To Our Nurse Friends: An Ode to Resistance

ABSTRACT

The concept of resistance in nursing has been garnering more interest in the last few years, with emerging focus on working conditions, power differentials in clinical settings, health inequities, and planetary health concerns. As a result, it's important to identify what is being resisted, and what is the purpose of the resistance carried out. In whatever way resistance is referenced in nursing, outright or not, it is our contention that it's in response to the same underlying cause, barring some local and contextual variations, which we refer to as ‘the Beast’, where the real catastrophe is societal, and is ‘existential, affective and metaphysical’. It therefore seems coherent to consider this macro catastrophe from an ontological point of view, that is, from the standpoints of ‘being’ in relation to the world, which necessarily refers to specific ways of apprehending reality. In this article, we therefore present two ontologies ‐ antagonistic in every respect, to better situate resistance in nursing in a larger ecosystem. Using the Invisible Committee's book and call to action To our friends, this is our modest contribution to celebrate resistance, to help equip fellow nurses to better organise and strategize in the face of incessant growth and too often undesirable change in healthcare.

1. Introduction/Context

The concept of resistance has been increasingly popular in recent years, whether it be in reference to geopolitical struggles and social movement, like civil uprisings or to the practice of healthcare (Essex 2020, 2023; Essex et al. 2023; Shutzberg 2019; Shaw et al. 2018; Poirier et al. 2022). Resistance studies scholars often aim to conceptualise types of acts to better categorise resistance and its different modes (Lilja and Vinthagen 2014; Lilja 2022a). In the nursing discipline, the concept of resistance has been referenced both in clinical settings, with the hallmark articles by Garon (1999; 2006) and Peter, Lunardi and Macfarlane (2004), and more recently others (Martin and Bouchard 2020; Laurin and Martin 2022; Mainey, O'mullan, and Reid‐Searl O'Mullan, and Reid‐Searl 2023a; 2023b) as well as in more philosophical reflexions of the nursing discipline, often coupled with posthumanism, postmodernism or anarchist frameworks (Laurin and Martin 2024; Dillard‐Wright, 2022; Dillard‐Wright and Jenkins 2024; Smith and Foth 2021), where resistance is a necessary response to certain social injustices and the increasing complexities facing modern societies struggling to be in symbiosis with the natural world. In certain instances, resistance in nursing is equated with resistance to change in organisations, where nurses' resistant behaviours are seen as disruptive for management to be able to enact proposed changes (DuBose and Mayo 2020, Cheraghi et al. 2023). McMillan and Perron (2021) have notably looked at change resistance through a positive lens, where nurses resisting is in fact nurses practicing moral authenticity. As the authors have suggested, through their commitment to create meaningful human connections, nurses demonstrate a moral desire to provide quality nursing care. It could be said that by deviating from ‘established practices and institutional expectations’ in rapidly changing care environments, by questioning the changes or not following standardised work processes, nurses can enact their discipline‐specific knowledge−grounded in relationality−by spending more time at the bedside (McMillan and Perron 2021).

What the different approaches used by the authors show is that resistance is a vast concept in nursing which pertains as much to working conditions, the way nurses are treated, population access to healthcare, planetary health concerns, inequities and the way power differentials in clinical settings impact decision making. Consequently, when looking at the concept of resistance, it's important to know what the target is, what is being resisted, and what is the purpose of the resistance. In whatever way resistance is referenced, outright or not, it is our contention that it's in response to the same underlying cause, barring some local and contextual variations. As nursing scholars, our travels, hospital visits, and presence at various conferences, as well as our interviews with nurses, managers, and professors, all lead us to the certainty that we are not witnessing ‘…erratic, separate, mutually unaware resistances that have yet to be linked together…’. ‘We are not contemporaries of’ scattered actions, but of a single worldwide wave of nursing resistance, within which resistant nurses communicate with each other, often imperceptibly, whether directly, through articles or even calls for special issues in journals, like this one. What we are witnessing ‘[is] a single historical sequence unfolding in a strict unity of place and time’ (Invisible Committee 2014, p. 15), whether in Canada, the United States or Australia, to name but a few, since ‘any insurrection, however localised, is a sign beyond itself, containing from the outset something global’ (ibid). For example, the experience of nurse practitioners and the difficulties encountered are similar. Australian NPs are experiencing the same power dynamics with doctors and with nursing management as what we are told by NPs in Quebec, Canada. Similarly, nurses resisting the increasing tempo of care in neoliberal institutions (Selberg 2013; Selberg et al. 2021) or physicians circumventing bureaucratic barriers for better access for their patients (Shutzberg 2019) are resisting the same social order.

However, in response to this nursing resistance, counter‐resistance is being organised simultaneously and in parallel. The protectors of the status quo are also getting organised, so that hospital administrators take a particular interest in disciplinary actions used against nurses, to stop them from speaking out or whistleblowing, by making examples of healthcare works who steal a slice of bread with peanut butter, a donut, or a slice of pizza at work (Amador 2022). In a context where human resources are so limited and working conditions so tenuous, suspending workers for such a banal reason is a sign of a much deeper problem. If it's common knowledge in today's world that the powerful plot with each other even better than the resistant communicate, then it's also true for the protectors of the status quo, who plot not only to preserve and extend their position, but also to tame nursing resistance in the most coordinated way possible. The primary characteristic of those who lead nurses currently is that they organise themselves, and in so doing, they organise nurses' lives in the most deleterious of ways, in such a way that Quebec nurses are leaving the hospital wreckage one after the other, either to go to the private sector or to leave the profession altogether (Plourde 2024).

If nursing resistance is communicating, if it is global, we must not forget that there is still ‘the greatest confusion within it’. There's a lot of confusion in our party, in the Marxian sense, of our nursing party. Despite the mounting literature and academic interest, resistance is still misunderstood in nursing practice. As much as we have observed a global response with nursing colleagues in response to shared experiences and common goals, we have also noticed how resistance is often viewed negatively in our society, and by extension, many nurses. This leads us to believe that ‘what we lack is a shared perception of the situation. Without this bond, gestures fade without trace into nothingness, lives have the texture of dreams, and uprisings end up in schoolbooks’ (Invisible Committee 2014, p.17‐18). We can even say that they sometimes literally disappear, as is the case with Madeleine Morgan's struggles, which aren't even taught to Quebec nursing students. In 1963, Nurse Morgan (2003), then head of the Nurses' Alliance of a large hospital, succeeded in convincing nearly 250 nurses to go on strike, which at the time was illegal. To get out of the illegal situation, she told the then Minister of Health, ‘If you want us to be legal, change your law!’ (p. 111). Her act of civil disobedience was motivated by nurses' solidarity and a strong desire for social justice in the face of unacceptable working conditions, including the obligation to work overtime for ‘starvation wages’ (ibid, p. 78). Significant gains in nurses' working conditions were possible not only at the hospital concerned by the strike, but also in most Quebec hospital institutions of the time (Martin 2015). If this courageous and effective act has largely been forgotten or ignored in Quebec's nursing history, at a time where Quebec nurses are fighting to improve their working conditions in the face of yet another healthcare restructuration, we believe it is time to strategize. In line with the Invisible Committee [le Comité invisible] (2014) − a collective and anonymous pen name who have written far left and anarchist works: Now, the Coming insurrection, and To our friends−when it comes to strategy, we have to be two steps ahead of global governance, or in our case entrepreneurial governance. It is in this spirit, like the political essay To our friends that we wish to address the feeling of hopelessness too often cited and present our modest contribution to the cause. There can be no resistance without a language that allows us to express both the conditions under which we work and the possible actions that will enable us to change the despicable way in which nurses, who are essential to life, are treated, and for that we need a mass of nurses determined to act together (ibid, p.17).

Thus, in this article, we want to share with our fellow nurses what resistance is to us, why it is necessary, and how it's currently being operationalized in healthcare. We agree with McKeown (2020) when he states we should appreciate ‘nursing radicals as a wholesome and positive force for good, with huge potential for making a difference at various degrees of scale, from the global to the everyday’ (p.1023). To get there, we will present two ways of being in the world, or ontologies, where resistance is emblematic of a care ontology, too often at odds with the way our society is structured. We wish to convey how resistance, in line with the way Essex (2023) presents it, is fundamentally hopeful and applicable to different struggles with common goals. But even with this common cause, there are local ramifications and contextual experiences. To illustrate what resistance means to us as nurses and scholars, we will use the example of Quebec's healthcare system, the way it's been changing in the last decades and the proposed changes set to go in effect at the end of this year. We will finish with a discussion centred around how to strategize resistance in healthcare, notably by using our social bonds and forming new alliances.

2. The Beast (Why Resist? To What Are We Resisting?)

The aim of this section is to describe the beast, to pave the way for us to subsequently present two competing ontologies, one based on catastrophe, the other on resistance.

Not only within the capitalist dynamic, but in all spheres of life, things are changing at a frantic pace. Whether in our personal or professional lives, we know we walk a fine line, a precarious balance between our many responsibilities and demands. We live in a world of constant upheaval, always having to produce more, do more, be more, where there are two outcomes for humans in our industrialised world: being overworked or burning out. That's not even mentioning the global problems, wars and extreme weather events that are multiplying every year. The very nature of what it means to be a human being is also changing, and if we allow these changes to unfold passively ‐ the same applies to care ‐ we can be expected to move towards an articulation of society that will be characterised by a new, permissible, and perverse form of authoritarianism (Žižek 2012). So, for the Slovenian philosopher Žižek, with whom we agree on this issue, things are already changing at a frantic pace, and this should give us the motivation to act concretely so that these changes take root in the direction we desire, in the direction nurses desire. If Žižek postulates that we are currently experiencing the end of the world as we have known it, we also believe that we are currently witnessing the end of the hospital as we have known it, and the end of nursing as we have known it. Drastic changes have occurred, are occurring and will continue to occur, and it is to be expected that these changes will occur in an even more authoritarian, arbitrary, and perverse way, since everything now seems to be allowed for hospital governance to impose its views (Martin 2015).

When considering our provincial healthcare system in Quebec, Canada, often referenced to as a wreckage or a structure on the brink of collapse, we find the Invisible Committee's (2014) analysis of capitalism producing experimental crises because they serve capitalism and in particular the tightening of neoliberal policies, an interesting comparison. As they noted, a permanent crisis prevents any actual crisis from arising (ibid, 24), where the crisis is the opening to introduce a remedy. We therefore can't consider we are witnessing a crisis of capitalism, but the triumph of crisis capitalism (ibid, 25). We believe that politicians have understood this for a long time, and that they are busy fomenting reforms that will scorch established public social intervention thus creating crises so that the population itself calls for the privatisation of our systems, a sort of domination by crisis. During the COVID‐19 pandemic in Quebec, we saw just how attractive the permanent state of exception was to our leaders, so much so that they didn't want to remove the ministerial decrees put in place to enact unilateral motions to supersede union contracts, and unions had to fight to have them rescinded once the initial state of emergency had passed. Deciding everything without democracy was exactly what Žižek had predicted 10 years earlier: the formal advent of a new form of authoritarianism but permitted in times of crisis. The crisis is over, long live the new crisis! Long live the crisis to come! Jessop (2019) likens this to a state of permanent austerity, which is “promoted in response to a ‘chronic’ crisis, real or manufactured” (97). Permanent austerity thus “becomes a major vector of the colonisation, commodification, and, eventually, financialization of everyday life” (ibid).

In Quebec, the current crisis in the health sector is being maintained in the same way, although we could say it's a context of domination by change, instead of domination by crisis. It is in this context that nurses are often at the mercy of incessant change in their workplace. Drawing on the writings of Boltanski (2009), we might associate the vagueness surrounding the exponential number of projects submitted to nurses with mechanisms of domination through change, articulated through a plurality of interventions whose effect is to disarm any form of criticism through their multiplicity. For the sociologist, these devices ‘intervene by valorising, accompanying and orienting change’, and are linked to capitalism as a form of economic organisation ‘that advocates change for its own sake as a source of energy’ (193). Drawing on the analytical potential of Boltanski's writings, we could thus assert that influential groups in the healthcare field acting within the hospital apparatus, whether from state apparatuses, professional orders, or hospital institutions, are part of a device of domination through change that subordinates the will of nursing staff to their own in a relentless quest for innovation and performance, or even just ‘doing more with less’ within care units (Martin 2015). In this sense, it's interesting to briefly look at the successive healthcare reforms since the 1990s, on the eve of yet another reform, to better illustrate this style of management, or domination by change and its effect on nurses.

In the early 1990s, in an effort to reduce costs by the restructuration of care delivery, one‐third of hospital beds were eliminated and around 6000 nurses were incited to retire early, with officials citing that there would be a lesser demand for nurses in hospitals once there were more community resources available. What ensued was a mass exodus of experienced nurses and no less pressure on hospitals since community resources weren't equipped or financed enough. In 2003, following the logic of New public management (NPM), different healthcare entities (hospitals and clinics) in a specific region of the province were merged into large structures in the hopes of improving collaboration between these establishments for a more fluid patient experience. The reality was large and unmanageable megastructures that effectively concentrated power and the lion's share of financing to hospitals, to the detriment of proximity clinics and social services (Bourque and Quesnel‐Vallée 2014). In 2015, the next reform of the Quebec health care system merged these 182 health and social service organisations into 34 megastructures of 12,000–15,000 employees, followed by extensive financial and staffing cuts to management and public health. What we now know is that these three reforms were followed by an explosion in the use of mandatory overtime, which has become less of an exception and more of a normalised management tactic, illustrative of a general tendency to want to do more with less, which has resulted in more and more work being demanded from fewer and fewer workers, and the known consequences on working conditions (Plourde 2024). The systematic use of mandatory overtime as a management tactic notably discourages full‐time employment, fuels nurse burnout and departure, and hinders retention efforts (Bae 2024; Rossignol 2017).

In addition to the aforementioned healthcare reforms we have witnessed in Quebec in the last decades, striving towards more centralised decision‐making by abolishing regional agencies and intermediate levels of management, another *new* healthcare megastructure is set to come to light, where one state agency Santé Quebec (Quebec Health) will integrate more than 325,000 employees and 1500 installations (clinics, retirement homes, hospitals etc.). Already large institutions cited as being too bureaucratically ‘heavy’ will be coalesced into an even bigger and complex apparatus, led not by a democratically elected official, but by a private sector ‘top gun’ appointed directly by the Minister of Health. An independent center, l'Institut de recherche et d'informations socioéconomiques [Institute for Socioeconomic Research and Information] (Plourde 2023) attempted to illustrate this new structure in a diagram, however they noted it was impossible to represent it in every detail, let alone a single image, since ‘the software used to build the organisation chart could not support the quantity of elements and links required to depict the agency in its entirety’. See image below:

The appointment of a CEO from the healthcare private sector to spearhead the new centralised healthcare agency, with a plethora of management specialists, the ex‐head of a nursing union and two specialist doctors on the board of director assures us that we are witnessing the ‘replacement of democratic governance by a science of optimised management’ (Goulet et al. 2014, 121). Instead of seeing public service as the embodiment of hard‐won social rights, and public servants as the guardians of those rights, entrepreneurial‐style governance ‘“will see it as a force to be tamed; the public service [will become] the mere executor of policies drawn up by central government, in the same way as if it were a service contract with, say, a for‐profit company’ (ibid, free translation). In contrast with the private healthcare system in the United States, Quebec's healthcare system is still public, but privatisation has been seeping in, threatening its very foundation. It's important to note that the management by change or by crisis we presented is appreciated and maintained because it allows structural adjustments (Invisible Committee 2014, 22) that will eventually lead to privatisation. However, what we're seeing is there's no need to privatise the system completely; on the contrary, the public system must remain in place, in particular to take care of nonpaying care and services, those with which it is difficult, if not impossible, to make a profit. In this economic climate, it's not necessary to fight for a universally private system; it's better to keep public social intervention as an ally that ensures the provision of thankless tasks. Different activities have already been outsourced to the private sector, likefamily medicine groups − private clinics funded and staffed by public funds − retirement homes, long term care homes, and private mini hospitals performing certain surgeries paid for by public funds.

More specifically in nursing, this healthcare ‘crisis’ is visible when nurses accept regular service breakdowns, involuntarily floating to other units to compensate for staff shortages, compulsory flexibility, and the ever‐pervasive mandatory overtime. The problem is actually a solution to the triumph of crisis capitalism, which again and again proposes rationalising solutions involving capital gains, and provoking crises that pay off. One of the hallmarks for the new healthcare structure, and the biggest point of contention in the latest nursing union negotiations is increased mobility, whereby nurses are considered even more a flexible, interchangeable commodity, where they could be asked to work up to 35 km from their current place of work, effectively making more nurses ‘float’, irrespective of their expertise or desire to work in a specific unit. These proposed changes are sure to continue encouraging nurses to flee their sector or even the profession, leaving their colleagues to work more, while HR costs are cut since there are less workers remaining, which is one of the hallmarks of NPM (Plourde 2024). To counter this trend, researchers in the last decades have notably suggested offering nurses more flexible schedules, promoting their institutional loyalty, and offering them better salaries (Aiken et al. 2001; Aiken, 2002; Laberge and Montmarquette 2009). Behind these solutions, which appear to be deployed for the good of nurses, a certain instrumentalization of nurses is sometimes apparent, with the sole aim of increasing productivity. Laberge and Montmarquette (2009) insist, for example, on the importance of increasing nurses' salaries, for a very specific reason: ‘to encourage them to work more’ (30), even if they have to work more to compensate for the colleagues who left and were never replaced (Martin 2015). Even if researchers and policymakers are focusing more on the structural and organisational factors affecting the workplace environment, most proposed strategies to strengthen the nursing workforce are still aimed at individual nurses (Virkstis et al. 2022; Buerhaus et al. 2023).

In the face of this seemingly untameable beast which thrives on crisis and perpetual change, there is a feeling that things are changing not in the direction we want, often bringing fatalist feelings that nothing can be done. Žižek (2012) has pointed out that he is regularly confronted with similar questions relating to pessimistic representations of the current state of the world in which we live, and whether it is possible to change the course of events. As Freitag (1998) skillfully pointed out decades ago:

“we are in a particular social reality, unique in history, where we are no longer required to take our place in an already established practical and symbolic order, to be faithful to substantially defined values, or even to strive towards the realisation of an ideal, but only to participate in the general movement and to adapt ourselves to the change that comes upon us of its own accord, mechanically, as an impersonal inevitability, independently of any finality that might be assigned to our individual and collective existence” (7, free translation).

In the case of our provincial healthcare system, citizens and healthcare workers alike have come to accept reforms and incessant change from above as being normal and unchangeable. A sensible question to ask is: how do we build from scratch then, from nothing? We believe that collective inertia can be challenged, but to achieve this, we have to shift the pervasive perspective that everything needs to start from scratch. The healthcare system is already there and in place, we can change it through our social bonds, through alliances and through acts of resistance. It's difficult to imagine, and the first step is to see it, as the Invisible Committee (2014) explains:

To move away from the paradigm of the government is to start from the opposite hypothesis in politics. There is no void, everything is inhabited, and each of us is the place of passage and knotting of a quantity of affects, lineages, history, meanings and material flows that go beyond us. The world doesn't surround us, it passes through us. What we inhabit inhabits us. What surrounds us constitutes us. We do not belong to ourselves. We are always already disseminated in everything to which we link ourselves. It's not a question of creating a void from which we can finally grasp all that escapes us, but of learning to better inhabit what's there ‐ which implies being able to perceive it, and that's no easy task for the belligerent children of democracy. Perceiving a world populated not by things, but by force, not by subjects, but by power, not by bodies, but by links. It is through their plenitude that forms of life complete destitution. Here, subtraction is affirmation, and affirmation is part of the attack (Comité invisible, 2014, 79, free translation)

In the following section, we will demonstrate two competing ontologies, to better understand how resistance is emblematic of a political ontology of resistance, before discussing how it can be operationalized to favour positive outcomes, in the way nurses wish.

3. Two Clashing Ontologies

If there's the beast we've just described, the real catastrophe is societal, and is ‘existential, affective and metaphysical’ (Invisible Committee 2014, 29). It therefore seems coherent to consider this macro catastrophe from an ontological point of view, that is, from the standpoints of ‘being’ in relation to the world, which necessarily refers to specific ways of apprehending reality. In this case, we're talking about two ontologies ‐ antagonistic in every respect.

3.1. A Quantitative Ontology

At first glance, the catastrophe to which we allude lies in the strangeness of the Western being's relationship to the world, an ontological relationship perverted on all sides, which it seems important to appreciate starting from an original relationship that will come to mark all the relationships and relations that this being will have, in a rationality diverted from its ends ‐ namely that this being makes itself ‘master and possessor of nature’. While Descartes, in concluding his Discourse on Method, literally called for this project of mastery and possession of nature by reason and science, Max Horkheimer and Theodor W. Adorno (Horkheimer 1996; Horkheimer and Adorno 1974) challenged this project head‐on, pointing out that this domination of nature can only be achieved through the subjugation of a considerable number of people by a minority of exploiters (Krebs & Giovannetti, 1996). This is what they call the instrumentalization of reason, a process that has taken place over the course of history, a technical/instrumental rationality that leads the Invisible Committee (2014) to postulate that catastrophe is well and truly upon us, and has been for ages, and that in fact, our civilisation ‐ that of human beings ‐ died a long time ago.

Within this rationality, the family, education, delinquency, and unemployment, but also collective action and resistance, become objects of economic reasoning and quantification. This is how contemporaries such as Gary Becker come to formulate theories, such as the theory of the family, that reflects in every respect our absence from the world ‐ today's dominant ontological nothingness. In this theoretical scenario, the family is literally apprehended as a firm, a private enterprise using a certain volume of resources to produce ‘goods’ and other ‘commodities’ such as children, prestige, skills, and so forth (Dardot and Laval 2010, 298).

This ontological divorcee from the world is a divorcee from existence, an affective divorcee from life. A divorcee from the ‘others’, of course, but also necessarily a divorcee of the Western being from himself, from his own vulnerability, from all that reality comprises that is unstable, questionable, aesthetic, beautiful, imperfect, and unquantifiable. The Invisible Committee identifies this specific ontology with a ‘quantified self’, which refers to a quantitative ontology that controls, measures and optimises every gesture of this increasingly inhuman humanity, every affect of those who make it up, which is less and less affected by anything. Cybernetics occupies a central place in the construction and maintenance of this zombified, non‐existent relationship to the world, which makes being ‘a system being inscribed in a complex set of information systems, the seat of self‐organising ¹ […] and communication processes’ (The Invisible Committee 2014, 112).

“I” share my geolocation, my mood, my opinions, my account of what I saw today that was incredible or incredibly banal. I run, I immediately share my route, my time, my performances and their self‐evaluation. I'm constantly posting photos of my vacations, my parties, my riots, my colleagues, what I'm going to eat and what I'm going to fuck. I look like I'm doing nothing, yet I'm constantly producing data. […] My daily life, as a stock of information, remains permanently valuable. I'm constantly improving the algorithm [that will control me later on] (Invisible Committee 2014, p. 114, free translation).

For the first time in history, we can precisely map the conduct of the masses, including nurses and all healthcare professionals, right down to their daily lives, their innermost desires, their actions and plans for resistance. If cybernetics is thus the producer of its own (in)nhumanity ‐ an (in)humanity inseparable from its technological environment and the plethora of devices that constitute it ‐ it is also oversaturated by information acting as background noise, constantly hammering home the inessential (Deneault 2010).

This is the teleological ambition of the overclass and the puppets it has put in place to govern us: to create an absence from the world that promotes the emancipation of economic logic from all practical humanity (Freitag and Pineault, 2000). And in a pragmatic way, to manage the unpredictable, to govern the ungovernable by acting directly on the virtual to structure the possible, and in particular resistance, by confining it to the very heart of the status quo, but also by producing the counterinsurgency of its protectors in an intensive management of perceptions.

3.2. A Political Ontology of Resistance

Another way of apprehending reality, on the margin of the absence from the world we have just demonstrated, must necessarily involve resistors who, it is important to emphasise, are both ‘the stake and the target of the permanent offensive’ of the beast, as a mode of government (Invisible Committee 2014, p. 161). To ‘be’ fully, to inhabit our world fully ‐ these are simple words that can characterise a political ontology in the sense of an expanded living together of fundamentally relational beings that many dispositifs have and continue to individualise.

We're talking here about reflecting on a political ontology in which the subject, if we're talking about the subject at all, is a subject in the making, which must necessarily invest itself in scenes of dissensus (Rancière), resistance (Foucault), deconstruction (Derrida), so as to (re)access its original power of life, a power “that makes us a subject capable of life” (Pierron 2023, 24). Faced with the screen that has been set up between beings and the world, hammering home the ideal plan of placing man under the rule of man, a screen that limits relations between beings and that conceals the image of suffering and death of the children who have dug day and night extracting the minerals needed to keep it turned on, there is no choice but to adopt a posture of being in the world that makes the invisible visible, the inaudible audible and the unspeakable speakable (Martin et al. 2018)

So, no one is locked into a social destiny, and it remains possible to undermine the digital order and the increasing disembodiment of the world it engenders, through political experimentation that is grounded in theory and relies in particular on the insight and strategic resistance of ordinary people. The beast is strategic, and the catastrophe it has engendered is the result of this strategy ‐ to continue to be, we must be strategic. Nurses, on the other hand, are living forces in the community, and they must realise this if they are to break through and deepen it as much as possible, and they must do so ‘with’ citizens, not above them as experts ‐ ‘because citizens are the key’ (Invisible Committee 2014, 152), the key to a new ontology, the key to symbiotic and supported resistance, the key to an insurrectionary democracy that will give us back our lives.

A nurse who isn't constantly critical, who doesn't transgress the norms that confine her, who doesn't denounce the professional hierarchies that constantly belittle her, who isn't able to inform the public about the failings of the system and of our healthcare system in particular ‐ a nurse who doesn't resist ‐ doesn't deconstruct the normative assignments and associated constraints, doesn't have access to her original life power. She wouldn't have access to what she should be ‐ she wouldn't ‘be’, but rather be the object of the beast, its creation, but also, in a way, the one who produces it. This type of ‘Other’ thinking, decentring, defragmenting, deconstructing and de‐hierarchising, produces an open, plural structure, in assembly with the citizen and always on the move, which delimits and calls into question various established norms, such as so‐called universal, historical and ideological truths, the positioning of the human being in reality and in particular in relation to devices and systems ‐ living or otherwise – (Laurin and Martin 2024) and this, on the margin of the quantitative ontology we've just described.

The original and decisive gesture that is the antecedent of this new nursing presence in the world, an authentic resistant presence that is fully involved in the care of our own group and the citizen, is a notch ahead of the state of the general nursing movement. This posture certainly breaks with the hospital status quo, but also with the status quo of resistance itself. A sensibility is a prerequisite for this insurrection of the senses, a sensibility nourished in particular by historical knowledge of the situation and a certain conscientiousness that helps enormously in gaining the necessary intuition (Invisible Committee 2014, 148).

If, teleologically speaking, the quantitative ontology we described earlier aims to create an abyss of being which distances us ‘from bonds of attention, real relationships, care and associated vulnerable complicities’ (Pierron 2023, 26), the political ontology of resistance aims ‘to rebuild a communal ethos’ (Invisible Committee 2014, 88) ready to (re)welcome the unanticipated and the resistance necessary to rebuild life.

3.3. Resistance for Us/The Purpose of Resistance

Considering what we have previously described, it becomes apparent that resistance is inherent to life. If there are many definitions of resistance in social sciences and more specifically in healthcare, our goal here is not to examine each one, but to share the ideas we have been using to structure our thinking around resistance in nursing practice, notably through the works of the philosophers Durand and Muller, as described by Martin (2015).

To begin, political action is defined as a vast concept which encompasses the moral objectives that underpin it as well as the means deployed to achieve these goals, namely to counter injustices and increase the chances to be free. Several terms are deemed synonymous to political action: dissidence, opposition, or resistance. Notions relating to political action and resistance are not simple concepts to deconstruct, considering the varying ways in which authors define them. The philosophers Durand and Muller provide a solid theoretical foundation for understanding these concepts regarding nursing practice. In this section, we will consider resistance and political action as synonymous.

Resistance must serve a cause, or political and social claims like the lack of democratic and egalitarian participation in institutions, or to oppose the domination of an economic system which sacrifices the common good, in a bid for social justice. For Muller, it should seek to transform current power struggles to imagine a future with radically different power structures. He describes oppression as submission to authority figures established within a collectivity. According to Muller (1981), strategies associated with political actions can be delineated into two categories: direct actions of non‐cooperation and direct acts of intervention. These non‐violent strategies include dialogue, inviting leaders to cease injustices, appealing to public opinion, bringing the conflict to the media, and all collective acts such as petitions, walks, boycotts or strikes. The basis for these actions lies in the nature of injustices which are deeply embedded in societal structures, benefiting from the complacent cooperation of the members of these societies. If an authority acts wrongly, the oppressed still participates in these actions by cooperating and allowing them to continue. The oppressed should then stop being cooperative with these perceived injustices, to not be responsible for the damage which can occur. By withdrawing their cooperation, the oppressed can demonstrate their will to stand up against an oppressing force, since silence and complacency is a stance. This shifts existing power structures and can even make the oppressor powerless. To be effective with these strategies, the author insists on the importance of collective strategies of non‐cooperation, as opposed to individual actions, to rally groups together to shift power in their favour and be as effective as possible (Martin 2015).

However, when these non‐violent acts fail, direct acts such as sit‐ins and civil disobedience can then be deployed. Civil disobedience is founded on the traditional theory of democracy where social order can only be maintained by obeying laws, which represent the majority opinion in a society. Without order there would be chaos. However, if the law is not in accordance with expectations of justice and liberty or workers' rights and is followed by an abuse of power from authorities, civil disobedience can be the best way to demand respect of one's individual rights in accordance with moral principles. This is a de facto collective action to publicly express solidarity in response to injustices perpetrated by oppressive forces (Martin 2015).

Durand (2004) expresses similar theories as Muller, however he highlights individual actions in situations of conscientious objections where a person can refuse to accomplish an act imposed by law or an institutional rule that offends their personal convictions, whether of moral, political or religious nature. He gives the classic example of a nurse who can be relieved of her duty to participate in abortions or medical aid in dying. Conscientious objections are for him both subjective and collective, by seeking to respect one's personal conscience while seeking the common good. There is a causal link between the two, where he considers that showcasing personal convictions by means of conscientious objection can incite others to do the same and have collective political outcomes. Conscientious objections can be applied to all spheres of human activity, for every unjust or immoral act imposed by a person, a political or social system like an institution or an employer that goes against personal ethical convictions. Durand adds that the motives behind these acts of resistance are not always easy to identify and that dissidence is not systematically an organised movement with a clear doctrine. He likens certain forms of dissidence to small isolated pockets which can sometimes cause chain reactions. Political action can then be effective without being part of an organised movement following a straight trajectory. Additionally, according to these authors there is no doubt political action can't be improvised, it requires a plan, established strategies and tactics. Obstacles encountered during political acts come from the adversary and their opposing power relations. To be prepared, Muller insists on the importance of understanding the inhuman situation, which is perpetrated by the injustice, by knowing the facts, doing a study or keeping a folder of past denunciations, to better understand how and why the injustice appeared and is perpetuated. It is also important to understand the political and economic forces at play in this dynamic, to analyse power structures and the struggles between them. Durand (2004) suggests personal reflexion, reading and discussion between peers as means to form one's conscience by being exposed to different subjective points of view (Martin 2015).

3.4. Typologies of Resistance

When looking at how Durand and Muller theorised resistance or political actions, we can clearly see the individual/collective and hidden/overt dichotomies. In The definition of resistance, Lilja (2022a) has theorised a new nomenclature for resistance that better accounts for the variations in manifestations of resistance, namely avoidance resistance, confrontational resistance, and constructive resistance ‐ which we will describe briefly.

Avoidance resistance, which relies on everyday, covert resistance, as described by JScott, can be either individually dispersed or collectively organised. According to Baaz (2021), we need to reconsider the imaginary line drawn between individual and collective forms of resistance. Indeed, a multitude of ordinary or banal acts are practiced on a daily basis in the family, the workplace or the community in reaction to relations of power (Kasbari and Vinthagen 2020). Confrontational resistance, on the other hand, directly opposes the power, rules and laws of various institutions through noncooperation, civil disobedience and various interventions such as demonstrations, strikes or occupations (Baaz 2021). Finally, constructive resistance goes beyond the conception of oppositional resistance to instead propose alternative discourses or social institutions (Vinthagen and Lilja 2007; Sorensen 2016; Lilja 2021; Rigby 2021). This resistance is therefore more than a binary opposition to power; it must be as mobile and productive as power to be effective (Malmvig 2016). We can therefore see the primary role of resistance, which can enable creative responses as well as new forms of power (Checchi 2021). This latter type of resistance can, however, include more traditional elements such as civil disobedience or demonstrations, so resistance can be both constructive and nonconstructive (Sorensen 2016; Lilja 2022a).

Another question posed by Lilja (2022a) is how different forms of resistance come together, so as to conceive of mobilisations that cut across collective as well as individual and everyday actions (Lilja and Baaz 2021; Lilja 2022b). According to the Foucauldian conception, different acts of resistance are linked when they respond to the same power relations in a particular historical and social context, and thus collectively confront power, even if they take place in an unorganised way (Foucault 1980). There is also a possible cumulative effect at the political level when several individuals carry out small‐scale acts of resistance (Bayat 2013; Baaz et al. 2017; Scott 1989). Several nurses, individually or in small groups, resisting in their respective workplaces can have a cumulative effect on a local and even global scale. We will look at this more in detail in the following section.

3.5. Creating and Growing “Living Powers”

If we accept as suggested that resistance is ontologically inherent to life, to existing, then we have to consider how that applies to nursing, especially in the context of domination by change, which thrives on preventing partisans who are on the verge of action from becoming active partisans. In a rigid world which prioritises quantifiable data and incessant growth, looking at that unstable and uncertain inhabited world through the prism of care and resistance, is a form of resistance. For Vaillancourt (2023), the slow morphing of neo‐liberalism and its expressions in our social fabric is a sign that this process is not a crisis, but rather ‘a normal, gradual shift, generating its share of disasters, but also raising a few hopes, a transformation whose onset is impossible to pin down precisely in time, and which is still in its infancy’ (21). This presupposes that to act strategically in the face of the ‘war’ that's out there, that's constantly changing, means “opening up to the situation, understanding it inwardly, grasping the power relations that shape it, the polarities that work it. Whether or not an action is revolutionary depends on the meaning it takes on in contact with the world' (Invisible Committee 2014147). Only then can we organise within the cracks of the system, to change our material circumstances in the way we would like it to evolve (Springer 2016; Mckeown 2020). Resistance is effectively saying and acting on the fact that things can be done differently. But how can this effectively be done?

We believe we must first address the need to have a common language. We should first and foremost understand resistance as positive in nursing, and we see that it's not necessarily the case yet, despite the mounting evidence and interest surrounding the concept. As we saw in the last section, resistance can be individual or collective, and it can be categorised as avoidance, confrontational and constructive resistance (Lilja 2022a). The following empirical examples demonstrate how nursing resistance in clinical settings is already being recognised, yet we suspect it is severely understudied and a more common occurrence than we are meant to believe.

4. Resistance in Empirical Projects in Nursing

4.1. Nursing in the Emergency Department (ED)

In her thesis project entitled: The Politics of Nursing‐ The Neoliberal Transformation of Nursing Emergency Care, Lauzier (2023) used an institutional ethnography approach to explore the organisation of ED nurses after decades of restructuration and budget cuts. She documented forms of active resistance when the ED initially became a Lean management project, where ‘nurses moved charts so patients with a higher acuity were seen first, or they refused to hand patients buzzers to come back for results […]’ (227). She found that even with the advent of new software which is used to track the pace of clinical activities, nurses were still resistant to neoliberal process changes, albeit in a more passive manner. She found that experienced nurses withdrew from workplace change committees, which are instrumental in implementing these new neoliberal processes in the ED. To this point, Žižek (2008) mentioned that it's important to question the possibility that the energies deployed will simply reproduce the dominant discourse, as would be the case when nurses invest time and energy in committees that only serve to reinforce neoliberal policies. In such situations, Žižek points out that it is sometimes preferable to do nothing, rather than try to act in the wrong way to transform the status quo. Refusing to participate in these committees can be seen as practicing moral authenticity, when nurses see the proposed changes as being detrimental to quality patient care (McMillan and Perron 2021).

4.2. Abortion Care

Mainey, O'mullan, and Reid‐Searl O'Mullan and Reid‐Searl (2023a; 2023b) looked at Australian nurses' and midwives' experience of providing abortion care to people victimised by gender‐based violence and found that on the individual level, participants bent or broke the law when they encountered barriers to person‐centred abortion care, even when they felt professionally compromised, since providing patient‐centred care was their priority. The authors found that when participants were resolved to help, they first had to network with like‐minded people who were committed to undoing the barriers and increasing support to women who need to undergo abortions. Once that network was established, “participants commenced transgressing. Due to the time pressures of abortion, the focus of most clinician's transgressive practice was misleading the system to get the person to the abortion” (2023b, 1336).

4.3. Barriers to Resistance

These acts, at both the individual and collective level, use both avoidance tactics and constructive resistance, where nurses are actively seeking solutions to identified problems. However, despite knowing that resistance exists in nursing, there are identified barriers. Notably, studies show that nurse differentiation is a deterrent to nursing solidarity for a common cause, and nurses reproducing the status quo means that nurses can also be complicit in issues their colleagues are trying to fight. As Lauzier (2023) noted in her study of ED nurses: ‘[they] are neoliberal agents, enacting a neoliberal rationale at the bedside with each action. The neoliberal rationale is not only deeply embedded in nurses' professional identity, but it also appears as a natural construct of their environment. Shocking proof of this was the fact that all interview participants could not imagine another way to deliver care in the ED, all they could see was the need for more staff and more space, highlighting how powerful and difficult it is to resist this rationale’ (p. 234). Moreover, to implement new processes in the ED, the collaboration of experienced nurses was necessary to operationalise them. As Lauzier (2023) mentioned, nurses were responsible for the transformations that led to work intensification and staffing shortages. In the context of nursing in Swedish hospitals influenced by NPM practices, Selberg (2013) also noted how: ‘work intensification is in part an outcome of ideals put forth from within the nursing profession […] NPM implementation on the shopfloor is controlled, maintained, and developed by nurses in management positions. New career paths for nurses open up for increased internal differentiation of the nursing collective, which also contributes to complicating the formation of resistance strategies’ (p. 29).

4.4. On Strategy

What these examples show us is that resistance is global, resistance is already happening, what's needed is to make a cartography of power relations in a specific system, with local actors and specific problems, to come up with a plan, a strategy and tactics. As the Invisible Committee (2014) tells us: ‘everything is local, including the global; we just have to localise it. Neoliberal hegemony stems precisely from the fact that it floats in the air, spreads through innumerable, often unseen channels, and seems invincible because it cannot be pinpointed’ (192). They go on to mention that: ‘a movement lives only through the series of shifts it makes over time. At any given moment, therefore, there is a certain gap between its state and its potential. If it stops moving, if it leaves its potential unrealised, it dies. The decisive gesture is the one that is one notch ahead of the state of movement, and which, breaking with the status quo, opens up access to its own potential. This gesture, which may be to occupy, to break, to strike or simply to speak the truth, is decided by the state of the movement’ (ibid, 147‐148). That is to say that: ‘if an accumulation of gestures is not enough to make a strategy, it's because there is no such thing as a gesture in the absolute. A gesture is revolutionary not because of its content, but because of the chain of effects it generates. It is the situation that determines the meaning of the act, not the intention of the perpetrators’ (ibid, 147) This collective response then offers an easy target and can even take on the traits of its adversary, which is why it's important to put in place strategies that will prevent resistance from turning into the hands of the adversary. Having a place where colleagues can be inspired by each other, like social media platforms is a promising avenue for organising resistance tactics to what's happening both locally and globally.

In this sense, in 2020 a website called ‘Je dénonce’[I denounce] from the largest nursing union in Quebec was set up to collect testimonials from nursing and non‐healthcare staff, as well as members of the public, to make them rapidly available to the public and the media, to inform them of the issues relating to pandemic management in the healthcare network (Perron et al. 2020). As Gagnon et al. (2022) pointed out, the Ministry of Health and Social Services promptly responded with the creation of a new email box called ‘On vous écoute’ [We are listening] to encourage health care workers to report issues directly to the Ministry, in response to the overwhelming success of the union's platform, diverting attention from it. This goes to show how quickly resistant strategies can be recaptured to be used to the advantage of opposing forces. In addition, it is worth noting how monitoring of nurses is possible even outside the hospital setting with sites like Facebook or Instagram. Nursing unions like the Fédération interprofessionelle du Québec have warned nurses not to ‘like’ their healthcare establishment's Facebook page, as this would enable bureaucratic monitoring that could harm them. As we noted when presenting the quantitative ontology, everything personal is susceptible to be shared with others through social media, enabling bureaucratic surveillance to be taken out of the hospital system, which opens up the most intimate parts of nurses to institutional governance, and more often than not, can harm them for purposes of control.

Much like healthcare needs to be decentralised to be effective, so too do our resistance tactics. When we question the importance of social bonds, we can't forget the importance of possible alliances with other groups, as ways of strategizing, as the Invisible Committee (2014) tells us. For nurses, seeking out other healthcare workers and what their experiences are in the face of the same “beast” can be useful to form a fragmented cartography, depriving hostile forces of any decisive target. We will now present some examples of localised resistance tactics in different clinical settings from other healthcare workers, as proof of possible alliances in the face of similar struggles.

5. Resistance with Other Healthcare Professionals

Shutzberg (2019) looked at how Swedish general practitioners ‘doctored‘ sickness certificates for their patients, in order for them to be approved by the Swedish Social Security Agency. Participants in his study referred to terms such as ‘embellishment‘, ‘uglifying’, ‘exaggerations’, and used different techniques like ‘exaggeration, quasi‐quantification, omission, depersonalisation of the patient voice, adjustment of disease progression, buzzwords, communication off the record and production of redundant somatic data’. Working around the rigid guidelines imposed by a centralised government agency by filling out paperwork in a way it will be accepted can be seen as resistance to the rigid framework they are forced to work in.

Social workers in Quebec also use many means of passive resistance to the bureaucratic changes which constrain their professional practice (Roy, Leblanc‐Huard, and Grenier 2024). They use passive forms of resistance, like refusing to respect allotted time for certain tasks, taking longer breaks, or using work time to work on personal tasks as protest (Aronson and Sammon 2000; Thunman 2016; Baines, van den Broek 2017). More overt protest strategies have also been described, like rejecting practice guides or guidelines if they deem them inappropriate, unnecessary, or impossible to achieve (Evans 2011; Saario 2012; Thunman 2016). Aronson and Sammon (2000) also mention that some social workers use supervision of trainees to empower them to resist standardisation of practice. Some social workers also attempt to turn the logic of NPM against itself by using their accountability data to advocate for social change or to influence public policy in the interests of vulnerable or marginalised populations (Lavee et al. 2018). On a more informal level, exchanges between colleagues and the use of social networks seem to be invaluable ways of making up for the lack of institutional support (Aronson and Sammon 2000), much like the use of a Facebook group ‘Infirmières en mouvement’ where nurses share their realities and attempt to organise themselves and strategize.

What these examples have in common is the predominance of individual actions by healthcare workers, even if as Essex (2023) points out ‘resistance speaks to more than individual acts, but failures in structures and systems that should support and enable the delivery of healthcare. It shows how systems, policy or procedure may be deeply flawed or inadequate, where there otherwise may seem to be little dissent’ (762). Whether speaking of access to abortion care, ED nursing, or any healthcare work in a neoliberal system, individual or even collective acts of resistance in clinical settings speak to larger issues. Issues like neoliberal policies with their culture of measure and indicators, centralised decision making, funding allocations which prioritise hospital‐centred tertiary care to the detriment of preventive and c,12ommunity care, social issues surrounding the acceptability of certain medical acts, or the bureaucratic system which imposes targets and monitors productivity.

Far from us to advocate for one form or another of resistance, since we know avoidance resistance, in the form of part‐time work for nurses, has been recognised as a frequent occurrence (Selberg et al. 2021; Martin and Bouchard 2020), we also believe that silence is also a form of acceptance. There's an all too pervasive discourse of a generalised nursing political apathy, even if by their sheer number and indispensable position in healthcare around the world (White 2023), nurses are powerful agents who can learn to make use of their social bonds to better resist − for more recognition, for better working conditions, and by extension a stronger healthcare system for their communities. Starting from the base, by convincing close friends and family members of their cause, can be an important starting ground to convince at the level of the government, like during union negotiations. Nurses must thus become living forces in the community, they are already on the right track, if they are to make headway with citizens by their side.

If we come back to the question of Quebec's healthcare system on the eve of yet another restructuration, we wonder what it would look like if different healthcare professionals united to resist the proposed changes in their workplace, if they could convince citizens to stand with them and defend a public and democratically run healthcare system which respects its healthcare workers and answers citizen's needs on a small scale.

6. Conclusion

After looking more in depth at the beast, at two different ontologies and how resistance is emblematic of the second ontology, it is our hope that readers, fellow nurses, will see hope in this way of seeing the world, where we don't have to unconditionally accept the incessant growth if the way it's evolving is not mutually desirable. We presented some tactics from the Invisible Committee (2014), including the importance of developing new social bonds, of forming alliances and of always being one step ahead, highlighting the need not only to act, but especially to strategize. We want to leave readers with this call to action from the Invisible Committee (2014) which aptly sums up the importance of action and resistance, which isn't some abstract far‐away concept, but a tangible everyday occurrence:

There's no social sky above our heads, only us and all the bonds, friendships, intimacies, proximities and effective distances we experience. There are only “us”, eminently situated powers and their capacity to extend their ramifications within the social corpse that is constantly decomposing and recomposing. A swarming of worlds, a world made up of a whole host of worlds, and thus traversed by conflicts between them, attractions and repulsions. To build a world is to elaborate an order, to give a place or not, to each thing, to each being, to each inclination, and to think about this place, to change it if necessary. (p.195‐196)

It is therefore only up to us to change the worlds around us, since ‘what is real is what resists’ (Invisible Committee 2014, 197).

Conflicts of Interet

The authors declare no conflict of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.