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 Preface

This book examines the evidence for a relationship between organisational

culture and organisational performance in the healthcare sector. It is one out-
come of a larger study commissioned by the UK Department of Health. The
empirical component of the study will be reported separately. Politicians,
managers and others have responsibility to ensure that public sector and to a
lesser extent private sector organisations are organised and managed efficiently.
They are accountable for how the public’s money is spent, in order to prevent
waste, fraud and other inefficiencies. They are also accountable for the quality of
the service that this money purchases on the public’s behalf. If it is possible to
analyse and intervene in any of the variables that mediate the process between
expenditure and output, then these possibilities should be explored. Organisa-
tional culture has been posited as one such key ‘variable’. This raises questions
about whether organisational culture can be said to exist in any tangible sense,
the mode of that existence, how we can gain a reliable knowledge of its exis-
tence, and how it is plausible to infer, analyse, describe or otherwise account for
its existence.
The book is divided into three parts, each of which addresses an important
aspect of the relationships between organisational culture and performance.
Part 1 traces the development of organisational culture as a subject, surveys the
different approaches to its analysis, and examines the role of leadership and
the management of change. Part 2 collects all of the culture assessment tools,
categorises them, and examines their application in healthcare contexts. Part 3
analyses the culture and performance link in terms of the evidence available
with regard to both healthcare and non-healthcare organisations, the different
scales or levels at which a relationship appears to operate, the choices to be
made in deciding how to select performance assessment criteria, and how to
conduct an assessment.

Tim Scott
April 2003
 About the authors

Tim Scott MA (Lancaster), PhD (Hull) is a Harkness Fellow in Health Care Policy, a
research fellow in the Department of Health Sciences at the University of York
and a visiting scholar in the Division of Health Policy and Management at the
University of California, Berkeley. His research interests include organisational
analysis, behaviour and symbolism, strategic change, and quality improvement
in healthcare. He previously worked in the NHS Centre for Reviews and Dis-
semination at the University of York, and in the Centre for Health Services
Studies at the University of Warwick.

Russell Mannion BA Hons (Stirling), PG Dip Hlth Econ (Tromso), PhD (Manchester) is a Senior
Research Fellow at the Centre for Health Economics, University of York. He is
also Director of the Masters course in Health Economics at the Nuffield
Institute for Health, University of Leeds. His research interests embrace: perfor-
mance management and measurement in healthcare; clinical governance and
accountability; economic aspects of healthcare organisation and delivery; insti-
tutional economics; and international health policy reform.

Huw TO Davies MA (Cantab), MSc, PhD, HonMFPHM is Professor of Health Care

Policy and Management at the University of St Andrews, and a former Hark-
ness Fellow in Health Care Policy when he was based at the Institute for Health
Policy Studies at the University of California, San Francisco. He is Co-Director of
both the Centre for Public Policy & Management (CPPM) and the Research Unit
for Research Utilisation (RURU) in the School of Social Science at St Andrews,
and is Associate Director of the Pharmaco Economics Research Centre (PERC) at
the same place. His research interests are in healthcare quality, encompassing
evidence-based policy and practice, performance measurement and manage-
ment, accountability, governance and trust. He also has a particular interest in
the role of organisational culture in the delivery of high quality care.

Martin Marshall BSc, MB BS, MSc, MD, FRCGP is a Professor of General Practice at
the National Primary Care Research and Development Centre, University of
Manchester, and a part-time general practitioner in an inner-city practice. Prior
to this he was a principal in general practice in Exeter for 10 years. His research
interests are in the field of policy-related quality of care: the development, use
and abuse of quality indicators in primary care; the public disclosure of infor-
mation about performance; and the relationship between organisational culture
and quality improvement. He was a Harkness Fellow in Health Care Policy in
vi About the authors

1998-9, based at the RAND Corporation, California. He was a member of the

General Medical Council/Royal College of General Practitioners working group
that produced Good Medical Practice for General Practitioners. He is currently
a member of the RCGP Research Group, an advisor to the Commission for
Health Improvement and their Office for Healthcare Information, the Modern-
isation Agency, the National Clinical Assessment Authority, the National
Patient Safety Agency and the National Primary Care Collaborative. He is
vice-president of the European Working Group on Quality in Family Practice
and a member of the Manchester Performance Panel.
 Acknowledgements

The authors wish to thank the UK Department of Health for funding this
research. The final preparation of the manuscript was undertaken by Tim Scott
while he held a Harkness Fellowship awarded by the Commonwealth Fund of
New York. Thanks are also due to Kath Wright for help with the database
searches, Ron Beswick, Sue Cartwright, Cary Cooper, Ron Cullen, Paula Green-
wood, Sue MacKenzie, Steven Shortell, Nicholas Sieveking and Keith Stevenson
for providing sample copies of their culture assessment tools, Debra Hender-
son for help with tracking down an elusive study, and Helen Parkinson and
Jessica Hemingway for their excellent secretarial support.
This book is dedicated to Elie, Cate, Laurie, Molly, Judith, Elizabeth, Catherine,
Thomas, Bryn, Padrig and Sue, with thanks for their love and patience.
PART 1

A theory of organisational
culture

The aim of Part 1 is to review the theoretical underpinnings to the study of

what is termed ‘organisational culture’. We begin by tracing the emergence
of the term in the academic literature and its subsequent use in organisational
analysis, behaviour and development. We then consider how a lack of con-
sensus over the proper meaning of the term ‘organisational culture’ can be
resolved by revising the form of the question ‘What is organisational culture?’.
Finally, we discuss the value of analysing healthcare organisations from an
organisational culture perspective, with particular reference to the NHS.

Introduction
It is difficult to review the topic of organisational culture succinctly. There is
little agreement among scholars as to what the terms ‘organisation’ and ‘culture’
mean, how each can or should be observed or measured, or how different
methodologies can be used to inform practical administration and organisational
change. The difficulties are exacerbated by the rich variety of meanings that
‘culture’ has in everyday language. It broadly signifies a symbolic approach
to organisations in order to study characteristic ideologies, language, dress
codes, behaviour patterns, signs of status and authority, modes of deference and
misbehaviour, rituals, myths and stories, prevailing beliefs, values, unspoken
assumptions, etc. Some students believe that the state and development of
organisations can only be managed effectively if the organisation is engaged at
a symbolic level as a complex social system or subsystem of wider society.
That belief is partly a response to the failure of ‘classical’ management theory
to deliver results in terms of economy, efficiency, quality, and employee and
customer satisfaction. There is also a tacit acknowledgement that occupational
‘tribes’ have status and rights over and above the instrumental demands of an
organisation to produce goods or services.
Thus it might appear that the concept of organisational culture promises to
meet both the needs of industry for greater efficiency and effectiveness, and the
material and social needs of employees. Unfortunately, most approaches to
2 Healthcare performance and organisational culture

organisational development offer similar promises and usually fail to deliver on

one side or the other – and often on both. There are other reasons to be
cautious, not least relative to organisational change and transformational narra-
tives. Any model that is adopted to effect organisational change will have little
effect on the severe objective constraints that are imposed by its environment.
For example, severe and chronic staff shortages in the NHS are likely to
undermine morale and reduce quality of care, irrespective of styles of leadership
or the management of organisational change. Nor will such measures affect in
any substantial way the demand for health services outstripping supply, or the
demographic trajectory towards a higher proportion of older, sicker members of
society. And these are just a few of the most obvious constraints at the macro-
level. Within a health organisation’s culture are likely to be found practices,
beliefs, values and assumptions that tend by their very nature to strongly resist
attempts to change them. Machiavelli was not exaggerating when he observed
that: ‘There is nothing more difficult to carry out, nor more doubtful of success,
nor more dangerous to handle, than to initiate a new order of things’
(Machiavelli, 1992). However, the opposite could equally be true – that noth-
ing endangers an organisation more than a failure to detect a need for change
and to carry the appropriate changes through, as the recent history of Marks
and Spencer amply demonstrates.
We can better understand the significance of organisational culture by tracing
its emergence as a distinctive approach to organisational analysis and behaviour.
Although organisational culture has the trappings of a cultural anthropological
approach to the study and management of organisations, and in some cases
adopts explicitly anthropological methods of research (Smircich, 1983), it
emerged as much from within organisation studies as from its influence by
anthropology. The development of organisational culture as a subject of study
can seen as a response to and to some extent an elaboration of earlier social
systems and social constructionist approaches. They in turn developed as
correctives to Frederick Winslow (‘Speedy’) Taylor’s scientific management, the
time and motion studies of his successor Frank B Gilbreth, and Elton Mayo’s
famous ‘Hawthorne experiments’, successively.
From at least Adam Smith’s The Wealth of Nations (Smith, 1970) to the present
day, the study of organisations has been conducted from within various different
theories or paradigms (Burrell and Morgan, 1979). Organisations have been
approached as if they were machines, as organisms struggling to survive in more
or less competitive environments, as information and control systems (cyber-
netics paradigm), as political systems, as psychic prisons, as fields of flux and
transformation, as instruments of domination and as cultures (Morgan, 1986).
As a comprehensive review of these paradigms is beyond the scope of this
report, we here offer a brief overview of developments in organisational theory
and research that have contributed to the development of an organisational
culture paradigm.
 A theory of organisational culture 3

A brief history of organisational culture

The term ‘organisational culture’ first appeared in the academic literature in
an article in Administrative Science Quarterly (Pettigrew, 1979; Hofstede et al.,
1990). Its constituent themes can be traced to earlier literature on organisational
analysis. Pettigrew’s own empirical study of a private British boarding school
appears to have been strongly influenced by Burton Clarke (Clarke, 1970). Both
traced the effect of strong, idiosyncratic individuals who had founded the
organisations. This concern with the role of leaders and leadership in turn
highlights the influence of Selznick’s Leadership in Administration (Selznick, 1957).
Selznick distinguishes between two ideal types of enterprise – on the one
hand, a rational instrumental organisation, and on the other, the value-infused
institution. According to Selznick, the term ‘organisation’ suggests a technical
instrument for harnessing human energies and directing them towards set aims,
while the term ‘institution’ suggests an organic social entity. In the mechanistic
‘organisation’, tasks are allocated, authority is delegated, communications are
channelled, and the whole enterprise is seen in terms of a co-ordinated rationing
out of work conceived as an exercise in engineering and governed by rationality
and discipline:
The term ‘organization’ thus suggests a certain bareness, a lean, no-nonsense system of
consciously co-ordinated activities. It refers to an expendable tool, a rational instrument
engineered to do a job. An ‘institution’, on the other hand, is more nearly a product of
social needs and pressures – a responsive, adaptive organism.
(Selznick, 1957, p. 5)
Selznick does not suggest that any given enterprise must be either one thing
or the other – although extreme cases might approach ideal organisations or
institutions. Most enterprises resist easy classification, being complex mixtures
of designed and responsive behaviour. Thus the formal technical system is only
one side of the ‘living association’ that we encounter, and the formal relation-
ships shown on an organisation chart provide a framework that is fleshed out by
more spontaneous informal human behaviour: ‘We see how the formal charter is
given life and meaning by the informal ‘‘social constitution’’ in which it is
embedded’ (Selznick, 1957, p. 6). This institutional analysis brings attention to
the emergence of ‘natural’ social processes within a formal association. These
two aspects of an enterprise are complementary, providing a structural reference
to guide individual and collective activity towards common, and sometimes
uncommon, ends.
According to Selznick, the litmus test of organisation vs. institution is
expendability. If an enterprise is a mere instrument, it can be easily cast aside.
However, when an infusion of value occurs, there is resistance to change:
People feel a sense of loss; the ‘identity’ of the group or community seems somehow to
be violated; they bow to economic or technological considerations only reluctantly, with
4 Healthcare performance and organisational culture
regret. A case in point is the perennial effort to save San Francisco’s cable cars from
replacement by more economical forms of transportation. The Marine Corps has this
institutional halo, and resists administrative measures that would submerge its identity.
(Selznick, 1957, p. 19)

Significantly, half a century later the institutions of San Francisco’s cable cars
and the US Marines still survive. However, the main topic of Selznick’s analysis
is leadership. According to Selznick, leadership is a slippery phenomenon that
eludes both common sense and social science. This is partly because what
leaders do is not obvious. Their leadership operates in complex and ambiguous
situations that are generated by institutional life. Nor is leadership necessarily a
personal trait – although it can be. Selznick’s definition of leadership suggests
an emergence of leaders contingent upon the types of social situations in which
critical decisions are needed to influence the course of events. We shall address
each of Selznick’s three criteria for leadership briefly in turn.
1 Leadership is a kind of work that is done to meet the needs of a social situation.
Selznick was influenced by the then relatively new discipline of social psy-
chology, which viewed leadership as being contingent upon the situations in
which it is observed. He supports this view by reference to post-war
research, including a review of military leadership studies:
Leadership is specific to the particular situation under investigation. Who becomes
the leader of a given group engaging in a particular activity and what the leadership
characteristics are in the given case are a function of the specific situation, including
the measuring instruments employed*. There is a wide variation in the characteristics
of individuals who become leaders in similar situations, and an even greater
divergence in leadership in different situations.
( Jenkins, 1947, cited in Selznick, 1957, p. 75)

Jenkins did not imagine a subpopulation of natural-born leaders in search of

people to lead and projects to lead on. Who will lead, and how, depends on
the context within which a need for leadership arises. Selznick does not
exclude the possibility that leadership in large-scale organisations could be
connected to traits of certain types of individuals. He emphasises that the
specific idea of leadership with which he is concerned is a function of the
dynamic social life of the institution, rather than of the static instrumental
framework of the organisation. Selznick also views leaders as ‘critical’ deci-
sion makers who affect the strategic course of institutional activities, rather
than the humdrum ‘routine’ decisions of everyday organisational life. He does
not view leadership as infinitely variable or wholly contingent on a situation,
but he invokes Stogdill’s review (Stogdill, 1948) of studies of personal factors
associated with leadership:

* We shall see later that a concern with the influence of measuring instruments on the definition
of the measured object is crucial to our understanding of organisational culture.
 A theory of organisational culture 5
The evidence suggests that leadership is a relation that exists between persons in a
social situation, and that persons who are leaders in one situation may not necessarily
be leaders in other situations. Must it then be assumed that leadership is entirely
incidental, haphazard and unpredictable? Not at all. The very studies which provide
the strongest arguments for the situational nature of leadership also supply the
strongest evidence indicating that leadership patterns as well as non-leadership
patterns of behavior are persistent and relatively stable.*
(Selznick, 1957, p. 65)

2 Leadership is not equivalent to office holding or high prestige or authority or decision

making. Selznick’s second definition follows from the previous discussion of
the socially situated context of leadership. Individuals in formal positions
of authority are not necessarily effective leaders. Their influence on critical as
opposed to routine decision making can be minimal.
3 Leadership is dispensable. Leadership arises only within the dynamic, social
institutional side of enterprise. The static instrumental organisation does
not need leadership, according to Selznick’s definition. Leadership is needed
where there are critical decisions to be made. Attempts to express leadership
in routine administrative situations are redundant and may be dysfunctional.
Selznick’s essay has been highly influential in organisation studies. It describes
the important distinction between the organisation as a rational, dispensable
instrument for the production of goods or services, and as a value-infused
robust social institution. Bringing people into association in the workplace,
the mechanical organisation also gives birth to the dynamic social institution.
Being dynamic and having a tendency to develop its own subsystemic goals,
the institution requires leadership to co-ordinate its activities in relation to the
instrumental means and ends of the enterprise.
These themes informed the conceptualisation and study of organisational
culture, and are part of its genealogy. In common with the human relations
movement, organisational culture emphasises the socially dynamic aspect of
organisations, as against the earlier mechanistic conceptions of Taylor’s scientific
management. An infusion of the organisation by values, and an associated
resistance to change, are both important aspects of the study of organisational
culture. We shall examine the question of leadership and organisational culture
later in this section.
Other early work on organisational analysis that is worth including in a
genealogy of organisational culture is JAC Brown’s The Social Psychology of

* The hypothesis of patterns of leadership raises questions about leadership and gender. The
word ‘pattern’ derived from pater (father). The extent to which studies of leadership and
organisational culture are influenced by gender issues is an important question. This is an
example of how carefully we should attend to organisational language as an important
dimension of culture. And this in turn should alert us to the fact that ideologies can advance
behind a mask of everyday language.
6 Healthcare performance and organisational culture

Industry (Brown, 1954), which elaborates Roethlisberger and Dickson’s (Roeth-

lisberger and Dickson, 1939) distinction between the formal and informal
organisation of the workplace. The formal organisation (to which Selznick’s
rational instrument organisation is similar) is the official hierarchy as it appears
on an organisation chart. This traditionally consists of three main substructures,
namely a line organisation (which is the formal system of authority), a functional
organisation (which is based on the type of work done) and a staff structure
(which is based on specialisation, e.g. engineers, designers, etc.). It was the
formal organisation of the factory towards which the efficiency-improving work
of Taylor and Gilbreth’s scientific management was directed. According to Brown,
the formal organisation of the workplace, so far as its theory is concerned, has
three main characteristics.
1 It is deliberately impersonal.
2 It is based on ideal relationships.
3 It is based on the ‘rabble’ hypothesis of human nature (i.e. that workers are
isolated units who may be moved about from one job to another depending
entirely on their ability to do the job).
Missing from the formal theory of organisation is any recognition of the
importance of workers’ personalities and of their collective relationships. These
relationships are defined by social or group psychologists in terms of primary
and secondary groups (Sprott, 1958). Large organisations are built up from a
number of smaller groups averaging about eight or ten people each. The number
is limited because problems of communication increase as the size of the group
increases. In the absence of adequate face-to-face communication there is a
tendency for the group to break up or subdivide after it has reached a certain
critical size.
Unless they are entirely independent, primary groups must communicate by
setting up another executive organisation:
That is to say, the leaders of the unit groups must not only be members of their own
working units – they must join together to form an executive unit which acts as a sort
of nervous system in maintaining contact between the individual groups.
(Brown, 1954, p. 124)

It is this development – the primary group outgrowing its own face-to-

face viability, splitting into further primary groups and thereby creating a
composite whole or secondary group – which gives rise to the need for an
executive function and the challenge of leadership posed by large organisa-
tions. The simultaneous contribution of an executive member to two groups and
two organisational levels by a single act is a critical feature of all complex
organizations. It transforms the complex into an organic whole (Barnard, 1938).
When the primary groups that together form a larger organisation contribute
to a common goal, that organisation is described as being well integrated.
 A theory of organisational culture 7

However, if the primary groups pursue their own ends, then the organisation is
described as showing a tendency towards segmentation (Brown, 1954).
According to Brown, the informal organisation of the workplace (to which
Selznick’s natural social institution is similar) exists at five different levels:
1 the total informal organisation of the workplace, viewed as a system of
interlinked groups of all types
2 interest groups that form around ‘hot’ issues or internal politics. These
groups may be large, diffuse, or extend through several or all departments
3 primary, face-to-face groups that are formed on the basis of shared work or
location (‘cliques’)
4 groups of two or three intimate friends who may be part of larger cliques
5 isolated individuals who rarely participate in social activities.
The functional contribution that is made by the informal organisation to the
viability of the formal organisation is crucial:
Without the assistance of informal organization, formal organization would often be
ineffective. This is frequently the case when managers try to determine every detail in
production. They are too far removed from production to envisage many of the problems
that arise. Yet frequently they give orders on the basis of presumed knowledge. If their
orders were completely obeyed, confusion would result and production and morale
would be lowered. In order to achieve the goals of the organization, workers must often
violate orders, resort to their own technique of doing things, and disregard lines of
authority. Without this kind of systematic sabotage, much work could not be done. This
unsolicited sabotage in the form of disobedience and subterfuge is especially necessary to
enable large bureaucracies to function effectively.
(Miller and Form, Industrial Sociology, cited in Brown, 1954, p. 145)

Thus Brown’s account of the formal and informal organisation parallels Selznick’s
analysis of the instrumental organisation and the value-infused institution. Both
emphasise the emergence of the informal, socially organic organisation from
the bare blueprint of the formal organisational structure. Both also emphasise
their interdependency. Is ‘organisational culture’ the same as Brown’s informal
organisation and Selznick’s institution? The problem with such a definition is
that it ignores the influence of wider society on the organisation, which the
analyst cannot afford to do, especially with such large, value-infused institutions
as the NHS and other large health systems, including large institutions in the
USA (e.g. the VA Veterans Health Administration) or Kaiser Permanente.
In fact, Brown does almost provide a definition of ‘organisational culture’:
The culture of industrial groups derives from many sources: from class origins, occupa-
tional and technical sources, the atmosphere of the factory which forms their background,
and, finally, from the specific experiences of the small informal group itself. Some of its
more important manifestations may be classified as (a) occupational language, (b)
ceremonies and rituals, and (c) myths and beliefs.
(Brown, 1954, pp. 145–6)
8 Healthcare performance and organisational culture

An analysis of occupational language, ceremony and ritual is familiar to any-

one acquainted with the literature on organisational culture. Let us therefore
examine only briefly what Brown means by these terms, and sketch out their
significance for analysing healthcare organisations.

Occupational language
Technical language, including argot and jargon, is a familiar feature of
occupations and institutions. Many of the terms that are used by accountants,
engineers, doctors and other specialised trades are strictly technical and have
no lay equivalents. In medical terminology, parts of the body, their func-
tions and diseases have a standardised Latin nomenclature. This provides an
operational and even international language which is designed to minimise
ambiguity in communication. However, medical terminology also forms a
symbolic boundary around the profession, showing who is in and who is out.
The language used between doctors differs from that which is used between
doctors and patients. The importance of occupational language and other
symbols, such as white coats and stethoscopes, is highlighted by impostors
who successfully pass themselves off as doctors simply by ‘talking the talk’
(i.e. managing the symbolic codes), sometimes for many years before they are
detected. Recent NHS scandals such as the Bristol Royal Infirmary children’s
heart surgery tragedy (Kennedy, 2001) suggest that symbolic professional
codes can even outweigh gross deficiencies in individual and collective behav-
iour. Like other clans, medics close ranks and protect their own.*
Although it is not mentioned by Brown, humour is another distinctive feature
of the language of occupational groups. For example, a ‘gallows’ humour can
be observed among nurses, which may help them to cope with distressing
experiences. Treating disease and death humorously might shock outsiders and
appear insensitive. A different interpretation is that this ‘black’ humour pre-
serves sensitivity by a ritualised display of contempt for disease and suffering.
‘Laughing at the devil’ in this way may be a highly functional form of
repression.

* The term ‘performance’ is noteworthy in this context. It is important to recognise two related
senses, namely ‘performance’ as a dramatic reference and ‘performance’ as a measure of
efficiency. The impostor who performs the role of doctor well may convince patients and even
real medics that he or she is a real doctor. The ambiguity is compounded by the argument that
even real doctors need to be able to perform the role of ‘doctor’ convincingly, to the
satisfaction of patients and peers. Arguably, therefore, the qualified and fake doctor both
practise in an ambiguous zone between the dramatic and efficient definitions of ‘performance’.
 A theory of organisational culture 9

Ceremonies and rituals

All of this leads us to consider the roles of ceremony and ritual in healthcare.
As Brown observes:
All well-integrated groups, whether in the Australian Bush, the South Sea Islands or a
London factory, have certain ceremonies and rituals which may be classified as initiation
rites for the novice who is joining the firm, rites of passage and rites of intensification.
(Brown, 1954, p. 147; our italics)
Initiation rites for the novice joining the group typically include teasing and
practical joking designed to ridicule and subordinate the newcomer to the
pecking order of the group – or more broadly to test his or her ‘temper’. Being
sent out to fetch non-existent tools, such as ‘a left-handed monkey wrench’, or
unlikely materials, such as a tin of striped paint, are typical examples, as is coating
the victim’s genitals with paint or engine grease, or even worse (Ackroyd and
Crowdry, 1991):
The (mainly unconscious) function of such behaviour is to demonstrate to the newcomer
his inferiority and ignorance in relation to the superiority of the group members, as a
consequence of which the morale of the latter is raised simultaneously with the desire of
the former to become fully initiated. The novice’s attitude towards the group is tested,
and his resourcefulness or lack of it made clear.
(Brown, 1954, p. 147)
We would add that newcomers do not always accept their expected role in the
established pecking order, and might successfully resist subordination attempts
by demonstrating a high degree of savoir-faire.
Rites of passage are ceremonies that mark the promotion, demotion or
dismissal of a group member – that is, when he or she is about to leave the
group. The function of rites of passage appears to be to settle ambiguity about
status and membership:
The function of the ritual may be to manifest group identification and loyalty, to ease
the process of separation from the group, to emphasize the finality of the social rupture,
or merely to indicate that all past animosities are forgiven and forgotten.
(Miller and Form, cited in Brown, 1954, p. 147)
Shaking hands, giving leaving cards, having a leaving party, gift giving and
speech making are all familiar examples of rites of passage in the workplace.
Between the rites of arrival and departure are rites of intensification – that is,
ceremonies which demonstrate the solidarity of the group. Rites of intensifica-
tion include ‘away-days’, providing cakes on birthdays, wearing ritual dress,
Christmas and New Year parties, sharing private jokes, and even making tea.
It may be thought that these everyday activities have little connection with the
complex rites and customs of pre-industrial societies, or that their significance to
the smooth running of organisational life is exaggerated. Although the potlatch,
10 Healthcare performance and organisational culture

the Japanese tea ceremony and the robust humour of bothy life differ widely in
detail, they all function to define a group’s membership and existence:
However attenuated the form these ceremonies may take, no group worthy of the name
ever assumes that membership is a mere matter of walking into it. There is no integrated
or coherent social group which does not make something of a ceremony of the arrival or
departure of members or take part in ceremonies which, in effect, indicate its distinctness
from any other group . . . . There always exists the awareness of what anthropologists
would call the ‘in-group’ and the ‘out-group’.
(Brown, 1954, p. 148)

Myths, beliefs and ideologies

Myths and beliefs justify the actions of the group and explain its relationship
to the wider organisation and the outside world. Strengths and weaknesses of
colleagues (past and present) are exaggerated and invented to suit the theories
and prejudices of the purveyor with regard to the position and status of their
own group. Each occupational group (management, doctors, nurses, etc.) has
its own mythology about itself and other groups. Each member is influenced
by a collective mythology, as few individuals are immune to the frames of
reference used by peers to make sense of a shared context. Myths are, as
Brown puts it, general trends in the thought of groups, and participate in their
identity and cohesion. Myths, beliefs or ideologies have a number of interest-
ing characteristics.

1 They are functionally equivalent to wrong theories (although not necessarily

wrong in every detail).
2 They are unchanged by the acquisition of correct knowledge (even extensive
first-hand experience which contradicts them is unlikely to change them).
3 They influence the individual’s interpretation and actions.
4 They form a more or less coherent whole which cannot be altered piecemeal.
5 The sentiments of the occupational group (e.g. management towards clini-
cians, or vice versa) are determined less by knowledge of the individual
manager or clinician than by the sentiments which prevail in the social atmos-
phere which surrounds the individual. (adapted from Brown, 1954).

Thus each clinician, manager or nurse tends to be seen first as a member of a

mythical class of clinicians, managers or nurses, and only later as an individual
in their own right.
Both Brown’s and Selznick’s analyses of the rational–instrumental and
social–systemic dimensions of modern organisations rest on foundations laid
by the founding fathers of sociology immediately after the French Revolution.