Group identities as the building blocks of organizations: a story about nurses' daily work

Stand. .i. Mgmt, Vol. 10, No. 2, pp. 131-145,1994 Copyfight 0 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved 09565221194 $7.00 + 0.00

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GROUP IDENTITIES AS THE BUILDING BLOCKS OF ORGANIZATIONS: A STORY ABOUT NURSES’ DAILY WORK KERSTIN SAHLIN-ANDERSSON Stockholm School of Economics Abstract -This article describes the everyday interactions in an organization composed of groups to which gender identities have been ascribed, namely a hospital ward. The female identity of the nursing profession is reflected in the interaction both within the group and in the interaction between nurses and doctors. The female identity of the nurses repeatedly appears as a norm and as a frame for interpreting their activities. However, work patterns are changing. In particular, those aspects of nursing which have been most closely associated with the female identity of the profession are being questioned, and great efforts are being made to change them. Conclusions are drawn about what effect such changed group identities may have on the organizational setting, and on the relations between occupational groups. Key words: Nursing, hospital, occupational

OCCUPATIONAL

groups, identity, gender, organizational

transformation.

GROUPS TO WHICH GENDER IDENTITIES ASCRIBED

HAVE BEEN

Organizations consist of groups which are institutionally defined and distinguished from one another. Gender is a frequent basis for classification in this context, serving at the same time to make sense of social events and social situations. Most occupational groups are perceived as either female or male; gender identities are ascribed to them. These identities reflect and affect the way the work is carried out, and the way groups relate to each other. Identities also shape interactions between the members of a group and between groups. The gender identity also reflects and affects the way in which tasks and responsibilities are allocated among the members of a group. Perhaps one of the most ‘female’ occupational groups, at least in Sweden, is nursing. Not only because more than 90% of all nurses in Sweden are women (SCB, 1990), and the Swedish designation for both female and male nurses (sjukskbterska), is in the feminine gender, but also because “nursing” is often associated with the traditional or stereotypical idea of what women are like and what they should be (e.g. Becher, 1990; Elzinga, 1990). “Typical” female traits that are often invoked include sensibility, passivity, irrationality (Weedon, 1987), expressiveness and concern for other people (Deux and Major, 1990). Nursing is often described as a “caring” profession. A nurse is expected to give a hand where she is needed, not to have a fixed plan for her daily work but to be constantly prepared to adjust her schedule to other people, and so on. Oral communication dominates the interaction within the group. Knowledge and competence are described as being based mainly on personal experience (Josefsson, 1987). In this paper I describe the daily work of the nurses on a hospital ward: how the female identity of this profession is reflected in the interaction both within the group and in the interaction 131

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between nurses and doctors. The female identity of the nurses repeatedly appears as a norm and as a frame for interpreting their activities. However, the current pattern of interaction and taken-for-granted work patterns is changing. We can expect extensive changes in the identity of this occupational group. In particular those aspects of nursing which have been most closely associated with the female identity of the profession are being questioned and great efforts are being made to change them. The gender identity of an occupation can change if the sex composition of the group changes. In the literature we find examples of occupations that have changed gender identity. An interesting study of the masculinization of an occupation was made by Sommestad (1992). The author described and analysed how Swedish dairymaids were replaced by dairymen. This change also meant that the occupation changed its identity, and came to be defined in more industrialized, scientific and technologically based terms than before. Today we can see many occupations which were previously male or female dominated, but are now mixed. Examples in Sweden include lawyers, headmasters, kindergarten teachers and nurses. The identity of an occupational group can also change as a result of changes in the society’s view of the female identity. A change in group identity affects not only the way activities are carried out and interpreted within the group, but also the relations between various groups. Most studies of altered group identities have focused on the effect of such changes on the members of the group. In this article I am concerned with the effects of such changes on the organizational setting, on organizational reform and on the relations between occupational groups. I do not attempt to evaluate whether the current transformations are good or bad for either of the groups.

ABOUT THE STUDY This article is based on participant observation in a Swedish public hospital ward, on interviews with a broader group of nurses and on documentary studies. The investigation started in the autumn of 1991. Over the following year and a half I spent a couple of days each month on the ward. I shadowed nurses, assistant nurses and doctors (Sclavi, 1989) as they went about their daily work, spending at least one whole working day with each of them. Apart from these participant observations on the ward, I also attended various meetings in the hospital. I also interviewed nurses in a hospital where several wards have been reorganized in a way which the nurses describe as more modem and which they see as a possible example to follow. On this ward there is more emphasis on the nurses’ individual responsibility, more planning and more written documentation. Since the hospital in which I observed the work on the ward is a university hospital with a school of nursing and a medical school, people there are used to receiving visitors and students. Until I introduced myself to the patients and staff, they usually took me for a student. Even after I had spent several days on the ward, accompanying a nurse and wearing nurse’s uniform* myself, doctors asked me questions as though I were a student nurse. Thus the hospital formed an open setting for participant observation, and there were no access problems. What is more,

*Clothes are very important in the hospital. ‘Ibis became clear to me one day when I was accompanying one of tire doctors. I had asked him what clothes to wear and he had told me to wear “doctor clothes”: a white coat, usually unbuttoned, and with one’s own clothes under it. In the morning I went to the nurses’ locker room, which is close to tbe ward, and took what I thought looked like the clothes I needed. During lunch the doctor told me that I had the wrong coat and took me to the doctors’ lockers far away from the ward. There I got the right coat. I could not see any difference.

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this small

detail

provides

one of many

illustrations of the strong group identity - and of the nurses. Each one subordinates herself to the group and is described and treated by patients and doctors as part of the group rather than as an individual. I shall present my study here as a selection of episodes which can be taken as representing what happened during my sojourn on the ward. In order to maintain the anonymity of the people studied, names have been altered. The episodes reported consist of events that took place on different days and on occasions when different nurses and doctors took part. For example, the nurse “Anna” does not exist; she is a combination of various nurses working on the ward. I have used female names for the nurses and male names for the doctors, so as not to confuse the reader and to stress the gender identity of the occupational group. On the studied ward, however, almost half the doctors were women and one nurse was a man. It is important to note that occupational identity is socially constructed and need not correspond to the sex of the individual person who at present happens to be engaged in an occupation. The episodes described and my more theoretical comments in connection with them mainly illustrate the identity at present ascribed to the group of nurses. But we should bear in mind that these work patterns and identities are currently being called into question and are undergoing great changes - something which was particularly visible at meetings and in the visions presented to me in the interviews. Possible manifestations and effects of these changes will be discussed at the end of this article, when I will return to the notion of group identities as the building blocks of organizations. Before turning to the empirical illustrations I would first like to clarify how the identity concept is used.

correspondingly weak individual identity -

INDIVIDUAL

IDENTITY,

GROUP IDENTITY

AND ORGANIZATIONAL

IDENTITY

Much has been written about how groups interact, or counteract each other, in organizational settings. One of the most influential theoretical insights in this context is to be found in Cyert and March (1963). Traditional ideas on these matters have recently come under critical scrutiny. Meyer et al. (1987), for example, claimed that: “Most social theory takes actors (from individuals to states) and their actions as real, a priori, elements of modem social processes and institutional forms” (p. 13). Against this received picture Meyer et al. put forward another, namely “the ‘existence’ and characteristics of actors [is] socially constructed and highly problematic and action [are] the enactment of broad institutional scripts rather than a matter of internally generated autonomous choice, motivation and purpose” (p. 13). The present article subscribes to the latter view, claiming that institutionally based group identities represent the building blocks of which organizations are constructed. The identity concept used here is based on a view of modem society as being highly structured by institutional rules, i.e. theories, ideologies and prescriptions about how society as a whole - and different parts of society - work, and how they should work. The institutional structure then constitutes the basis for the identities of legitimate social entities such as individuals, occupational groups or organizations (Meyer et al., 1987; March and Olsen, 1993). Individuals acquire identities in the course of time, as they are named and recognized by others (Pizzomo, 1991). Identity formation is thus a process of structuration. Activities are assumed to be based on the expectations of the actors concerned and of those with whom they are interacting. Expectations about how a person will act in a certain situation, and interpretations of his or her

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activities, derive from the ascribed identity. This identity is then reproduced or reconstructed in a continuous narrative (Czamiawska-Joerges, 1993), in which activities are accounted for and made sense of. Activities are made sense of by being described in terms of criteria shared by others (Pizzomo, 1991). The identity is thus dependent upon what can be recognized and named, by reference to classifications and knowledge shared by others. Identity evolves as a subject interacts with others or is compared with them, but identity also determines who a subject will be compared with. Individual subjects confirm or change their identities by imitating or comparing themselves with others. However, this does not mean that identity is created in each separate interaction or relationship. As we have seen, expectations and interpretive schemes are both socially constructed and are based in societal institutions which are known and taken for granted as objective knowledge. That identities are institutionally constructed does not mean, however, that they are treated as being “out there”; rather, they are internalized, thus serving to structure the individual’s own consciousness (Berger, 1966). For example, the identities of nurses and doctors structure the daily interaction between them. The identities appear as norms for their activities and as a frame for interpreting and judging these, and are then reproduced in the continuous narration of activities. Thus, identities are reproduced and they may change as a result of interaction between doctors and nurses; but the basis for how a doctor and a nurse will act is socially grounded, and not created in each separate interaction or relationship. Individual nurses or doctors are defined as part of the group of nurses or the group of doctors. It is their “belongingness” to the group which endows the members of the group with identity and thus gives meaning to the activities carried out by the individuals, and gives order to the collective (Garfinkel, 1967). From this follows that there are boundaries between subpopulations which are perceived as more or less alike. Further, the reproduction of an identity can be described as a way of both defending and confirming the boundaries, and a change of identity as a way of conquering, dissolving or blurring them (Gergen, 1991; Pizzomo, 1991). Gender identities Gender is one of the most important bases for classifying and making sense of social events (e.g. Berger, 1966). This does not mean that all differences between men and women are inherent or natural or given once and for all (Weedon, 1987); rather, the possibility of referring to differences as being grounded in an assumed order of nature is one reason for the strength of such classifications (Douglas, 1986, p. 46). Garfinkel (1967) described how an intersexed person, Agnes, achieved a female identity and female sex status. Not only individuals, but also collectives such as occupational groups are ascribed gender identities (Bradley, 1989; Sommestad, 1992). The labour market is highly segregated. In 1985, 42% of all women employed in Sweden worked in occupations where at least 90% of the work force were women (SCB, 1990). However, the gender classification does not always automatically derive from the present composition of the group; a classification in gender terms is usually based on the traditional sex composition of the group in question (Williams, 1989). For example, even though there are many female physicians or lawyers in Sweden today, male identities are still ascribed to these occupations. Welfare work and work which is seen as having a main element of care, on the other hand are usually ascribed a female identity. Modem individuals and modern organizations are conceived as actors Modem society, it has been claimed by Meyer et al. (1987), Gergen (1991) and others, has changed the way in which we understand ourselves. The modem individual, or rather the modem

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man (this distinction is further discussed below), is assumed to be an actor, i.e. is assumed to have intentions, to be purposive, consistent and at least to some extent rational, aware of and able to control his activities. The actor is a decision-maker who is assumed to be able to make his own decisions based on intentional reasoning. An actor is also expected to be in some sense unique, or individual (Berger etal., 1973), so that actors and environments can be distinguished from one another. Identity is predominantly a concept applied to individuals; the transfer of the concept to groups or organizations follows from the notion that not only individuals in our modem society, but collectives, such as organizations and nation states, are perceived and presented as actors (Meyer et al., 1987). Czarniawska-Joerges (1993) claimed that one of the most popular modern conceptions of organizations is that of a super-person. Organizations are perceived and presented as actors who think, reason and behave in a coordinated and consistent way (see also Brunsson, 1989). In different social settings we find different combinations of individual identities, group identities and organizational identities. These levels of identities are mutually related so that changes in a group identity affect and are affected by the organizational identity. As this article is about the identity of (mainly) one occupational group, what we are concerned with is the identity of nurses as organizational members. In several of the episodes described below it is shown that while the female identity ascribed to nurses does not assign distinct identities to each individual, the professional identity ascribed to doctors does. As group identities change, this will not only change the identities ascribed to the individual organizational members whose identities are derived from the group, but it will also change the boundaries between the groups and thus the organization of the work. Thus alterations in group identities are important aspects of organizational transformations.

NURSES’ DAILY WORK The ward The ward I studied had just been created by a merger between two medical wards. Its special focus is on endocrinology and diabetes. The ward is part of a large university hospital. The staff consists of highly specialized senior physicians, assistant physicians, nurses and a few assistant nurses. The interests and competencies of the senior physicians greatly affect the way the work is done, both as regards routines and the way the patients are to be treated. Because it is a university hospital, staff turnover is quite high, especially among the assistant physicians who work on the ward as part of their specialized training. The ward has 20 beds. Most treatment is planned and consists of taking tests, diagnosing and getting people started on medication (mostly insulin). Most of the patients can look after themselves. They can take their meals in the ward’s day-room, they can make their own beds, and they can take at least some of their medicines themselves. Approximately four nurses, one assistant nurse and the head nurse work on the ward at the same time during the day. Each nurse cares for a group of patients, which means that apart from taking tests, giving medicines, helping the patients to control their insulin and so on, she also answers the phone, helps the patients to make their beds etc. This way of working differs from the earlier practice, whereby each nurse performed certain well-defined tasks, for example taking certain blood tests on all the patients on the ward. Formally there are two parallel hierarchies on the ward. The physicians are organized in one

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hierarchy. The senior physicians on the ward are subordinate to a chief physician for one sector of the medical clinic. This sector chief physician is subordinate to the clinic chief physician. The head nurse is also directly subordinate to the clinic chief physician. The nurses on the ward are formally organized in a separate hierarchy and are not subordinate to the doctors on the ward. Physiotherapists, dietitians etc., who divide their working day between several wards, form a separate formal hierarchy. It is rather interesting to note that when the ward “staff’ or simply “the staff’ is mentioned as a group, the physicians are not included. Those working on the ward were often referred to as doctors and staff. The doctors divide their work between various parts of the medical clinic, whereas the nurses usually spend their whole working day on the ward. To the doctors the ward is not seen as a bounded organization. The nurses on the other hand see the ward as an important unit, and at meetings they take up questions which help to define and support the ward as an organization. For example, they stress the importance of having regular meetings on the ward. Several differences between the occupational groups became obvious to me as I compared my experiences of them. When I accompanied a nurse, I noticed how difficult it was to get any idea of what the doctor did; for example, whether or not he had a heavy workload during the day, what difficulties he ran into during the day etc. Similarly when I accompanied a doctor I had no chance to keep track of the nurses’ work. Oral communication The day-nurses start work at 7 am when all nurses meet in the nursing office. The office is located in the middle of the ward. This is the meeting-place for everyone working on the ward. This is also where patient records, test results and most other documents concerning the current patients on the ward are filed and kept. Appointments to be remembered are written on a special list which remains on the table in the nursing office all day. The night-nurse reports to one of the day-nurses, telling her what has happened during the night, how the patients feel etc. The nurse who receives the night report then reports to the rest. In order to structure her talk she uses the patient records where patients’ personal data, medication, tests and examinations, treatment and therapies and other observations are documented. She reports on each patient: what they will be doing during the day, what they did the day before, how they feel, whether there is anything special the nurses should watch out for. In its structure this report sounded to me very much like daily small talk, like a conversation between the members of a family or between neighbours discussing what’s been happening and how they are feeling. It was a mixture of quite precise information about appointments, test results, planned examinations and treatments, and more general comments about how the patients feel, what they have done and said, and reflections about things that had happened during the night or the day before. No specialization Before this report starts, the nurses decide which patients each of them will look after during the day. They take into account which patients they know, whether any special treatments are planned for the day, whether anyone has to go to a meeting outside the ward during the day etc. A nurse and an assistant nurse sometimes share the responsibility for one room, or the nurse will take care of it on her own. The number of patients each nurse cares for differs from day to day. Some days one nurse will care for a couple of patients, other days she cares for eight or ten. Although the nurses represent the two different specializations that merged when the ward was created, so that some are more highly specialized in endocrinology and others in diabetes, this is not the most important criterion for allocating the day’s work.

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In the morning the nurses also decide the approximate time for their lunch breaks. They cannot all take lunch at the same time. One day the head nurse told the group of nurses that one of the assistant nurses had asked if the lunch breaks could be decided definitely in the morning, but the other nurses objected, saying it was impossible for them to plan the day in advance. This was one of the many occasions when it became obvious that nurses’ work is seen in terms of adapting to others: to other people’s work, to their demands and appointments, or to whatever might happen during the day. The nurses’ work is now-oriented and characterized by constant adjustments of this kind. A focus on the present (in contrast to a focus on the future or on the history) has been found to be common in groups which perceive themselves as lacking control (Leshan, 1952). This time-orientation can thus be seen as deriving from and reproducing the nurses’ subordination to others. The group of nurses constituted a bounded actor One day I accompanied Anna, one of the nurses. After the morning-report, we started taking blood tests. Before we had finished, we had to portion out the medicines. When we went back to the blood testing, we found that someone else had taken the tests we were doing when we left to portion out the medicines. As we entered the nursing office, another nurse told us that she had centrifugalized some of our blood tests. The blood tests have to remain in the test-tube for half an hour or so before being centrifugalized. Now, the other nurse had found the tubes on a table (where all blood tests are kept before being sent away to the lab), and she knew that we had taken them earlier in the morning. As we walked along the corridor a couple of patients approached us and asked why they hadn’t had their morning medicine yet. These were not “our” patients for the day. Probably the nurse who was responsible for these patients had had to postpone this task for a while. We told the patients that she would be with them in a minute. Another patient asked for an aspirin since she had a bad headache. We gave her an aspirin and made a note of it in her record. When we met one of the other nurses, Anna told her about the headache and the aspirin. Anna then called at another ward to report on one of our patients who was going to be moved there later that day. While Anna was talking on the phone, Christine passed her and asked her to deal with some tests which needed to be taken at 9 o’clock when she herself would be at a meeting. Anna agreed. She already knew what test it was. Before Anna had ended the telephone call, however, the head nurse came and told her that she was to deal with Christine’s test. Almost immediately she returned and told us that Christine’s test had already been dealt with by someone else. We then dealt with a specimen of urine. Usually the assistant nurse does this, but since we had a little time to spare we coped with it. Since Anna does not do this kind of test very often, she followed the instructions in a written manual step by step. It was then time for one of our patients to go for an examination in another part of the hospital. Anna checked her watch and said: “We’ve got time so we can go with him. That way we save 100 crowns or so, because that’s what our ward has to pay for an orderly to come and collect him.” When we returned to the nursing office we found a bit of an upset. A patient had arrived, and none of the nurses had expected her. The nurses were irritated, since they assumed it meant the doctors hadn’t informed them. But Anna did actually know about the patient. One of the senior physicians had told her the previous afternoon. She had a note about it in her pocket, but had forgotten to tell the others during the report meeting in the morning. Another nurse just remembered that she had also got some information from the senior physician. He wanted to introduce new routines for a certain test. The head nurse commented in an irritated voice “All

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that sort of information is supposed to go through me, otherwise how can I be sure that everyone’s been told?‘. Both patients and doctors would often approach a nurse - either giving or asking for information. The nurses were approached as a group - as a single actor-rather than as separate individuals. Doctors and patients told one of them and assumed that the information would spread through the group. And this was usually the case. The nurses shared tasks and information; they felt joint responsibility for tasks to be done. The nurses continuously told each other what happened. They checked with each other if they were in a hurry or if they needed help. They asked one another to give a hand, or they just took over each other’s work when they saw something that needed to be done. They asked each other for help or information. They commented on patients, on tasks or on things happening to themselves or others. They tried to keep everyone in the group informed about the work the rest were doing. Within the group, as well as in the interaction between their own and other groups, action was taken on the assumption that every member of the group could and should be aware of everything the other members were doing. Members of the group were seen as interchangeable. The nurses filled in for each other. The nurses’ way of handling tasks, of interacting among themselves and with others, confirmed repeatedly that the group as a whole was perceived as a single actor: an internally controlled, coherent and consistent entity that is aware of what it is doing and which has clear boundaries vis-d-vis the rest of the world. The boundary-lines between the nurses’ and the doctors’ groups in particular were never questioned, but were regarded as distinct and clearcut. The boundaries between the nurses and assistant nurses and others working on the ward were less clear. Nurses and assistant nurses often shared tasks and, whenever possible, filled in for each other. That the nurses were perceived and presented as a coherent and consistent group, that they . represented a single actor with an ascribed identity, does not mean that all nurses were alike. As I accompanied the nurses in their daily work, I found that they all had their different ways of working. While a few strictly followed the rules and regulations, asking the doctors about every move they made, others often took the initiative themselves. They simply reported formally after the event, but drew their own conclusions about what to do in certain situations. Common identities need not mean that individual experiences are alike. Weedon (1987) emphasized that the language and commonsense knowledge of a group, or about it, reflects and reaffirms social acceptance. Thus experiences are interpreted and perceived in terms of the widely accepted and ascribed group identity. Thus, as will be shown below, the different identities of doctors and nurses reflect conventional group categorizations, rather than the unique experiences of the separate individuals. I hardly ever heard comments about, or references to, individual differences among the nurses. The individual identities of the group members were not emphasized. Even though the formal organization of the nurses prescribed that each nurse should be responsible for a certain number of patients, thus assuming clear boundaries between nurses, this was no taken-for-granted order. As we have seen, the nurses generally functioned as one coherent body, but there were clear boundaries between the nurses and others, especially between nurses and doctors. There was hardly ever any uncertainty about which tasks belonged to the nurse and which to the doctors. It was not assumed that information would spread automatically between doctors and nurses. The interplay between modern and premodern identities At the end of the day Anna went through the patients’ records. She checked that she had done everything that was planned for the day and that she had documented it all, and she made notes

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about important activities, appointments etc. for the next day. She found some notes about examinations in other clinics and picked up the phone to make the appointments for them. She also arranged a patient file for a patient who was coming in the next day. The file contains personal data, appointments for tests and examinations and medication. The nurses also note any instructions about the daily routines to be followed, and document everything done for the patients in these files. Anna wrote that a certain person’s temperature should be taken twice a day. I asked her how she knew what directives to write. She answered: “I know that Dr. Svensson likes this for his patients.” The nurses as a collective responded to the needs and wants of the individual doctors. The nurses seldom go to just any doctor for information; nearly always they need to give or get information from a specific doctor, and they know how to adjust their own work to the individual doctors. A distinct group identity is also ascribed to the doctors, with clear boundaries between their own and other groups. Group identities of this kind are one of the basic features that define a profession, and professionalization strategies are usually strategies aimed at establishing, strengthening and maintaining group boundaries (Collins, 1979; Bourdieu, 1988). However, unlike the nurses’ group identity, the doctors’ allows for individual differences. Again, unlike the nurses, every individual doctor was addressed and perceived as an actor. There were clear boundaries between individual doctors. It was not assumed that every doctor would know everything the other doctors did, and differences between doctors were often referred to and allowed for, not only among the doctors themselves, but also in their interaction with others outside their group. The identity of the doctors accords well with the identity ascribed to modern man. Although he is part of a collective, each one is perceived as an autonomous, purposive and reasoning actor who controls his own activities. The collective is perceived as a supplier of knowledge - a device for the individual’s reasoning and decision making - rather than an entity controlling the individual doctors. The nurses’ identity, on the other hand, could be described as premodem. A premodern self* is identified as an exemplar of a more general category (Gergen, 1991). Activities are seen as based on intuition and experience rather than on rational reasoning. The purpose of actions is to be found not in individual intentions, but in adjustments and accountability to the community (for further comparisons between modem identities and other historical forms of identity relevant to explaining the transformation of organizations, see Czarniawska-Joerges, 1993). These differences in the group identities of nurses and doctors correspond closely to conventional societal gender categorizations, i.e. to differences in male and female identities. Women are traditionally identified as part of a collective, while men are identified as autonomous individuals (Ferguson, 199 1; Gergen, 199 1). Thus the identity of the nurses is not only a female but also a premodern identity which stands in sharp contrast to the identity of the modem man. Subordination and adjustment Another day I accompanied Helena, who is assistant head nurse. She handles the ward’s waiting list. Helena has brief notes and forms on which the doctors have written approximately when and why a person needs to be called to the ward. Helena explained to me, pointing at a

*To talk about a premodem identity is of course an oversimplification. However, as in our present context it serves as a contrast with the modem identity, we need no elaborate descriptions of different premodem variants; this short list of characteristics that summarize some premodem identity traits can suffice.

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whole pile of papers marked urgent, “I can’t tell which is the most urgent - who is worst. The doctor has to do that, but I try to check myself first. For example I can see if the patient is already having treatment, whether the patient has been here before and if so when, and so on”. Going through her pile of papers, she put some of them aside; these were cases on which she needed clarification from the doctor. Others she sorted into two piles - very urgent and less urgent. Before calling the person to the hospital Helena makes appointments for the various tests, X-rays and examinations in other clinics that the doctor has asked for on the intake form. Helena also sends for patient records and X-rays from other hospitals. She explained to me: “I’ve sent for the X-rays from this patient’s local hospital. They are to be discussed during the Xray-round next week. I ought to check if they’ve arrived. Because of the way formal responsibility is allocated, I have to send for them in the doctor’s name, not in my own. So it’s difficult for me to know if and when they arrive.” The extensive authorization system, whereby the doctors have to sign all notes in the patient records about medical treatment, and only doctors are allowed to request certain types of information, reflects and reinforces the intergroup boundaries. Although the nurses frequently take an active part in the doctors’ daily activities, the clearcut boundarylines between the groups is nevertheless maintained in all the documentation, and in the formal allocation of authority and responsibility. Thus the separate group identities and the subordination of the nurses to the doctors are both emphasized and reproduced in the formal representation of their work. Abbott (1988) showed that differences between professionals and semiprofessionals, such as those between doctors and nurses, are more evident in formal documentation and organizing than in the daily work. Further, this affects people’s expectations vis-ri-vis nurses and doctors, and the relations between them. Formal documentation and organizing are part of the continuous narration of activities that construct and reconstruct identities. Nurses are regarded as subordinate to doctors; they constantly adjust the timing and content of their work to the doctors’ requirements. The following is another illustration of this: when the evening nurses arrive in the afternoon, the day nurses report to them just as the night nurse does to the day nurses in the morning, so Anna told the evening staff about a new patient who had arrived before lunch “This patient has some kind of wound that needs seeing to. However, the patient couldn’t tell me all about it because the medical student who was to examine him arrived before we’d finished talking about it”. One morning we were going to take a test of a kind that required the presence of a doctor. Anna called for the doctor who had not yet arrived at our ward. It was going to take a while before he could get there, so Anna told Christine, another nurse, that she would help her to wash a patient in the meantime. The patient was at present in the bathroom and was going to ring a bell when she needed help. Just as the bell rang, the doctor arrived. Anna then asked Sofia, another nurse, to help Christine wash the patient, while we took the planned blood test instead. Around nine o’clock the doctors’ round usually begins. A couple of days a week the senior physicians and professors attend these rounds. On other days the assistant physician does it alone, generally with a group of medical students in attendance. First of all everyone attending the round sits down, and they discuss the patients one by one: diagnosis, treatment, what tests and examinations ought to be done, when the person can go home etc. In some ways the structure of these rounds resembles the nurses’ reports, with a combination of concrete information, reflections and some small talk. But this is a more focused meeting, with clear authority; the topics to be discussed are also more clearly predefined. It is the doctor - the senior physician when he is there - who leads the meeting. The doctors ask the nurse for some information, the nurse takes notes about the treatment and tests which the doctors have decided. These notes are

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then signed by one of the doctors. When students are in attendance the meetings often take the form of a lecturing session or seminar, which serves to reinforce and reproduce the authority structure in the group attending the meeting. After the meeting the group walks round the ward, getting information from the patients and giving them information in return. Since the nurses have organized their work so that each nurse is responsible for the care of a group of patients during the day, different nurses have to attend the round depending on which patient is being discussed. For example, the three patients for whom Anna is responsible are discussed and seen first; then Anna has to leave the room and Christine who is responsible for the next five patients comes in instead. This has caused some irritation among the doctors. They find the system time-consuming and confusing. One question that came up over and over again, when the organization of work was discussed at meetings, was whether or not the nurses need to walk round the ward with the doctors. It was agreed by both nurses and doctors, that they should. During my study, however, the practical problems had not (yet?) been solved. On several of the days when I accompanied the nurses, we started to walk round with the doctors, but left again after a couple of minutes and continued working on other matters instead. A prominent element in the traditional view of women is that they are the objects and men the subjects, the role of the woman being to please and support the man (Smith, 1990). During the rounds the nurses were treated as people who were there to support and inform the doctors. When the nurses walked round the ward with the doctors, there would come a point when the doctor did not seem to need any more information; the nurses then usually pointed out that they had done all that was necessary, and left. These examples of nursing accord well with results from other studies of nursing in Sweden (e.g. Lindgren, 1992). Even by authors who do not seem to have been very interested initially in the question of gender, the issue is at least mentioned (e.g. in several studies of nurses such as Becher, 1990; Elzinga, 1990). It seems to be such a basic classification that it is difficult to ignore it in any study of health care organizations. However, current patterns of presentation and interaction show that the nurses’ group identity is being questioned, and efforts are being made to change it.

AIMING AT MORE INDIVIDUALIZED

IDENTITIES

At a meeting later in the afternoon with the head nurse, the assistant head nurse and all the doctors, the head nurse emphasized the importance of formal structures and claimed that meetings at least between her and the senior physicians should be held regularly, that information from the doctors to the staff about routines etc. should follow the formal structure, that she as head of staff needed to be kept informed. This is one of several examples of nurses reacting against their identity as a single actor, subordinate to the doctors and adjusting to their needs. The nurses described the current pattern of interaction, with its heavy reliance on oral communication and their own subordination to the doctors, as problematic. They strove to achieve more structure and autonomy in their work. In their interaction with doctors the nurses stressed the need for formal structures, for administration, for plans and schedules to be kept. On the notice board in the nursing office there was a typed note with the following text: “New round schedule from 3rd February will be evaluated later” (then follows the new schedule). The note was placed there by the head nurse, and is another example of the nurses’ quest for more fixed administrative routines.

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Among themselves the nurses also stressed the need for a clearer division of responsibility. And this discussion did not originate on the local ward; rather, the discussions and changes on the local ward reflected changes in the occupational group and the health care system in the country as a whole. One example of this is that the head nurse has been given a new title. In Swedish the old title was avdelningsfiirest&zdare (roughly ward superintendent), while the new one which has been introduced in several places is vdrdavdelningsschef (ward manager). This new title emphasizes her role as head of the ward more clearly than before. The new title is also more in line with modern management terminology. I attended a one-day conference for head nurses in the hospital. Common themes in the speeches were: the need for extended documentation, a clearer allocation of individual responsibility, and the importance of questioning routines. Frequent references were made to management, business and science. The importance of greater continuity in the work of individual nurses was emphasized. In conversations during lunch breaks in the ward, the nurses also stressed the need for greater continuity and their desire to achieve it. As the emphasis on continuity increases, the question of documentation becomes crucial. Previously, everything which the nurses documented, often only in the form of brief reminder notes, was thrown out once the patient had left the hospital. Only documentation produced by the doctors was saved. Now, the nurses’ documentation is also saved in the patient record, where an increasing amount of information is included about how the patients are being treated and how they respond to different stages in their treatment. Courses on documentation are currently being run for nurses. Nonetheless, oral communication dominates the interaction among the nurses, and they regularly describe this means of communication as problematic. They think it is timeconsuming and imprecise, often leaving it unclear who has done what, and who has made which decisions. The unclear division of responsibility and lack of strict planning which result from the way of working, are also seen as a problem. The nurses would like to see responsibility allocated more clearly. The ideal, they tell me, is for each nurse to have full responsibility for a few patients, and for oral reports to be almost entirely abandoned, so that most interaction could utilize written documents. The nurses told me about other hospitals where the nurses’ work had been reorganized in this way. I visited one such hospital which had been described to me as being organized in a “modern” way. Its written documentation was far more elaborate and oral reporting was kept to a minimum. Individual responsibility was emphasized, and the nurses planned their working days and their care of the patients in advance to a greater extent, and largely as a separate activity that was not simply subordinated and adjusted to the doctors’ medical treatment. These developments are signs of a reaction against the group-identity described above. Especially those aspects of nursing which have been most closely associated with the female identity of the job - the lack of differences between the members of the group, the constant adjustments to others, keeping track of others and subordinating oneself to them, the continuous emphasis on the group rather than the individual, the now-orientation, the emphasis on oral communication and experience-based knowledge - all these are being questioned and great efforts made to change them. This sort of strategy is not unique to nursing. Zuboff wrote “Efforts to optimize the production process tend to concentrate on three strategic objectives: increased continuity, controllability and comprehensibility” (1985, p. 104). We recognize these terms from the definition of the wellfunctioning actor, as it was defined at the beginning of this article. The current discussion among nurses reflects a tendency to strengthen the identity of the individual nurse as a single actor, while the current strategy involves a move away from a premodern, collective identity and towards a

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modern identity, the individual actor-nurse. This strategy corresponds closely to the reconceptualization of women, who used to be - and to a great extent still are - ascribed more or less premodern identities, in the sense that they are seen as a collective, of which every individual woman is an exemplar who is thus subordinated to the collective; at the same time the collective as a whole is subordinated to men. The construction of a female identity has recently undergone great changes, partly in reaction to the common binary opposition between male and female (see Ferguson, 1991, for an overview). One such change is that women are beginning to be seen less as a collective and more as a group of individuals - as separate actors who may exhibit great differences among themselves. From this it can be concluded that the differences among women may in many aspects be greater than the differences between men and women. This altered social construction of gender also affects the identity of the group of nurses, and thus the boundaries between the nurses and the doctors. We may perhaps ask ourselves whether nurses will achieve an identity as modern actors, or whether together with postmodem man - and thus possibly organizational members in general -they will acquire a paradoxical and relational postmodem identity that would be componential, fragmented or anonymized (Berger et al., 1973; Gergen, 1991). However, this is not a topic to pursue in our present context. Instead I shall present some comments about the possible organizational changes that may result from the current changes in group identities.

THE DISSOLUTION

OF GROUP IDENTITIES

In the introduction and empirical illustrations above I have shown that individual identities, group identities and organizational identities are mutually dependent. We can expect that when the nurses’ group identity does change, this will affect not only relations among the nurses themselves, but also the boundaries between the nurses and other groups. Just as the nurses in my examples interacted with each individual doctor, so may the interaction between a nurse and another group or another individual - if the identity of the nurses does become more individualized - take the form of an interaction between the individual nurse and the other. Given such a development, the differences between individual nurses may come to be noted and referred to more frequently than they are today. Another way of describing such a possible development is to say that the group of nurses will dissolve and cease to exist as a coherent actor. Gergen (1991) claimed that one feature of the (post)modern society is that traditional categories and genres are blended and re-formed. As this happens, what used to be easily identifiable and classifiable spills across borders, merges, melds and mixes. Distinct groups are no longer as easy to identify. Gender is one such active site for the redefinition of human nature (see also Weedon, 1987). It is no longer as easy to distinguish ways in which girls or women are supposed to be different from boys or men. The categories on which the ascribed identities are based become blurred (Gergen, 1991). The changed identity is partly a result of the above-mentioned strategies pursued by nurses and of the reconceptualizing of gender, but it also stems from the fact that the medical and nursing professions are becoming increasingly gender-mixed. As long as most doctors were men and nurses were women, each group seemed to be quite coherent and distinct. The difference in appearance, assigned tasks and behaviour between doctors and nurses, for example, seemed obvious and the order in these organizations thus appeared self-evident. Nonetheless, obvious differences in appearance between these groups are still maintained. We have seen examples as

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regards clothing and documentation methods above. However, as the differences between the groups in terms of gender identity weakens, the particular distinction between them that might have been the most basic and clear, is no longer present. The boundary between the groups may then become less distinct, and it may be more possible than before to question and discuss the division of work. As a group changes identity the change will affect not only the way activities are carried out and interpreted within the group but also relations between various groups and the division of labour as well. The distinction between the groups is no longer regarded as given; there is no longer a taken-for-granted order of things. At the beginning of this article I pointed out that identities can be found at three levels in organizations, namely the organizational identity, the group identity and the individual identity, and that these are mutually dependent. I have shown that the identity ascribed to nurses did not allow for individual differences. Further, the group identities in the hospital were not subordinated to a common organizational identity. The groups defined various units as being organizationally relevant. In organizations that consist of distinct groups, the organizational identity often seems to be weak. Groups are the building blocks of such organizations. When these building blocks dissolve, an organizational identity may replace them as the presenter and interpreter of the organization’s activities. It will thus be the organization, rather than separate groups, which will be defined as “an actor” with clear boundaries distinguishing insiders from outsiders. Well functioning actors were described above as individuals who are aware of their own activities and can account for them. An actor is defined as a consistent and coherent entity which is often assumed to be controlled by one sovereign, i.e. it is led from the top. When the organization is viewed as a single actor, the hierarchical dimension of the organization is stressed. In such a perspective, the way of organizing is often described in terms associated with the individual; i.e. the head thinks and the hands and feet - the people on the floor - make the moves decided by the head. This kind of terminology is not well suited to organizations composed of a number of groups with separate identities and with clear boundaries between them. Professional groups cannot be easily subordinated to this kind of organizational identity. When groups dissolve we can expect that an individualized conception of the organization may replace the idea of the organization composed of groups. Just as we expect a person to know what she is doing and assume that her thoughts at least partly control her actions, so we expect a modern organization to be controlled by its head and assume that its head can account for what the organization is doing. This does not mean that groups become irrelevant, but that group identities are derived from and subordinated to the organizational identity. Boundaries between the organization and its environment are emphasized. Common organizational policies are developed which distinguish the organization from its environment. In such an organization control, the organization of work and the allocation of tasks and responsibilities will be defined as managerial tasks, rather than being regarded as part of a pattern given by the distinct group identities.

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