This site is intended for health professionals only

Unhealthy competition?

Dr Raj Persaud
Consultant Psychiatrist
The Maudsley Hospital,

Nurses work hard and conscientiously for their employers, but how much is the NHS exploiting them without them realising it?
The old Marxist analysis of the capitalist salary strategy for toiling workers "down t'mill" was that the successful mill owner drove workers to effort that maximised efficiency. Pragmatically employees were thus always on the verge of starvation, but yet paid just enough to keep them going.
It didn't make financial sense to pay them so badly that they couldn't work because they were too physically exhausted to get out of bed, but it also wasn't economically sensible to remunerate them any better than was necessary to keep them turning up at the mill each morning ready to give their all yet again.
We may have thought this nightmare scenario had no relevance to today's workplace and was merely now a distant Victorian memory, except that an academic economist at Bowling Green State University, Ohio, has recently published a mathematical model of modern-day salaried professions that suggests that old Marxist analysis of how we get rewarded for our efforts applies today in any competitive work structure where promotion happens to the lucky few - such as nursing.
This new mathematical model suggests that those working in nursing and medicine, and similar professions, toil on the verge of depression or burnout, much as wage workers toiled on the edge of starvation.
Alan Day Haight, the economist advocating this new mathematical model's application to financial services workers, points out that promotion-track workers in various professions, such as nursing and medicine, are motivated largely by their hopes for advancement to some senior post. Since they basically accept hope as a means of payment, they are convenient targets for "surplus extraction". In other words, senior partners in the firm get much more work out of them than juniors are strictly paid for, because the juniors are largely being paid for in "hope". The hope that one day all this surplus effort will result in promotion to a senior role.
Haight reminds us that, in a typical office, the senior professionals benefit financially from the long hours put in by juniors. A little rivalry enhances the diligence of the younger professionals, so the partners have an incentive to hire more than one junior professional for each anticipated promotion. But how much rivalry among the underlings is enough, from a partner's point of view, in order to extract maximum surplus effort from them?
The new mathematical model suggests an answer that may seem dismally realistic to many promotion-track workers: there is enough rivalry only when the junior professionals are suffering from so much promotion anxiety that they are to some extent always on the verge of "giving up" or "burning out".
If any associate were to put in less than the minimum hours, he or she would be summarily dismissed (and easily replaced with someone from the large pool of applicants) before coming up for promotion. In practice, each associate typically works more than the bare minimum to impress and thus gain promotion. This prime motivator means they are now working harder than necessary just to earn their basic salary.
Haight notes that maximising hope is the key art for the senior managers, but this hope must also be hopeless to some extent - more people must work hard on the assumption they are going to get promoted than is actually going to be the case.
Haight concludes: "If staff burnout did not exist, it would be necessary to invent it." Competitive juniors give more surplus effort if each individual is so stressed that they are on the verge of giving up. Nurses should become more aware of whether they are working for actual payment that they receive - or are they working for and being paid for in hope, and should they be more aware, if they want to avoid being exploited, of when the hope is realistic or just hopeless?