the role of ritualistic ceremonial in removing barriers between subcultures in the national health...

NURSING AND HEALTH CARE MANAGEMENT ISSUES

The role of ritualistic ceremonial in removing barriers between

subcultures in the National Health Service

Ian Brooks BA MBA

Head of School of Business and Management, University College Northampton, Northampton, UK

and Reva Berman Brown PhD

Head of Business School Research Centre, Director of Doctoral Programmes, Professor of Management Research, Oxford

Brookes University, Oxford, UK

Submitted for publication 26 July 2001

Accepted for publication 19 February 2002

� 2002 Blackwell Science Ltd 341

Correspondence:

Reva Brown,

Business School,

Oxford Brookes University,

Wheatley,

Oxford OX33 1HX,

UK.

E-mail: [email protected]

B R O O K S I . & B R O W N R . B ( 2 0 0 2 )B R O O K S I . & B R O W N R . B . (2 00 2 ) Journal of Advanced Nursing 38(4), 341–352

The role of ritualistic ceremonial in removing barriers between subcultures in the

National Health Service

Background. One of the ways in which it is possible to achieve successful

organizational change is through the elimination of those ceremonies that reinforce

or preserve the negative aspects of professional and work group autonomy, thus

maintaining the barriers between subcultures. Conversely, the encouraging of

ceremonies which reinforce positive aspects is likely to achieve more flexible, team-

orientated changes.

Aim. The paper considers those ceremonies, which perpetuate barriers in a

National Health Service (NHS) Trust, and explores new ceremonies which may

question, weaken or eliminate current dysfunctional practices.

Design. Our research approach was mainly phenomenological, as we wished to

elicit the symbolic significance of organizational routines. The primary source of

data was spoken language. The findings are based on purposive sampling

of informants by means of semi-structured interview and observation. Other types

of information were also collected, including business plans, reports and brochures.

Informants included the Chief Executive and four Board members, three consult-

ants, the director of nursing and midwifery, 10 middle managers and eight junior,

nonmedical and nonmanagerial employees.

Findings. Two broad bands of ceremonies have been identified – those which

preserve the existing norms and autonomy of professional and worker groups,

which we have named Ceremonies of Preservation, and those which encourage

change, which we have called Ceremonies of Change. Considerable data are

provided to help to ‘tell the story’.

Conclusion. The paper argues that attention to ceremonial in the wider change

process may facilitate the desired, specific change or changes in practice. It suggests

that changes which confront unnecessary demarcation, but which do not undermine

professional integrity, can create real benefits for NHS hospitals.

Keywords: nursing, subcultures, ritual and ceremonial, National Health Service,

change, symbol, demarcation, organizational culture

Introduction

Attempts have been made within the British National Health

Service (NHS) to reduce the negative consequences of

demarcation and to develop an appropriate skills-mix of

team orientated, flexible employees (Schofield 1996, Depart-

ment of Health [DoH] 2000). Such changes often aim to

achieve an appropriate match between the skill levels of

personnel and the demands of the task and, in so doing, to

maximize both value for money and effectiveness. For

example, many tasks undertaken by skilled professionals

could be (and are beginning to be) conducted by less-skilled

personnel, at lower cost – the serving of food to patients, and

the making of beds have been progressively devolved to

nursing assistants, leaving the nurses, who used to do these

tasks, free to undertake those tasks which need their profes-

sional (rather than domestic) skills. Similarly, many tasks

conducted by doctors could be (and are being) managed by

trained and experienced nurse practitioners.

This paper reports on research investigating the authors’

view that (a) many of the negative aspects of work group and

professional autonomy are preserved by organizational cere-

monial, and that (b) if these ceremonies can be changed, the

resultant positive breakthroughs may feed into a wider

organizational change. The site chosen to explore these views

was General Hospital (GH), a hospital Trust based in the

English East Midlands; the focus was the changes being made

there; and the main aim of the research was to consider the

way in which the manipulation of ceremonial could facilitate

change, with the special intention of identifying those

ceremonies that maintain barriers between the Trust’s

subcultures. It was hoped that new ceremonies could be

recommended that would facilitate the desired changes in the

Trust.

We present our argument in the following order: In the first

section, the wider context of change in the NHS is discussed.

The next section describes GH, the general hospital which

was the site of the research, and the context of the changes

being made there. Next, we provide the research design. The

fourth section discusses the role that ceremony plays in

organizational change. The findings are discussed in the final

section, in terms of the conclusions that can be drawn

concerning ways in which ceremonies can be used to remove

the barriers between subcultures in the NHS.

The wider context of change in the NHS

The NHS as an organization, and health care as an activity,

have been under a state of continuous change in recent

decades influenced by a complex and interrelated array of

political, social and economic factors. Systematic change,

arguably, began with the 1962 Hospital Building Plan and

was punctuated by the NHS Act (1973). However, it was the

Conservative governments of the 1980s, which fundament-

ally altered the structure and management of the service. The

Griffiths Report Department of Health and Social Security,

DHSS (1983) identified the need to develop management

thinking and activity in the NHS while the establishment of

quasi autonomous NHS Trusts, as a result of the NHS and

Community Care Act (1990), provided a logical development

of this thinking. The internal market was developed in the

1990s with most definable service units gaining trust status by

the end of that decade.

In parallel, the NHS has seen the development of the

Patients’ Charter, Health of the Nation (1995), and a

renewed emphasis on primary and community care. The

NHS Plan (2000) establishes ambitious objectives for change

in many aspects of the service, including structural and

labour market reform and reinvigoration. Stress is now

placed on working in partnerships, which span previously

separate ‘territorial’ boundaries between units, occupational

groups and professions, in the pursuit of enhanced patient

care.

Managers within the NHS have generally been positive

about the changes, but not the political interference. It is

argued that the reforms have led to an erosion of professional

autonomy and a corresponding increase in the power of

nonelected elites who staff the Boards of the Trusts. Certainly

within NHS units, manifestations of managerialism abound;

strategic planning systems, business and corporate plans,

mission statements, business managers and a proliferation of

‘new’ initiatives, such as learning organization, total quality

management and investors in people are prevalent (Lawton

& Rose 1991, Pollitt & Harrison 1992). NHS managers, as

opposed to clinicians, trade unionists and, some have

suggested, patients, are seen as the beneficiaries of change

(Ferlie 1994) (see Robinson et al. 1999 for a brief summary

of continuous reform in the NHS).

General hospital, the site of the research, and change

The research for this paper focused on microprocesses, and

was undertaken as part of a larger study in a general hospital,

which provides a full range of acute and midwifery services to

a population of about a quarter of a million people. Trust

status was acquired in 1993. The hospital has made consid-

erable progress in many respects in recent years, and is

generally considered to be a fast-improving and well-

regarded Trust. The managerial/clinical interface appears to

be a more constructive relationship than that reported

I. Brooks and R.B. Brown

342 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(4), 341–352

elsewhere in other NHS Trusts, and, as described in its

various annual Business Plans, progress has been made on

external measures of quality and operating success. The

management team have overseen the restructuring of the

organization since 1991, including the development of

separate clinical directorates, each headed by a lead consul-

tant who sits on the Senior Management Executive. Business

managers were introduced to each directorate and a small

senior management team appointed and developed. Systems

were introduced to facilitate the achievement of operational

and strategic objectives. These changes have enabled the

organization to cope with, and prosper within, the internal

market and to gain Trust status. They have also facilitated the

shortening of waiting lists and the achievement of many

externally and self-imposed targets. Whether they have

significantly changed professional practice, furthered patient

centred care ideals, contributed to cross-group teamworking

and facilitated other cultural changes is less certain.

At GH, an intrinsic and stated element of the business plan

was to ‘produce a multiskilled workforce’ (GH 1995, p. 14).

GH has, since that plan, attempted to introduce multiskilled,

team-orientated, flexible, ward-based generic workers

referred to as ‘care assistants’. The assumption is that

employees benefit from the resultant job enrichment and

co-operative teamwork, cost savings are achieved via

enhanced efficiency and, in the case of the NHS, patient care

is improved.

Although the above description of GH and its operation is

functionalist in tone, this is not to suggest that all GH’s

decisions about personnel are made for entirely financial

reasons. Such functionalism, however, is pervasive in the

language of the hospital managers. We have used a func-

tionalist description for our explanatory outline of GH as it

seemed a way to convey a ‘feel’ of the place in a succinct

manner, although it leaves aside any cultural analysis of the

workings and effects of such language.

The study

Research design

The paper is based on qualitative data from a major research

project, which immersed itself in the minutiae of organiza-

tional life in an NHS general hospital Trust. Our research

approach was mainly phenomenological, as we wished to

elicit the symbolic significance of organizational routines.

There were two phases of investigation; the first took place

over a 9-month period during 1994–1995, shortly after the

organization in question gained Trust status, and the second,

in intermittent periods, from 1996 to 2000.

Data collection

The primary source of data was spoken language, ‘the main

symbolic offering of culture’ (Bate 1984, p. 48). This focus is

consistent with Barley’s (1983, p. 393) contention that

‘organizations are speech communities sharing socially

constructed systems of meaning’. The findings are based on

purposive sampling of informants by means of semi-struc-

tured interview and observation. Other types of information

were also collected, including business plans, reports and

brochures. Informants included the Chief Executive Officer

(CEO) and four Board members, three consultants, the

director of nursing and midwifery, 10 middle managers and

eight junior, nonmedical and nonmanagerial employees.

All of the interviews were taped and comprehensive

transcripts were made. Over 30 hours of ‘rich description’

(Geertz 1973) resulted, which contained ample evidence, in

the form of informants’ discourse, to support the analysis of

ceremonial presented in the paper.

Data analysis

Data were content-analysed and categorized into distinct

themes based upon a prior literature review. These themes

comprised predetermined categories of ceremonial which

were given descriptive labels to aid data analysis. Both

researchers, independently of one another, undertook to

analyse the data and in so doing verified categorization. As

themes developed, they were recorded on cards and further

evidence, mainly in the form of respondents’ discourse,

collated in support. A process of iteration, the testing of

categories on subsequent interviewees, helped to confirm and

substantiate our analysis. Thus data collection and coding

was conducted in parallel as an ongoing, iterative process.

The role of ceremony in organizational change

We suggest that ceremonies (in the sense of organized and

planned activities that communicate cultural messages) form

an intrinsic part of change processes, and that particular

ceremonies are associated with different phases in cultural

change in organizations (Brown 1994, p. 147; Martin et al.

1995).

Kilmann et al. (19852 ) suggest that ceremonies and rituals

cannot be managed at all, while Johnson (1990) takes the

opposite view, and argues that it is possible to use ceremonies

and rituals to manage culture. Trice and Beyer (1990)

consider that what they have termed ‘rites’ of passage,

degradation, renewal, conflict and integration may actively

be employed, either to maintain the exiting status quo or to

accomplish cultural change – depending on how they are

configured and on the perceived needs of the organization at

Nursing and health care management issues Removal of barriers in the NHS

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(4), 341–352 343

the time of change. But because the outcome of a ceremony is

not totally predictable, the ceremonial side of change

programmes could either reinforce or undermine the cultural

values and beliefs that are being managed.

Suggestions have been made in the literature as to how a

change process may be more successful if different types of

ceremonies are used at strategically advantageous times

(Kilmann et al. 1985, Brown 1994). We have gathered our

data, and interpreted them, using an amalgamation and

adaptation of the work of Trice and Beyer (1984, 1990),

Beyer and Trice (1987), Brown (1994) and Martin et al.

(1995). We adopted (and adapted) the categories in the

Trice and Beyer typology – rites of passage, degradation,

renewal, conflict reduction, enhancement, and integration,

regarding them as ceremonies – and, from what we

discovered in the data, we have categorized further ceremo-

nies – of belonging, continuity, sense-making, legitimization

and resistance/questioning. By means of the concept of

organizational ceremonial, we have been able to structure

our understanding of the changes at GH, by means of

uncovering what is acceptable and unacceptable behaviour.

We are of the opinion that a change model using the

concept of ceremony allows for the incorporation of

dynamism and interaction, because ceremonies are an (often

very obvious) indication of the social meaning, structure and

politicality of organizational change.

Thus while ceremonies are concerned with preserving and

promoting what already exists, they also help in the manage-

ment of change, either through the modification of existing

ceremonies to incorporate new ways, or by the creation of

new ceremonies to consolidate those ways. It is that ability to

‘concretize’ or preserve that enables them to preserve new

ways. Trice and Beyer (1990, pp. 393–394) put it thus:

Rites thus clearly can be used to facilitate cultural [and thus

organizational] change. To use them effectively, however, managers

and others must recognize the rites and ceremonies already occurring

around them and become aware of both their intended and latent

consequence. With such an awareness, combined with a healthy

respect for the power of rites to help people maintain some sense of

stability in the midst of change, managers can begin to use rites

creatively and effectively to achieve desired cultural [and organiza-

tional] change.

Findings and drawing conclusions from them

This section aims to locate the research within the wider

organizational cultural context, hence the opening analysis

explores the minutiae of the organization. We then divide the

ceremonies encountered at GH into two broad bands – those

which preserve the existing norms and autonomy of profes-

sional and worker groups, which we have named Ceremonies

of Preservation, and those which encourage change, which

we have called Ceremonies of Change. Considerable verbal

data are reproduced within this section to help to ‘tell the

story’ (Spradley 1979).

The wider cultural context at GH

The term culture is used in this paper as a kind of interpret-

ative framework for understanding change processes (Gray

et al. 1985, Isabella 1990). The Trust hospital in question is

best viewed as a culture (Smircich 1983) consisting of

Webs or networks of shared meaning and outlooks which over time

have become deeply ingrained in the members’ world-taken-for-

granted and common-sense ways of thinking (Brooks & Bate 1994,

p. 179)

Culture comprises a series of cultural schema or collective

knowledge structures (Sackmann 1991), which are socially

constructed and rely on negotiation, consensus and agree-

ment for their sustenance (Hedberg 19813 ). They are commu-

nicated and maintained through the socialization process and

in everyday interaction, through ceremonies, rituals, myths

and symbols.

The local cultural infrastructure of GH provides an

inherently rich and complex context for this research. That

complexity is ensured by the existence of multiple subcul-

tures; hence doctors, nurses, the professions allied to medi-

cine (PAMS), porters, domestics and managers have, in large

measure, developed separate cultural identities.

Tribalism within health care

It comes as little surprise that the Trust’s Deputy Chief

Executive believes ‘the NHS is ingrained with tribalism’,

while another respondent commented that ‘tribalism is rife’

within this unit. The anthropological category of ‘tribe’ is a

useful metaphorical descriptor for the groups within an

organization which share a broad ‘territory’. The term

‘tribalism’ was first reported as in use within the NHS by

Strong and Robinson (1990) who noted the pervasive inde-

pendence of subunits and professions within health care. We

would suggest that tribalism is ingrained within the NHS,

creating rich breeding grounds for ceremonial activity. Tribal

instincts are reinforced by the existence of numerous subcul-

tures, considerable investment of emotional capital, the

existence of powerful professional groups who enjoy

devolved authority, a great deal of routinized behaviour

and large, complex organizational structures. Ceremonial is

omnipresent (Walsh & Ford 1989, 1994).



Entrenched ideas and practices

Staff turnover at GH is low by comparison with most general

hospital Trusts in urban areas. As a result, a Directorate

General Manager (DGM), one of the new breed of nonclin-

ical, professional NHS managers, concluded ‘We don’t see

many newcomers with new ideas. Instead, we have a lot of

staff who have been here a long time who are so firmly

entrenched’. Another manager, speaking in the same context,

bemoaned the absence of a ‘breath of fresh air practices’ and

of ‘state of the art, cutting-edge experiences’. Others

complained that most change attempts to date have focused

on structures and systems or ‘hard’ changes. A degree of

scepticism concerning the effectiveness of such change is

apparent from the analysis of respondents’ discourse. One

middle manager suggested that ‘It’s not changed down there,

people doing the same things, in the same way, following the

same routines’. A manager from the Human Resources

department revealed an insight, of considerable relevance to

the findings of this paper, that a fundamentally different

approach is required as ‘we need to be tackling the intricacies

of culture’. The evidence presented above suggests that GH is,

broadly, a nonreceptive context for change (Pettigrew et al.

1992), one where the dominant paradigm is proving to be

resistant and enduring, in contrast to the macro-observa-

tional findings of, for example, Ashburner et al. (1996).

The need to think culturally

This paper illustrates that intentional and fortuitous attempts

to ‘think culturally’ when negotiating change have become

more commonplace in GH recently. A thought-provoking

comment from the Director of Human Resources focuses

attention on the perceived failure of previous change

programmes to influence culture: ‘Inside the hospital is a

little cottage with roses hanging over the door, where

everything is just as it has always been, and it’s all quite

happy. Nothing is touching that. Nothing is touching the real

heart of what is going on’. This paper argues that by paying

attention to organizational ceremonial, managers and other

employees can ‘touch’ that reality.

Ceremonies of preservation at GH

In Table 1, we present our analysis of the Ceremonies of

Preservation observed within GH. The identified ceremonies

are classified according to the amalgamated recipe derived

from our reading of the literature, plus the ceremonies that

we identified from our data. The table illustrates a selection

of those ceremonies; in particular, although not exclusively,

we emphasize ceremonies which serve to preserve demarca-

tion between groups or subcultures and, hence, detract from

team working, multiskilling and aspects of patient-centred

care.

Unquestioned ceremonial

The daily drugs and drinks dispensing round at 6Æ00 a.m.,

which often involves waking patients prematurely, the

procession of ‘hand maidens’ waiting upon a surgeon, and

each clinical profession’s insistence on collecting the same

personal data from patients, all take on ceremonial signifi-

cance.

When asked to explain the reasons for having the drugs and

drinks dispensing activity so early in the morning, medical

professionals argued that ‘it’s always been done that way’ and

that to do anything about it ‘means changing a lot of people’s

preconceived ideas about how to do things’. Another manager

argued that ‘a lot of drugs are administered purely because the

night staff have got to do it before the end of their shift’. As a

ceremony, however, it serves a purpose, not least in reducing

potential sources of conflict between night nurses, who wake

the patients and ‘get them fed and alert’ and their day

colleagues and those medical consultants who like to start

their rounds early. It also serves to identify a specific and

meaningful role for night nurses, and is, in the words of a nurse

manager, ‘a very tender issue’. Tribalism, preserved in cere-

mony, ensures that the demarcation of roles and responsibil-

ities is maintained. Professional, grade and task barriers, such

as those illustrated above, thus assume ceremonial significance,

while contravention of these cultural norms creates, often

fierce, reaction. They are indeed ‘tender issues’.

Sustaining boundaries

This research revealed deeply entrenched, potentially

dysfunctional attitudes which are consistent with observed

ceremonies and which serve to preserve them. Numerous

overt employee comments are evidence to that. For example,

day shift nurses frequently refer to night nurses as ‘the

knitters’ or ‘babysitters’, and suggest that ‘at midnight, the

chocolates come out’ (Brooks 1999). One manager suggested

that the two groups of nurses are ‘separate beasts’. More

subtly, employee discourse betrayed concern for ‘ownership’

of ‘territory’ and many roles and tasks were thought to

‘belong’ to particular groups. ‘Boundary’ issues were

frequently referred to by respondents. A number of ceremo-

nies have been observed which sustain these boundaries.

Ceremonial behaviour which serves to create and sustain

grade and task barriers is common in the working life dramas

of nonclinical support staff. As a supervisory manager noted,

‘Two hundred domestics just clean, forty porters just move

patients or run errands and fifty ward hostesses just deliver

food and drinks’. Ward hostesses, those caterers for whom it



is permissible to venture onto the wards, differentiate them-

selves from other catering assistants and preserve this

demarcation in ceremonial. These two grades of employees

fall within one department; but, as their supervisor

commented, ‘Ne’re the twain shall meet’. Only ward host-

esses deliver the large ‘regeneration trolleys’ carrying food to

the wards, and only they ‘probe’ the food to assess its

suitability. These duties are often conducted with ceremonial

and theatrical pomp and deliberation. If the food is passed fit

for consumption, nurses assume responsibility for delivery of

individual trays to patients.

A designated ‘handyman’ is summoned whenever a light

bulb requires to be changed, and nothing is done till he

arrives and deals with what is a very simple act; neither

porters nor ward hostesses will mop-up an accidental spillage

and it remains until a cleaner is available to deal with it; and

cleaners stick rigidly to their routines, including the cleaning

of major arterial corridors during ‘rush-hour’ traffic, despite

the inconvenience caused to themselves as well as those using

the corridors. Little imagination is required to picture the

ceremonial dramas that accompany these activities. A senior

porter attempting to summarize ‘the way things are done

around here’ suggested, in animated fashion, ‘Right, you’re

here to nurse [pointing in one direction], you’re here to do the

food [pointing in another] you’re here to clean [a third

direction], we’re here to move things, and I mean, if anything

needs moving, we move it; if it needs feeding, you feed it; if it

needs cleaning, you clean it.’ Simple.

Gender also serves as a demarcation criterion. A domestic

supervisor suggested that ‘men [porters] think that cleaning

isn’t their duty’, while a senior porter contributed a similarly

stereotyped view: ‘Women can’t lift, and men can’t clean’.

With tribal-like adherence, the hospital porters assemble,

discuss the ‘orders of the day’ and engage in socially binding,

culturally reinforcing gossip. It is an exclusive male club. The

physical artefacts in the porter’s lodge, including the building

Table 1 Ceremonies of preservation at GH

Ceremonial activity Ceremonies of preservation (plus accompanying, subsidiary ceremonies)

Acts of demarcation:

• Hospital porters, domestics and cleaners keep to

their ‘jobs’ and territories

• Each professional group’s contact with a patient usually

generates replicative, and multiple, patient details

• Between night- and day-shift nurses actions which maintain

a ‘them and us’ attitude between them

• Nurses resist moves to delegate food serving duties to

domestic staff

Preserves the social identity and power of each professional group

and/or subculture

Ceremony of Belonging: enhances sense of ‘us-together’ for the

group or profession

Ceremony of Continuity: maintains a sense of coherence between the

past, present and (threatened) future

Ceremony of Resistance/Questioning: allows ‘safe’ resistance to or

questioning of change

6Æ00 a.m. Drugs and drinks dispensing round, often waking

patients

Preserves nursing culture and power, and helps to differentiate between

night- and day-shift subcultures

Ceremony of Conflict Reduction: reduces conflict and aggression

between nursing shifts

Hospital porters assembling in the ‘Porters’ Pool’ between tasks Preserves the social identity and power of porters as an identifiable

subculture within the hospital, and maintains dysfunctional task

demarcation

Ceremony of Integration: encourages common feelings, thus binding

porters together and enhancing their commitment to their social system

A UNISON ballot of members on the multiskilling issue

(December 1994)

Preserves the power of the union

Ceremony of Resistance: allows overt expression of the union’s ‘right’

to resist change

Ceremony of Degradation: reduced the power of management by means

of the unfavourable ballot result

The main hospital corridor is cleaned at 9Æ00 a.m. irrespective

of need, of levels of congestion and the weather conditions

Preserves the social identity, and protects the role, of cleaning staff

charged with this responsibility

Ceremony of Belonging: enhances sense of ‘us-together’ for the

group or profession

Ceremony of Continuity: maintains a sense of coherence between the

past, present and (threatened) future



itself, assumes a symbolic near-totemistic importance –

symbolic because a totem is an actual animal or plant, or

an image of these, used as the badge or sign of a tribe, and is

thus a concrete symbol of its identity.

It is not surprising that a generic care assistant concept,

piloted in 1994–1995, which aimed to combine all cleaning,

catering and portering roles, was perceived as a threat to these

culture-reinforcing mechanisms and was rejected by

employees. In the actors’ life ‘drama’, the proposed change

represented not merely a change of act or scene, but a new play.

Demarcation practices

Demarcation is also common between professional subcul-

tures in GH. For example, each professional group within the

hospital maintains separate patient notes. A senior medical

consultant and Director of a major department acknow-

ledged, unprompted, that a ‘cultural difference exists between

the two strongest professions [medicine and nursing]. For

instance, when a child comes up to the ward, there is a

medical record and a nursing record. There is a great deal of

duplicated information; separate files that neither one nor the

other ever sees. It’s cultural, almost nihilistic; it’s a ritual’.

That same consultant suggested that ‘this attitude percolates

throughout the organization; two parallel courses of action

running along side each other’. The record-keeping ceremony

is a salient manifestation of ceremonial/ritualistic activity

which serves to preserve and enhance each professional group

or subculture’s identity and power.

Ceremonies of change at GH

Some have argued that managers can interpret (Trice & Beyer

1984) and even manipulate (Johnson 1990) ceremonies in

attempts to change cultural knowledge, while Kilmann et al.

(1985) suggest that the development of ‘transition rituals’ may

serve to ease the hardship of change and gain acceptance of new

cultural norms and behaviours. Ceremonies or rites of passage,

such as induction or training programmes, have been identified

as highly visible and economic mechanisms for instilling new

values and beliefs (Brown 1994). Others have suggested the use

of ceremonies in different stages of the change process. One

such case at GH is the ceremonial activity of the then-new

CEO, who, in 1991, ‘walked the job’, asking managers and

consultants directly how they were going to manage and cope

with the demands of the soon-to-be-imposed internal market.

He also held a number of short-notice away-days for senior

management and consultants to discuss the impending ‘crisis’.

One senior consultant, holding that ‘survival’ was an impor-

tant consideration for him and his staff, suggested that, ‘my

colleagues, both in medicine and nursing, viewed the changes

as a process of survival; as individuals, departments, directo-

rates, and as a hospital’. This intentional ceremonial behaviour

of ‘walking the job’ and the institution of the away-days

created the illusion (or highlighted the reality) of crisis and the

need for substantive change, at least to structures and systems

in many parts of GH.

Ceremonies of Change (Table 2) oppose those that seek

to preserve (Table 1). Hence, management who wish to

benefit from the use of ceremonial behaviour need to

reduce the power of ceremonies enhancing stability or the

status quo, and enhance the ceremonies which seek

renewal, new integration and passage. Nevertheless, change

needs to be carefully considered, as the conscious removal

or significant change to a ceremony, such as the early

morning drugs and drink round, or closure of the porter’s

pool, holds more than token significance. It is symbolic of

wider change as it weakens the reinforcing mechanisms

that maintain existing ways. Managers have to reconcile

the potential unknown effects of removing or manipulating

ceremony with the preserving and reinforcing effects of

their remaining in situ.

Creating a precedent

At GH, many ceremonies, which had become blatantly out-

of-touch with the organizational environment have been

abandoned or removed by management, such that precedent

for ‘interference’ in ceremony has been established. Previ-

ously, for example, expectant women were all given

9Æ00 a.m. appointment times at out-patients and, during

labour, male partners were excluded from the delivery room.

These now-redundant, nonpatient-centred ‘rules’ assumed

symbolic significance, creating, in their time, all manner of

related ceremonial behaviour, for example, the stuff of

sitcoms – the ‘expectant’ father, smoking heavily, biting his

nails and pacing up and down outside the delivery room.

Legitimizing activities

Clearly, managerial ‘interference’ and manipulation of organ-

izational culture and, more specifically, ceremonial raises the

issue of legitimacy. In many change management contexts,

respondents suggested the need to legitimize their activity,

such that attempts to seek or construct ‘legitimate’ rationales

for action and thought become ceremonialistic. For example,

a senior consultant suggested, ‘We need to facilitate these

changes [towards single shared patient records] in a way that

does not undermine the professional integrity of the different

participants’. He could legitimize change by reference to a

shared value (patient-centred care) and avoid ‘people being

threatened and standing behind the ‘‘protect your profession’’

banner’.



The CEO could legitimize asking the question, ‘How are

you going to cope with the internal market?’, to people who

hadn’t changed for years, because it was an unalterable,

imposed change. He suggested that ‘I could use the

ever-decreasing timeframe as an opportunity to legitimize

my discussions with colleagues about change’. A middle

manager recalls an exchange with his CEO at the time when

he was told that ‘the clock is ticking’, while other respondents

were conscious that ‘we might go under’, ‘we will not survive’

and might ‘fall over’. The CEO admits to ‘consciously using

some form of crisis language’ with the aim of ensuring that

‘the road was clear for us to introduce the reforms’. The

imposed change and the urgency it created was, the CEO

argued, ‘very useful’.

Similarly, following a series of senior management away-

days, a consultant argued that ‘for the first time we realized

that there were as many views as [there were] people present’.

The divergence of opinion between consultants from different

directorates helped to legitimize management intervention.

Leadership was seen as essential to ensure fair play. Hence the

consultation, sense-making and ceremonial challenge

processes were themselves ceremonies of legitimization, partly

planned but largely fortuitous frameworks for legitimate

change-making activity. A nursing sister argued that ‘nurses

need the agreement of consultants to stop waking patients at

6Æ00am’ and that ‘legitimization needs to come from both the

Clinical Director and from the Director of Nursing’. Another

middle manager confirmed that ‘most nurses need direction,

Table 2 Ceremonies of change at GH

Ceremonial activity Ceremonies of Change (plus accompanying, subsidiary ceremonies)

Ancillary and portering staff reclassified as care assistants

(1997)

Ceremony of Passage: facilitates the transition of staff into social

roles and statuses that are new to them

Ceremony of Degradation: removes previous social identities and

the power inherent in them

Ceremony of Renewal: remodels the social structure and

improves its functioning

Facilitate dialogue and feedback about change: diagonal slice

across the organization; management and consultants

away-days (1992 to date)

Ceremony of Sense-making: enables staff to share their interpretations

and make sense of what is happening

Ceremony of Integration: brings together multifunctional and

multiprofessional personnel

Ceremony of Challenge: provides a forum and mechanism to challenge

existing practices and attitudes

Up-skilling nursing staff (after Calman Report to date) Ceremony of Passage: facilitates the transition into new social roles

and statuses

Ceremony of Renewal: remodels social structures and improves their

functioning

‘Patient-centred’ label Ceremony of Integration: legitimizes cross-professional collaboration

in patient care by placing emphasis on the patient as opposed to

the carer

Ceremony of Passage: acknowledges the need for and growing

existence of multidisciplinary, multiprofessional teams of carers

Focused rewards: e.g. ward assistant teams sharing gifts from

patients; CEO giving gifts to ‘islands of progress’

Ceremony of Passage: contributes to the acknowledgement of

new, more flexible, teamwork roles

Ceremony of Integration: helps to actualize a member of staff’s new

social identity as part of a multifunctional team

Benchmarking: e.g. senior management visiting other

hospitals to witness ward assistant experiments there

Ceremony of Challenge: symbolizes that others may be doing things

better and that there are benefits to be derived from learning from them

Ceremony of Legitimization: we have a desire and a duty to adopt

sectoral good practice

Talk-up the crisis: e.g. new CEO on the introduction of the

internal market; competitive threat of nearby large hospital

Ceremony of Legitimization: sensitizes individuals to the significance

of proposed changes

Ceremony of Challenge: throwing down the gauntlet – indicating that

traditional ways of doing things are no longer appropriate while

inviting others to challenge existing practices



need legitimization’ to change. As suggested below, bench-

marking activities both internally and with other hospitals are

a common ceremonial activity that serves both to challenge

existing practices and to legitimize change.

Easing the transition

A number of change-orientated ceremonies have developed at

GH. These are indicated in Table 2. They primarily aim to

renew, to challenge, to help people make sense of change and

to ease their passage into new work-based identities.

Ceremonies of sense-making (Martin et al. 1995), as indi-

cated in Table 2, enable people to share their interpretations

of what is happening within the environment and the organ-

ization itself. Some of the potential negative aspects of these

ceremonies can be reduced by careful, open and sensitive

communications and by support and facilitation. Open meet-

ings, away-days, newsletters, informal and formal group

discussions and the use of diffusion techniques can all assume

ceremonial significance in this regard. At GH, a ‘diagonal

slice’ of 15 staff, largely self-selected from a variety of grades,

groups and professions, were charged by senior management

to listen to ‘clearest common reality’ on the ground and were

given access to senior management to report concerns. They

were to be, as a middle manager suggested, ‘our eyes and ears

to identify what people were worried about and what people

were talking about out there and a vehicle to bring those issues

forward’. These ceremonies of sense-making, it was hoped,

would, in the words of the Deputy CEO ‘demonstrate

symbolically that we really did want to listen’.

The CEO argued that it was ‘important to mix social

interaction with business’ at senior management away-days

and to ‘encourage radical people in the organization to

challenge what all of us are doing’. Another senior manager

suggested that these strategic away-days, involving senior

medical consultants, needed to be ‘high profile, high presence

where we would answer any and all questions and ask plenty

ourselves’. Such ceremonies of challenge (Martin et al. 1995)

trigger sense-making ceremonies. These ceremonial away-

days also serve to bind together individuals and groups in a

ceremony of integration, which the Director of HR argued,

‘locked people in to the strategic management and change

processes’.

A consultant paediatrician, concerned about the ‘distance’

between medical and nursing staff, suggested that ‘using the

patient-centred concept can be a powerful bridge; we’re

looking at the patient needs and saying, ‘‘Look these are my

skills, these are yours.’’’. The use of such ‘labels’ carries

ceremonial significance. It acts as an appeal to, he argues, ‘a

higher value, which no one can question in this context,

[which could be used to] build a new kind of professional

satisfaction in being a more complete member of the team’.

Facilitating teamwork

Ceremonies of passage and of renewal may contribute and

concretize new social groupings which serve to diminish the

importance of ‘artificial’ work group or professional bound-

aries. The aim to create and sustain ceremonies that

symbolize patient-centred teamworking and collaborative

effort may be instrumental. The issue of new uniforms, name

and title badges and communication bleepers to nonclinical

support staff, and changing their previously narrow job title

to ‘care assistant’ (part of a meticulously planned and

partially implemented change process currently in hand) are

all ceremonial activities which symbolize passage to a new

social identity. Evidence of the symbolic significance of such

ceremonies is clear from the discourse of those affected at

GH. One portering supervisor suggested, ‘It’s the words

‘‘porter’’ and ‘‘cleaner’’ that’s the problem. Let’s forget

the word ‘‘porter’’; we’re all here for the same reason; it’s

for the patients’. Other ceremonial activity which facilitates

the concretization of ‘passage’ was alluded to by a number

of the domestic staff (engaged in a pilot for the new ‘care

assistant’ project), ‘Now we’re part of a ward-based team,

we’re included in things, so when chocolates are given by

patients, we get chocolates; when they have a night out, we

have a night out; there was none of that before’.

Acknowledging good work

The CEO has initiated other ceremonies in order to facilitate

change. He regularly gives token gifts to individuals or

departments who achieve something out of the ordinary in

order ‘to overcome some of the perceptions through the use

of symbols’. He continued, ‘People know it comes from me,

not a committee, but from me’. Curiously, these gifts are

willingly received and cherished as a junior manager in

Medical Records suggests, ‘You wouldn’t believe how excited

a bunch of people could get over a basket of fruit; we could

have auctioned an apple for a fiver [£5]’. Additionally, the

CEO holds a small (£5000) annual fund to encourage

innovative practice. In ceremonial fashion, individuals or

groups apply to him for small sums, which are almost always

granted. He hands over personally a cheque in a brief

ceremony and devolves all budgetary responsibility to the

group. One junior manager, who received £250 to conduct a

study of pedestrian flow within a block in order to facilitate

more effective cleaning and maintenance, commented, ‘He

didn’t want to know how I was going to spend the money,

just the end result’.



Benchmarking

Benchmarking, both internally and with other Trust’s activ-

ities has been actively encouraged at GH. Frequent ‘fact-

finding’ visits become ceremonies which serve to challenge

existing practices and to legitimize subsequent changes.

Considerable respondent discourse bestows the advantages

of benchmarking. A portering supervisor, following a

weekend visit to a general hospital in the south-west of

England, suggested, ‘We’ve got to bring the system here

[ward-based care assistant]; it works there, it will work here’

and a middle manager on a similar visit commented, ‘We’re

comparing like with like; they [employees at GH] have got to

accept that’. A senior manager revealed that ‘these visits are

doubly useful. Firstly, we find out all the things that went

wrong when they implemented it, and, secondly, it demon-

strates that we aren’t the best’. He continued, ‘The only way I

could get my people to listen was to take them away for

2 days to see for themselves. They soon got cracking when we

returned’. The Deputy CEO encourages other groups to visit

the Pathology Directorate in GH as ‘they work very differ-

ently and effectively with a degree of harmony and are a

useful role model for other directorates’.

Discussion

Ethical considerations

An ethical issue emerges from the findings: taking it that

managers can ‘manipulate’ (a word with a pejorative conno-

tation) organizational culture, should they exercise this

capacity? Is it enough to mean well and hope that this results

in doing good? Organizational culture is more than a

management ‘tool’; in some ways, it can be seen as the

essence of organizational meaning. The issue of whether

managers should, or should not, attempt to control culture is

either central or peripheral, depending on one’s stance and

perspective, and is beyond the remit of the paper to address.

Implications for further research

Three other areas are also not part of the paper’s original

intentions, and would be worth pursuing in a further study.

First, we have not asked our respondents to express an

opinion as to whether or not the ceremonies used were

appropriate and had been consciously managed. Nor have we

considered whether the ceremonies employed have different

levels of significance – or even different meanings – across the

organization’s departments and hierarchical levels. Secondly,

we acknowledge that removal of barriers is not simply a

matter of identifying old and redundant practices and doing

away with them. Having identified barriers between subcul-

tures, we did not investigate which of them are productive,

and which are dysfunctional. Thirdly, we have not analysed

whether the introduction of new ceremonies has a greater

impact on the change process than the withdrawal of existing

ceremonies.

Managing change

We have been able to confirm that the management of change

can be eased by the judicious administration and removal of

dysfunctional ceremonies, and we leave aside the problem of

whether the ‘can’ need be transmuted into ‘should’. We

suggest that the removal of identified dysfunctional ceremo-

nies will serve to ‘unfreeze’ the organizational paradigm and

unlock its culture when it is operationalized alongside, and in

parallel with, changes in organizational structures and

consequent power positions and control systems.

It is the ‘soft’ and symbolic aspects of paradigm or cultural

reinforcement that are often neglected by managers in the

NHS and elsewhere. Yet attack on this front is essential if

cultural change is to be achieved. As cultural ‘knowledge’ is

stored and ordered in cognitive knowledge structures,

changes to ceremonies, rituals, and other symbolic processes

addresses culture at its root. One of the reasons why

achieving cultural change is so elusive is that attempts

frequently adopt a secondary or divergent route and focus

upon ‘hard’ structural or systems change. In other words,

using the wrong tool for the job can only ever hope to achieve

mediocre success. The dual attack upon the paradigm from a

series of ‘soft’ and existing ‘hard’ changes will weaken it and

lay it open to more fundamental, and hopefully patient-

centred, change.

Nevertheless, professional groups may resist changes that

are likely to disrupt existing ceremonial and symbolic activity.

They will develop protective mechanisms, which Pettigrew

(1973) argues might lead protagonists to deny the competence

of change agents and to withhold information. They may also

attempt to influence divergent individuals and groups by

ceremonies of intimidation (O’Day 1974) and degradation

(Trice & Beyer 1984). For example, if clearing accidental

spillages on a ward were to become the responsibility of care

assistants (not left for the cleaner), then accusations of neglect

of responsibility and verbal intimidation may result. Similarly,

some of the portering staff who participated in the care

assistant pilot scheme at GH were ostracized by some of their

colleagues. Because ceremonies are rooted in organizational

history this temporal association proves a powerful symbolic

weapon ‘for challenging the taken for granted and signalling

change’ (Johnson 1990). Therefore, it is normal to experience



resistance and although this needs to be handled sensitively,

real cultural change may result.

How much does this research advance the discussion about

ceremonial in organizational settings? We admit that we have

not provided a Great Leap Forward, but we have provided a

new way of seeing an old scene in that we have concentrated

on the dynamic and expressive qualities of what has often

been viewed as static. A ceremony is, after all, a routine, and

a routine is a repetition of a well-established action; it can

thus be carried out under ‘automatic pilot’.

Conclusion

We have shown in this study that when deliberate change is

undertaken in an organization, it is helpful to uncover the

dynamic meanings of organizational ceremonies. We have

demonstrated that to identify and explore those ceremonies

that are dysfunctional now, would continue to be dysfunc-

tional after the change, and, if modified, would contribute to

the design and implementation of the change and the chances

of success.

The implicit assumptions underlying this research are

easily made explicit. We undertook this research with the

assumptions that:

• the concept of organizational culture is of value for

systematic organizational analysis;

• the concept of ceremonial is not old, passe and ‘worked to

death’, but is still a robust and effective means of under-

standing organizational activities;

• new research undertaken using the old concept of ceremo-

nial nevertheless has something of value to contribute.

The concept of organizational ceremonial is a rich one.

Our data brought to the fore ceremonies other than the six

identified by Trice and Beyer (1984) and the Brown (1994)

typologies; no doubt, had we gone on looking, we would

have found others. Human organizational behaviour, in its

complex intertwining of the social, political and symbolic, is

difficult enough to understand without attempting to alter it.

We hope that, with this research, we have adequately shown

that ceremonial has a role in removing barriers between

subcultures in the NHS.

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