within healthcare organizations by temporal pressures, performance time-oriented objectives, and lack of time (Kälvemark et al., 2004; Preshaw et al., 2016). For example, time-and-motion studies, which serve to collect and analyze a specific task’s time duration from an external observer’s point of view, have become a focus of interest in improving clinical-workflow efficiency (Lopetegui et al., 2014). Therefore, healthcare professionals may be tempted to prioritize economic over professional principles such as relational quality and meaningful interpersonal exchanges with patients (Loscher & Kaiser, 2020; McNair, 1991; Picard et al., 2014). Thus, although the impact of the acceleration of the speed on the ethics of care has not been the object of in-depth study, one may assume that the ethics of care is likely to be shaped by such speeding-up pressures.

A second significant issue regarding acceleration is associated with a humanistic perspective in management that recognizes the relevance of the notion of human dignity by highlighting the alignment with the public interest and its connection to social welfare creation (Kostera & Pirson, 2016; Pirson, 2017). Pirson (2017, p. 45) highlighted “that the dominant economistic management approaches have left concerns about human flourishing, ethical development, social relationships, and the environments at the margins of the discipline rather than in the center”. However, Sen and Nussbaum argued that dignity is a cornerstone of successful capability development (Nussbaum, 2002; Sen, 2005). Other studies have argued that well-being cannot be achieved without dignity (Pirson, 2021). Nevertheless, the humanistic perspective is challenged by the dark side of acceleration, which may lead employees into overwork, to the point where they may appear to be exploited (Hutter et al., 2006; Kellogg et al., 2006; Mariappanadar & Aust, 2017; Michel, 2011).

The third ethical issue concerns the side effects of this accelerated pace on healthcare workers’ well-being, which can be undermined by time pressure. For example, speeding-up imperatives may impact how healthcare professionals manage their emotions (Mitchell et al., 2019). Emotional work is defined as “emotional regulation required to display organizationally desired emotions by the employees” (Zapf & Holz, 2006, p. 1). In healthcare, an emotional work perspective recognizes the act of caring as work since it requires key skills such as empathy and compassion (Bagdasarov & Connelly, 2013; Henderson, 2001; Karimi et al., 2014; Smith, 2012; Vincent, 2011; Zapf, 2002). Prior literature has found that there is often a cost for workers in meeting institutional expectations since this may affect the degree to which one listens to one’s feelings and sometimes one’s very capacity to feel (Hochschild, 1983). Thus, in order to meet the emotional expectations associated with their work, healthcare professionals may manage their emotions in ways that do not reflect how they actually feel. Prior literature has identified emotional dissonance as a major factor in stress and emotional exhaustion when emotional displays are required but do not correspond to felt emotions (Zapf & Holz, 2006).

Thus, working under the temporal pressure of acceleration may result in increased levels of stress and induce emotional work that may alter immune functions. Evidence also highlights the health risks associated with the experience of stress, which may be associated with burnout (Demerouti et al., 2004), depressive disorders (Maurya et al., 2016), psychosomatic symptoms (Burke, 2002), emotional exhaustion (De Croon et al., 2004), immuno-suppression, gastrointestinal disorders, cardiovascular diseases, headaches, and sleep disturbance (Chrousos, 2009; Kivimäki & Steptoe, 2018). This raises the question of whether it is ethical for employers to push healthcare workers to increase speed to meet institutional demands without protecting them from stress, emotional dissonance, and emotional exhaustion.

Studies have also shown that coordination needs are extremely significant in the healthcare sector (Henderson et al., 2008; Sterponi et al. 2019). Zerubavel (1979) highlighted the significance of temporal coordination among physicians and nurses in relation to their work being covered by others when they are absent. This author noted that any time change made within an individual’s work schedule disrupts an entire temporal order, which is shared collectively and requires, therefore, some coordination with the work schedule of at least one other individual (Zerubavel, 1979).

However, while time is by no means a neglected topic in the organization studies literature, no prior studies in business ethics have examined how the processes of social acceleration and dynamic acceleration entail an increase in the speed of work and an experience of acceleration for various health professionals, which, in turn, entails ethical implications on a day-to-day basis. This study aims to empirically address this issue and to shed light on the associated practical implications within healthcare organizations.

Method

Research Context: The Case of French Public Hospitals

The context for this research is a case study of a medical unit in a French public hospital. In France, several reforms based on NPM principles and a results-based control approach have transformed how hospitals are financed through the development, in 2004, of a system called activity-based payment (tarification à l’activité) (Hood, 1991, 1995). Since 2004/2005, national tariffs have been calculated for homogeneous groups of patient stays, founded on diagnosis-related groups (DRGs). The aim of this reform was to improve the relationship between resource allocation and resource use, and to reduce the high level of spending of health-insurance funds set by ONDAM (the national objective for health-insurance spending). In this context, NPM principles were interpreted quite differently than in Anglo-Saxon countries and the United States, which have disaggregated public services. In contrast, in France, the prices for health services are not set by the market but by the government (Simonet, 2015).

In parallel with these structural changes, the Hospitals, Patients, Health and Territory Law (HPST) of 21 July 2009 has transformed hospitals’ internal organization into decentralized medical units. Each medical unit contractually commits to achieving certain performance objectives. Among the different indicators, we note, for instance, that both the assessment of the average length of stay, and thus the shortening of the duration, and the occupancy rate are significant and contribute to the rhythm of patient turnover. Indeed, prior literature has emphasized that healthcare organizations are increasingly focusing on performance measures (Broadbent & Guthrie, 1992, 2007; Lapsley, 1988, 2008; Morinière & Georgescu, 2021; Steccolini, 2018).

Data Collection

The study’s design consists of a qualitative analysis (Padgett, 1988) of a single case study (Yin, 2008, 2012). We draw on ethnographic immersion, covering 240 hours, within a medical unit. Ethnography is needed to discern the complexity of social structures and relations, allowing researchers to understand “how things work” within organizations (Hammersley, 2006; Jeffrey & Troman, 2004; Sanday, 1979; Van Maanen, 1979; Watson, 2011). Ethnography is an inquiry method comprising observing daily routines, activities, and interactions between different actors (Becker, 1958). The ethnographic observation took place from October 2018 to February 2019 and from September 2019 to March 2020. The goal was to observe daily practices and social interactions between organizational actors in situ (Cornelissen et al., 2015; Hallett, 2010; Hallett & Ventresca, 2006; Zilber, 2016). We started by observing the work of the nurses and caregivers since these professions are the ones who are in direct relation with the patients. We then chose to observe the senior healthcare manager of the medical unit due to her crucial role in the management of the healthcare managers of the different departments. In order to distance ourselves from the emotions we experienced and to increase our reflexivity (MacBeth, 2001; Mauthner & Doucet, 2003), we wrote a detailed notebook where pages were dedicated to facts observation and, other pages were used to report feelings and any difficulties encountered. We then decided to specifically observe the way actors use performance measures. To do so, we asked for access to accounting meetings about activity forecasting and budget negotiation. We also attended the weekly medical-unit meetings with the chief physician of the medical unit, the senior healthcare manager and, the administrative manager. Finally, we attended individual meetings between the physicians and the administrative manager concerning forecasts for the number of consultations or surgeries.

A total of 48 semi-structured face-to-face interviews with professionals at different hierarchical levels were conducted to complete our observations. Interviewees included physicians, healthcare managers, nurses, financial controllers, and the chief financial officer (CFO) (see Table 2 in the Appendix). The interview guide included several sections covering the following topics: background information about the interviewees; tensions related to professional values; relationships within the organization; attitudes towards project processes and performance measures; and perceptions of tensions and injustices in general. Interviews were led by the same researcher and lasted for approximately one hour (see Table 3 in the Appendix). Informed written consent was obtained for the interviews to be audio-recorded; these were subsequently transcribed, with confidentiality ensured. The observations and interviews were complemented by financial documents provided by the CFO and the administrative manager. Information about the interviewees is provided in the Appendix.

In addition, we carried out a series of telephone interviews in 2017 and 2018. The sample comprised 20 directors practicing at different levels of responsibility in 20 different public hospitals of various sizes (see Table 4 in the Appendix). The interview guide included, among others, several questions about the vision for the future of public hospitals in 20 years’ time and about management (see Table 5 in the Appendix).

Data Analysis

Once transcribed, the data were analyzed and coded in several steps using NVivo 12.2 software through an abductive approach, following both inductive and deductive methodological principles. Our empirical research was initially framed by the literature concerning the use of performance measures within healthcare organizations and the tensions that may emerge from their use, which reflects our broader research objective. However, when conducting the data analysis, we first created a list of preliminary categories for emergent topics and the theme of time, among others, came to the fore as a focal point in relation to tensions. We then utilized thematic coding to reexamine the data, further focusing on time and temporality. Throughout the reanalysis of our data, we developed a preliminary list of descriptive codes, such as “increasing the pace” or “focusing on the production growth,” and we created a final list of first-order categories (see Table 1). At this point, we returned to the literature review to relate our findings to prior work (Eisenhardt, 1989; Langley, 1999). From this point, we positioned our findings in relation to, on the one hand, the literature on acceleration and ethics and, on the other hand, the theory of social acceleration and dynamic stabilization (Rosa, 2015; Rosa et al., 2017) as a framework through which to interpret our results.

Table 1 Data analysis
Full size table

Findings

This section analyses the empirical material collected, focusing on the question of how professionals experience acceleration within French public hospitals and whether and how this experience generates ethical concerns. We begin by describing the speeding up of organizational shifts in French public hospitals and the process of dynamic stabilization and, subsequently, we identify and outline several ways in which associated ethical concerns emerged for health professionals.

The Speeding Up of French Public Hospitals: Organizational Change and the Process of Dynamic Stabilization

Three distinct but related aspects of acceleration were found in our results. First, we identified a speeding-up of technological acceleration that has led, in turn, to a second aspect of acceleration: the increase in the pace of work. Historically, French public hospitals have been organizations whose mission was to provide help, accommodation, and food to the most disadvantaged people before providing technical and chirurgical care. However, technical and medical innovations have revolutionized how medicine is provided and have transformed how care is delivered, as the speeding up of production has made it possible to shorten patients’ length of stay significantly:

The idea is that, as technology advances, as innovations advance, we won’t keep patients in the hospital anymore. So, broadly speaking, we will have extremely short stays in the hospital. (Director)

These two first processes are related to a third one: an increase in the speed of social change. Due, in part, to these technological and medical innovations, change is occurring at an increasingly rapid pace. In this context, several of our interviewees pointed out that, in the future, French public hospitals would focus mainly on technical aspects of treatment, leaving the other dimensions of care, such as chronic disease, polypathology, and long-term care, to other structures:

We’re getting closer and closer to a hospitalization without overnight stays with the development of outpatient services that need well thought-out technical facilities and a well-honed outflow. (Director)

Without these incessant transformations, which involve integrating technological and medical innovations, public healthcare organizations risk becoming obsolete and out of date and may lose their competitiveness compared to private organizations. From this perspective, the functioning of French public hospitals is characterized by the process of dynamic stabilization that we described earlier, as they need to innovate simply to maintain their position:

Change is the major principle: technological progress, the progress in medical knowledge. This progress means that if you stay with an offer that becomes outmoded, very quickly you lose your attractiveness. And after that, patients and doctors who usually send patients to you will turn away from you and send these patients to more competitive structures. (Director)

Within the organization, the process of dynamic stabilization is also visible in how each department within the same medical unit and hospital needs growth or innovation to preserve its existing conditions. Indeed, without expansion or innovation, beds are likely to be transferred to other departments, or departments are likely to be closed; as a consequence, medical teams internalize the idea that they are in competition and that they need to produce ever more in order to maintain the status quo and to keep their current structure. Without this, they risk losing their economic competitiveness:

Our productivity keeps growing in the ward and if it isn’t growing, the number of beds is decreased. In the sectors where productivity has not grown, the number of beds has decreased, and the work pace gets faster (…) The doctors say that the pace is becoming difficult to keep up with, and it’s difficult for us also. In particular, in our ward, our productivity has increased dramatically. (Healthcare Manager)

The problem here lies in the equivalence between the number of activities performed and the pace at which this is achieved; the pace remains unchanged when the work intensity drops because this decrease may lead to a transfer of beds from one department to another. Thus, our analysis reveals that this phenomenon leads to a process of the escalation of care production, which seems to be getting faster and faster. This process is visible through objects and interactions and, in particular, through the use of performance measures, such as the average length of stay. Indeed, performance measures and associated performance objectives play a key role at this point in pushing professionals to speed up and to increase their work intensity in order to obtain financial resources:

In fact, when you ask for something from the administration, you’re asking for funds. In fact, the indicators are always optimal just before you get the funds. You do more with less funds, you get the funds, you normalize it all, and then your indicators decline. [Physician (Universitarian)]

This quote illustrates the spiral of dynamization, which requires starting over every time just to stay in place. Drawing on these processes of acceleration and dynamic stabilization, our subsequent findings reveal that these processes entail ethical issues for health professionals, which we examine next.

Ethical Implications Raised by the Experience of Acceleration

The Expected Flexibility of Directors Facing Acceleration

Regarding the processes of technological and social acceleration, the increase in technological and medical innovations leads to an experience of acceleration in change and, in turn, uncertainty as these processes have rendered orientation unstable and ephemeral:

The world moves so quickly nowadays that we can’t say ‘I am directing my hospital with such and such a vision for ten years ahead.’ It’s not true because the world is moving much faster than it did 10, 15, or 20 years ago. Politics, economics, technology, innovation – it’s all going fast with a capital F. (Director)

This quote reveals that directors have no longer a long-term vision conscientiously elaborated. Even when they try to anticipate the future transformations in order to remain competitive, one of our interviewees pointed out how these projections can turn out to be wrong, as the orientations are likely to change very quickly:

We have to have plans for the organization in the future while trying to take into consideration the directions that the whole world is taking for such and such a type of pathology in view of adapting the structures we are going to build for what will be operational in three or four years, sometimes more. Well, that, that is a risky exercise because sometimes you succeed and sometimes you’re dead wrong, because those perceived directions, in the end, may not turn out to be correct. (Director)

Drawing on these structural difficulties, directors have to become more flexible in order to adapt the organization to these perceived directions. The shortening of the time-spans is one of the most obvious effects of acceleration for these directors. Consequently, on the one hand, the time-scale is called into question, creating new challenges for them and, on the other hand, this concentration on immediate and short-term considerations involves the omission of long-term issues, giving rise to significant concerns for caregivers and medical professionals that are discussed below.

The Erosion of the Ethics of Care

The second ethical implication we analyzed in our results is the erosion of the ethics of care. French public hospitals have, historically, been organized around three distinct professional bodies with their own rationalities: medical professionals; caregivers; and administrators. Nurses and medical professionals collaborate with patients and families to provide safety and quality of care in the best possible conditions. Regarding experts in care, their mission is also associated with the expression of a relational dimension related to care and a vocational dimension of serving others. From the caregivers’ perspective, care requires time to listen to patients and to dialogue with them. In this sense, the time devoted to care is highly valued as care is seen through a holistic lens within which the relationship is crucial. Relational rhetoric related to the ethics of care implies time, slowness, and the need to be present for patients. However, this relational dimension is not always possible because of the lack of time:

In my opinion, the patient needs someone who listens, who will spend a little time with them, which is very difficult since we are constantly disturbed, sometimes scattered, sometimes not concentrated on only one task. It’s hard to give time to all the patients. (Physician)

A second quote implies momentum, acceleration, economic growth, competitiveness, and the imperative to speed up:

We never have enough time, it’s like we’re all chasing the clock. Everything goes too fast. We’d like to spend more time with a patient, with a family. (Nurse)

Through this experience of acceleration, professionals experience time as passing more quickly and as being a scarce resource. In this context, our results reveal that experiencing acceleration is quite challenging as it requires them to resynchronize themselves to another temporal logic, focusing on speeding up, when they themselves would actually prefer deceleration.

In this regard, the need for speed and growth creates various ethical concerns among different actors, as some want to slow down while others want to speed up. In this context, some interviewees pointed out how the acceleration imperatives have a different temporal logic than the one of the ethics of care. Indeed, the acceleration imperatives are seen as a need promoted by accounting culture. In the context of the experience of acceleration, medical professionals, nurses, and healthcare managers feel rushed and have to synchronize their rhythms in accordance with this accounting logic. Thus, healthcare workers perceive accelerating time as conflicting with their ethics of care. In this context, the use of performance measures plays a critical role in embodying the acceleration imperatives and in enhancing a pervasive constant escalation of rhythmicity and speed:

You have to spend a lot of time with some patients, which is not very profitable as they say. So, it’s true that there’s no recognition of the quality of care. The problem is that there is an administrative logic that is based on accounting. It’s contrary to the attitude of a healthcare worker who doesn’t measure out their time (…) In that accounting mentality, a patient is such and such an amount of time, it’s such and such a number of nurses for so many patients. They don’t consider the relationship between the healthcare worker and the patient, which is very different from one case to another and, by definition, much more complex. (Physician)

This quote suggests that attempts to transform care’s specific temporality produce ethical concerns, as the accelerating pace of work transforms the way care is accounted for. In addition, our findings reveal that care workers perceive the experience of the acceleration of the pace of work as a driver of unethical decision-making, which conflicts with their values:

Sometimes I have seen myself put patients out on the street. There is no post-treatment care, there’s no follow-up. We put them out on the street because they’re pushed out, there are emergency admittances coming in. It’s a factory. There’s a pressure to get the patients out. (Nurse)

In addition, this accelerating pace may give rise to several tensions between different groups attempting either to slow down the rhythm or speed it up. During our fieldwork, our observations revealed that the surgeons of one department had agreed to increase surgical operations by 12.1% by 2020 compared to 2017 in order to be able to hire a new specialist and to buy innovative equipment already used by private clinics in the region. In this context, we observed recurrent disputes between the healthcare manager of this department and the surgeons, highlighting two distinct ways of conceiving of care, driven either by the dynamization spiral considerations or by a holistic perspective. The surgeons wanted to overbook the operating room by adding more patients every week, while the healthcare manager wanted to slow down the rhythm because of the consequences of the pace on the number of patients in the department. Indeed, every week, because of the overbooking of planned surgery, patients could not be placed within the proper department and had to be transferred to other, non-specialized areas. During the dispute between the healthcare manager and the surgeons which lasted five consecutive hours, this mode of organization was highly criticized by the healthcare manager, who expressed deep concern about the poor quality of care provided to patients. Nevertheless, despite the repeated criticisms, the surgeons kept pushing this frenetic pace so that they can preserve their status quo. To do so, they attempted to meet the increase in chirurgical operations they had promised in order to remain competitive with the region’s private clinics. In the next sub-section, we present the third ethical issue raised for health professionals by the experience of acceleration.

The Process of Mechanistic Dehumanization

The third ethical issue concerns how acceleration engenders mechanistic forms of dehumanization, as professionals are treated like automata, machine-like, replaceable, and in an emotionally distant manner. Hence, our results highlight subtle forms of alienation that should not be ignored.

The problem is the pace of work, patients one after another. We feel sometimes like it’s an assembly line in a factory. You can’t keep people too long, they have to get better quickly. Sometimes, this kind of work pace leads to patients having to come back because they are released too early, and also because there are others waiting in line behind them and we don’t have enough beds. (Healthcare Manager)

Moreover, the experience of time acceleration is related not only to having less time or feeling time pressure, but also to collective disorganization. Indeed, the more absenteeism increases, the more nurses have to work overtime and shorten their rest time before their next shift. In this regard, from the nurses’ perspective, the experience of acceleration becomes a vicious spiral, which blurs the lines between their private and professional life and which may lead to a form of subtle exploitation:

I’ve been here for two and a half years, and I’ve already done 150 extra hours that I’m going to put into my CET (time savings account). It’s been over a month of extra hours! (...) My manager was able to give me a few days off and then she said ‘do not answer if the hospital calls you because they are going to tell you to come back from your leave.’ It’s fortunate that my health executive warned me, but in itself it’s dehumanizing. (Nurse)

This quote highlights how the nurse feels undervalued within the hospital and how her time is exploited in an emotionally distant manner by the institution. From the healthcare manager’s perspective, this spiral is contradictory in terms of what she considers to be an ethical attitude towards nurses. In this situation, healthcare managers face ethical dilemmas between what they consider to be ethical behavior regarding organizational principles and the principles of their profession, as they have to choose between finding someone to do the job and respecting nurses’ personal lives:

As a manager, given the present functioning of the hospital, I have to say that I do not respect my employees at all, I use them. Sometimes I am not honest, I am obliged not to be honest and to manipulate people. To deal with absenteeism, I have to depend on them, and I know who I can ask not to take their days off and to work overtime (…) Given this duality, it’s difficult to be in sync with your own values. (Healthcare Manager)

Ethically, healthcare managers highlighted how these types of managerial decisions are questionable with regard to their values:

Ideally, you should respect their personal lives, you should respect the schedule, but that is just not possible. So, we tire them out, we exhaust them. And for me it’s difficult (…) in fact, not to be able to make it so that their work brings them pleasure. I both don’t respect them and can’t provide them with the work–life quality that I took this job to ensure. I became a manager for that, to privilege life over work. (Healthcare Manager)

This exploitation of the nurses seems to correspond to a factory-type logic and one of our interviewees even pointed out that the automatization of human labor could become a solution to keep the pace going over time:

To make a factory work, either you automate it or you bring in human labor. Today, if there is no human labor, I can’t guarantee that the operating rooms will run at capacity. All of the rooms are in operation, but at low capacity. Instead of having four nurses in the operating room, you might only have two. (Senior Healthcare Manager of the Operating Department)

The actor here suggests that the way hospitals are managed like a factory devalues human labor. In the following section, we show the fourth ethical implication raised by the experience of acceleration for health professionals.

The Adverse Effects on Emotional Work and Workers’ Well-Being

The fourth ethical implication refers to the adverse effects of the perceived acceleration on emotional work and workers’ well-being, which can be observed in the increase in speed, which in turn leads to the risks of stress, depression, absenteeism, and burn-out:

The higher the patient turnover, the higher the workload for doctors, for interns, and for the care workers. That means that if you release a lot [of patients], the release papers are required, and there you have a problem because in transit the papers are not yet ready because the intern hasn’t done them, they didn’t have time. So that creates stress for everyone. And, unfortunately, we’re all aware that patient turnover is going to keep increasing. (Healthcare Manager)

The doctors have a plan for greater productivity. We can see this as consultations have increased. Before, when recent patients were admitted, they had consultations twice a week for the first month. Now the time slots for consultations are so full that for some patients, who really are quite well, they only come once a week in the first month. And then the doctors, you see them crushed daily under the weight of this productivity because they have to manage medical opinions, calls, emergencies, they have to manage the paperwork for release. The doctors say that this pace is becoming difficult to keep up with and it’s difficult for us too. Particularly in our ward, productivity has exploded. (Healthcare Manager)

Thus, care acceleration and dynamic stabilization have become ethically problematic and are increasingly difficult to maintain over time. The human resources that keep the engine running are not inexhaustible and may suffer from stress reactions to these excessive demands. Similarly, several interviewees criticized the difficulties caused by these structural changes:

There’s a whole relationship in healthcare that we no longer have the time to build. Healthcare workers are not comfortable with this, and the patients are not comfortable with this either. The profession has not changed, because the nurses do the same work in terms of care, but it isn’t done in the same way. That creates tensions, which creates aggressiveness, which creates dissatisfaction at work; I think that we have never had so much absenteeism, so much sick leave and burn-out. (Healthcare Manager)

During our fieldwork, the senior healthcare manager of the operating room suffered burn-out and was moved to an administrative job. Similarly, some interviewees described critical events related to stress and exhaustion:

I think that during the first six months, once a week, when I was going home from work, in my car, I cried just for stupid things. Too much stress. And so, the co-workers that I train, I tell them this, I tell them, ‘That, that is going to be hard.’ Just recently, my coworker who got here three weeks ago said to me ‘I’m exhausted, I can’t do it anymore, there is too much information at the same time, our work pace is super intense.’ (Nurse)

In the same context, one of our interviewees described how one of the nurses had quit because of time pressure:

A nurse had what I call a mid-flight explosion, that is, she had been there for four and a half years but this summer she lost it: ‘I won’t do that,’ ‘I’ve done enough.’ She refused to follow medical orders because it wasn’t possible to do them in the given timeframe. (Healthcare Manager)

In summary, our findings reveal that the increase in work pace has created tensions and severe ethical issues for health professionals, which are discussed below.

Discussion and Conclusion

In this article, we have aimed to provide an empirical analysis of the ethical implications raised by the experience of acceleration for health professionals. We now present the theoretical contributions of our paper and we shed light on how the ethical concerns we identified earlier reinforce each other and create a subtle dehumanizing culture, before pointing out some potential avenues for future research, as well as practical implications.

Our study suggests that Hartmut Rosa’s theory of social acceleration and dynamic stabilization is useful in shedding new light on how the experience of acceleration brings ethical concerns to the fore for health professionals. Rosa et al. (2017) defined the processes of social acceleration as the way in which society requires (material) growth, (technological) augmentation, and high rates of (cultural) innovation in order to maintain the status quo. Our study reveals that there are significant ethical implications involved in this process as it entails adverse effects for health professionals. In this regard, the findings enrich understanding of the concept of social acceleration by revealing the concrete ethical concerns encountered by health professionals, which until now have not been fully analyzed.

Our first contribution is to the ethics of care literature (Gilligan, 1982; Held, 2006; Tronto, 1993) by drawing on the theory of social acceleration and dynamic stabilization (Rosa, 2015, 2017). While prior literature has somewhat suggested ethical problems related to the lack of time for health professionals, however, to date, this research does not directly address the challenges raised by the processes of social acceleration and dynamic stabilization. In this regard, our findings are particularly relevant in light of the prior literature discussing how interpersonal connectedness, deep relational quality, and human interdependencies are considered as the basis for good care delivery (Gilligan, 1982; Held, 2006; Tronto, 1993) and how durational expectancies, listening time, and relational ethics are significant in care relations (Egede-Nissen et al., 2013; Sellevold et al., 2013; Waterworth, 2003). Indeed, thanks to the conceptualization of the three processes of acceleration and the dynamization spiral, we examine how the ethics of care, considered as a temporal experience, is threatened. Thanks to this theorization, we offer a more nuanced insight into the way medical professionals may be in favor of the acceleration of the pace by revealing the process of dynamic stabilization and the fear of losing the status quo underlying these practices. While facing an increasing intensity of work, medical professionals want to keep the pace going to preserve their current working conditions. In parallel, we shed light on how these practices affect healthcare managers and nurses who experience conflicting temporalities in their daily work. Health professionals feel rushed and have to synchronize rhythms in accordance with the accounting logic, which requires them to boost their productivity and speed of work. In this regard, our findings reveal that professionals who experience time acceleration are likely to feel a conflict between their ethics of care and temporal features of the situation.

Our second contribution is to the humanistic management literature which rarely studied the ethical implications of temporal experiences (Kostera & Pirson, 2016; Pirson, 2017). Indeed, the humanistic turn in management stands “against the widespread objectification of human subjects into human resources, against the common instrumentalization of human beings into human capital and a mere means for profit” (Kostera & Pirson, 2016, p. 3). We add to this literature by highlighting in our results the structural tensions induced by the processes of acceleration. The uncertainty faced by the directors in anticipating the future directions of their organization leads to a concentration on immediate and short-term issues, giving rise to the exclusion of significant long-term considerations such as the creation of a dehumanizing culture for health professionals. Consequently, this incapacity in having a clear long-term strategy, especially regarding human resources management, is causing profound damages by promoting a disregard toward the creation of mechanistic forms of dehumanization. Indeed, we highlighted in our results how professionals are viewed as automata, machine-like, replaceable, and are treated in an emotionally distant manner in order to sustain the organizational pace.

Hence, our study highlights that subtle forms of alienation and exploitation may occur and should not be ignored. Based on these ethical concerns, our study raises significant questions regarding the management of healthcare organizations: Is acceleration jeopardizing healthcare organizations by eroding the ethics of care and promoting a dehumanizing culture among health professionals? Is acceleration inappropriately leading health professionals towards an erosion of ethics in relation to patients? Ultimately, the ethical implications regarding acceleration should be considered as questions regarding the type of healthcare organizations we want to create for health professionals and for the people they serve. In this extent, the processes of social acceleration and dynamic stabilization pose a core challenge to the protection of dignity in the workplace, both for health professionals and patients. Based on the findings of this study, two levels of dignity should be considered: employees’ dignity; and the public’s dignity. Rosa (2015) emphasized how capitalist systems of all types resemble a bicycle that gains stability with the speed of its forward motion, while it easily tips over when slowing down or coming to a halt. However, the dynamic stabilization described by Rosa (2015), which requires structural escalation, is only possible within healthcare organizations by demanding that human resources work beyond their capabilities. Following this line of thought, we suggest that the concept of “resonance to the world” (Rosa et al., 2017, p. 68) has parallels with prior humanistic management literature emphasizing the centrality of human dignity to life (Pirson, 2017). Indeed, this concept emphasizes the significance for the subject of a relationship of non-alienation with the world; a relationship that speaks to the subject. In this regard, our contribution could be generalized beyond the specific case of French public hospitals as we point out the risks of these forms of acceleration which can produce dehumanizing practices and habits within organizations by objectifying human subjects as if they were a mere means for profit.

Our third contribution is to the literature on emotional work related to the act of caring (Bagdasarov & Connelly, 2013; Henderson, 2001; Karimi et al., 2014; Smith, 2012; Vincent, 2011; Zapf, 2002). Our results point out the broader ethical concerns raised by the side effects of the accelerated pace on healthcare workers’ emotional work, which can be undermined by time pressure. However, while prior literature has highlighted how speeding-up imperatives may impact how healthcare professionals manage their emotions (Mitchell et al., 2019) and how there is often a cost for workers in meeting institutional expectations since this may affect the degree to which one listens to ones feelings and sometimes ones very capacity to feel (Hochschild, 1983), there is still little work regarding whether and how the processes of acceleration have adverse effects on emotional work and workers’ well-being. Our results reveal that, for nurses and healthcare managers, these groups experienced repeated tensions in their daily work with what they consider the “right thing to do” regarding their professional values.

However, while there is evidence that health professionals experience ethical concerns when complying with these processes of acceleration, our results reveal that not all the professionals want to slow down, as there are benefits to sustaining the status quo. Future research would likely benefit from studying these diverse attitudes towards the experience of acceleration. Moreover, future research, specifically in the healthcare setting, could further examine whether there is a relationship between time acceleration, early patient discharge, and inappropriate readmission.

We suggest that these ethical concerns have implications for public policy as they suggest that experiencing acceleration is not merely about having less time but also about collective disorganization (Zerubavel, 1979) and the loss of meaning. By shedding light on the specific ethical implications entailed by the experience of time acceleration, we seek to criticize the capitalist form of care production in modern society. In terms of practical implications, the present research reinforces the importance of reaffirming the significance of healthcare workers’ mission of care, which cannot be simply reduced to technical gestures.