Organizational Identity Struggles and Reconstruction During Organizational Change: Narratives as symbolic,emotional and practical glue

Abstract

The article offers a novel perspective on the formation of organizational identity (OI) during major organizational change. The empirical context of our studies is the establishment of a new acute care department and the reorganization of care, where nurses and managers struggle to construct and reclaim a legitimate identity within the hospital and simultaneously strive to gain a leading position among acute care departments in the country. We use Bourdieu’s theoretical ideas combined with a focus on narratives as an original and fertile perspective for studying OI. We propose that OI is inherently temporal, embodied and socially configured and cannot be separated from the institutionalized context of its setting because it is interlaced with (in this case) health professional logics. We show how OI is constructed through the strategizing moves of managers and nurses. This includes their narrative constructions of their quest for care progression and a legitimate OI that function as symbolic, emotional and practical glue.

Keywords

Bourdieu hospital department narratives nursing organizational change organizational identity strategizing

Introduction

Starting from the premise that organizational identity (OI) is shaped by the interrelation between social structures and embodied socialized actions of organizational members, this article offers a novel perspective on the formation of OI during a major organizational change, where OI is found to be particularly salient (Alvesson & Robertson, 2016; Carlsen, 2006; Corley, 2004; Whetten, 2006).

Identity construction in organizations is recognized by several authors s a fertile perspective for understanding a range of organizational processes and outcomes as well as offering ‘great theoretical promise’ (Alvesson, Lee Ashcraft, & Thomas, 2008, p. 7; Brown, 2019; Coupland & Brown, 2012). The OI literature is vast, but there are still unresolved issues worth grappling with, which may lay the groundwork for an extended understanding of OI and further theoretical and empirical contributions (Brown, 2019). These include questions that concern the nature of OI, how it emerges or is constructed (e.g. Alvesson & Robertson, 2016; Brown, 2019; Corley, 2004; Oliver, 2015; Watson, 2016), and along these lines, the scope for agency in identity generation (Albert & Whetten, 1985; Alvesson et al., 2008; Alvesson & Willmott, 2002; Doolin, 2002). Moreover, recent discussions have drawn attention to issues that so far have been neglected. These include how macro-level contextual factors are connected to micro-level identity processes (Alvesson et al., 2008; Alvesson & Robertson, 2016; Brown, 2019), and how embracing the embodied aspects of OI offers promises for new insights, which involves a break with more traditional cognitive approaches (Carlsen, 2016; Harquail & Wilcox King, 2010; Knights & Clarke, 2017).

We advance a theoretical framework, inspired by Bourdieu’s theoretical ideas (Bourdieu, 1991, 1998), allowing us to analyse the formation of OI as the embodied strategizing moves of organizational members, transpiring in a dialectic between macro-level political ideas and micro-level practical activities. Bourdieu (1998) explains strategizing as temporal and embodied – as a habitus-generated capacity for skilled anticipation of the future, informed by the past and the present.

A Bourdieu-inspired theorization of OI is new in the literature, and by uncovering the how, what and why of OI construction (Alvesson et al., 2008), we aim to demonstrate its virtues for generating novel understandings of OI. The perspective theorizes OI as inherently social and relational as it emerges as the material as well as symbolic and perceived differences to other (intra- or extra-organizational) groups. Moreover, we see identity as both dispositional and mobilized (Bottero, 2010; Bourdieu, 1991), whereby OI formation is concerned with questions of agency and structure.

In our data, we identified the narrative construction of organizational members as salient for how they sought to establish and claim new OI. Narratives are generally recognized as a theoretical perspective for OI (Brown, 2006; Carlsen, 2016; Humphreys & Brown, 2002; Rhodes & Brown, 2005), and we complement Bourdieu’s pillar concepts of field, habitus and capital with a narrative perspective, where we understand narratives as embodied performative discourse (Bourdieu, 1991; Fleetwood, 2016; Menary, 2008). We propose that rethinking OI along these lines has major implications for understanding the social and political nature of OI construction and constitution.

We draw on an ethnographic study, as we examine how and why the establishment of a new acute care department (with the pseudonym department Q) was marked by identity struggles and positioning battles, both within the hospital organization as well as in relation to other acute care departments in the country. We focus on hospitals as a particular kind of organization for OI constitution, where institutionalized professional logics dominate (Currie, Finn, & Martin, 2009; Forty, 1980; Wicks, 1998), and we show how OI is conditioned on these logics. Thus, whereas the majority of OI studies commonly focus on identity at the organizational level, ‘who we are as an organization’ (Alvesson et al., 2008), we identify the OI fault lines along that which has particular and differentiating value in the hospital field (Currie et al., 2009; Ernst & Jensen, 2018a). We thus respond to a call by Carlsen (2016, p. 124), who suggests that we should go beyond the question of OI as organizational integration, to a question of ‘what is going on here that is potentially identity salient?’ We thus seek to challenge and extend existing knowledge on OI, by suggesting a perspective where identity construction progresses through the everyday strategizing moves of organizational members in an alternating and mutually constituting relationship with the outside world.

Our study shows that the core ideas upon which the new department rested were challenged by the rest of the hospital organization, and therefore, the desired identity of the department could not gain acceptance (Croft, Currie, & Lockett, 2015; Thornborrow & Brown, 2009). Achieving a legitimate identity within the organization thus required skilful strategizing by the department management and the nurses, and an epic story of pioneering for the improvement of care was constructed (Frye, 1990; Gabriel, 2000). This story tied the staff together as a group in opposition to the rest of the organization and in competition with other acute care departments in the country. We thus show how nurses and managers engaged in what we term ‘double positioning’ struggles – within the organization and outwards to the wider field.

In the remainder of the article, we sketch the literature that we draw on in our conceptualization of OI, and how we see our paper offering an extended understanding. After having outlined our theoretical framework, we explain how we conducted our empirical studies, and present our empirical data. Finally, we discuss our findings and our contributions to the literature.

Approaches and Challenges to Understanding OI

We propose a theorization of OI through Bourdieu’s pillar concepts of field, habitus and capital, which connect all levels of the field. The field is a construct Bourdieu uses to describe the social arena where (professional and organizational) life takes place. Habitus is an embodied system of socialized pre-verbal dispositions that shape and structure perceptions and actions, and capitals are the strived-for resources of a field that structure it and determine the position of agents in the field (Bourdieu, 1990; Lockett, Currie, Finn, Martin, & Waring, 2014). In the context of our study, habitus, capital and field connect the strategizing moves of nurses and managers at the hospital floor with the level of organizational strategy, as well as with the forces of the wider hospital field that influence the local formation of OI (see, for example, Ernst & Jensen, 2018b). In the following, we address some challenges in the OI literature that allow us to make empirical and theoretical contributions to it.

The classic conceptualization of OI (Hoon & Jacobs, 2014) has its roots in the tradition of functionalism, where OI derives from formal aspects of the organization, and from managerial attempts at identity control through values, goals and mission statements (Alvesson et al., 2008). It draws primarily on Albert and Whetten’s (1985) identity characteristics of centrality, endurance and distinction, where OI is seen as a collective, homogeneous and relatively stable construct that unites organizational members (e.g. Evans, 2015; Gioia, Schultz, & Corley, 2000; King & Whetten, 2008; Ravasi & Phillips, 2011). We argue that this perspective on OI may run into difficulties in the face of empirical cases, where OI displays more heterogeneous characteristics construed by multiple groups and stakeholders inside and outside the organization (Corley, 2004; Harris, 2011; Pratt & Rafaeli, 1997). Moreover, it has been observed that much of the OI literature suffers from a traditional cognitive bias ‘whereby identity is treated as something principally residing in the minds of organizational members’ (Harquail & Wilcox King, 2010; Knights & Clarke, 2017; Nag, Corley, & Gioia, 2007, p. 824). For example, Gioia, Thomas, Clark and Chittipeddi (1994, p. 363) assert that strategic change involves a ‘cognitive reorientation’ of the organization, and Haslam, Postmes and Ellemers (2003, p. 364) suggest that shared OI forms the basis of a ‘form of collective mind’. The latter study draws on social identity theory (Ashforth & Mael, 1996; Turner & Tajfel, 1982), which has been highly influential in OI studies, with its focus on the psychological foundation of the identity concept, and what are seen as impasses between the individual and collective levels of OI (e.g. Alvesson, 2000; Haslam et al., 2003; Ozdora-Aksak, 2015). However, we find that these perspectives neglect the embodied aspects of identity construction, and therefore fail to see how identity is socially configured and sustained (Harquail & Wilcox King, 2010; Nag et al., 2007).

We are inspired by a limited literature originating from ‘the practice turn’ in social theory, which maintains that OI is crafted and instituted in organizational practice (e.g. Bourdieu, 1991; Carlsen, 2006, 2016; Nag et al., 2007; Oliver, 2015; Schatzki, Savigny, & Cetina, 2001). Practice theories are fundamentally in opposition to Cartesian social ontology thats split subject and object, intention and cause, the material and the symbolic, and the mental and the real (Oliver, 2015; Schatzki et al., 2001). The practice concept links the here and now of everyday social practice with its historical genesis, rendering OI a contextually and temporally bound concept (Carlsen, 2016; Oliver, 2015). Specifically, OI has been linked to ways in which practitioners use knowledge to proceed in day-to-day organizational life (Carlsen, 2016; Nag et al., 2007; Oliver, 2015), where Carlsen (2016) suggests that identity formation is embedded in formative organizational practices that include identity-producing discourse.

The practice-oriented OI literature has often connected identity formation with the concept of strategy, where, for example, OI is seen as emerging out of ‘strategizing’ processes. Strategizing is, however, predominantly seen as calculated processes, through which managers construct plans to control the future (Carlsen, 2006; Harris, 2011; Hoon & Jacobs, 2014; Nag et al., 2007; Oliver, 2015), seeing these processes as rational and disembodied (Chia & MacKay, 2007; Minocha & Stonehouse, 2007). Moreover, this literature tends to see OI as a monolithic and strategic organizational asset, that restricts strategizing to managerial activities, and is predominantly interested in the study of situated activities and thus on micro-level practices (Chia & MacKay, 2007; Whittington, 2003). Thereby it fails to see how local OI formation activities are embedded in wider societal forces (Chia & MacKay, 2007). Drawing on Bourdieu (1998), we understand strategizing as temporal and embodied – as a habitus-generated capacity for skilled anticipation of the future informed by the past and the present, meaning that OI formation transpires in a dialectic between macro-level political action and micro-level practical activities.

Another dominant strand in the OI literature has studied OI through discourse, for example, through the analysis of organizational narratives (e.g. Brown, 2006; Carlsen, 2016; Coupland & Brown, 2012). Our study builds on contributions from this literature where organizations encompass several possible identity constructions at group level, and different identities compete for legitimacy (Humphreys & Brown, 2002; Rhodes & Brown, 2005). Discursive perspectives, however, are criticized for presenting OI as an almost exclusively linguistic phenomenon, resulting in a neglect of embodied understandings (Knights & Clarke, 2017). While acknowledging this critique, we aim to contribute to this literature by showing how narrative identity constructions are socially configured, and thus products of a social and political context. We do so by suggesting that narrative OI construction can be seen as sequences of embodied experiences and perceptions through Bourdieu’s habitus concept (Bottero, 2010; Carlsen, 2016; Fleetwood, 2016; Harquail & Wilcox King, 2010; Menary, 2008). Hence, when coupling the narrative constructions of organizational agents with Bourdieu’s habitus concept, we see these narratives as generated by pre-verbal dispositions for perception and acting in the world (Fleetwood, 2016; Menary, 2008). Since habitus is temporally and socially grounded, this approach to OI provides a way of engaging with the contextual, temporal and relational aspects of organizational life (Carlsen, 2016; Fleetwood, 2016). Thus, where, for example, Harquail and Wilcox King (2010) see organizational discourse as ‘interpreted and enriched through members’ embodied modalities, we argue that discourse is actively generated by the socialized embodied dispositions of organizational members (Carlsen, 2016; Fleetwood, 2016; Menary, 2008).

In summary, we seek to challenge and extend existing knowledge of OI by suggesting a perspective where OI construction progresses through the everyday strategizing moves of organizational members, which we term identity strategizing and where the narrative construction of OI is an important part of these moves. We explain this further in the theory section.

Theoretical Framework: Embodied Strategizing and OI Narratives in the Hospital Field

We suggest that Bourdieu’s concepts of field, habitus and capital are central for understanding organizational strategizing and identity formation. Inspired by this perspective, we understand OI as the dynamic, material and symbolic characteristics that differentiate organizational agents in a particular field along the fault lines that define capital in the field.

Bourdieu (1990) defines fields as sections of the social world held together by a common interest, implying that something is at stake for its members, as they invest in ‘games’ (Bourdieu, 1990, p. 67) in their efforts to win and accumulate the capital of the field. By using the ‘game’ metaphor, Bourdieu underscores the competitive and social dynamics of fields, which render them arenas of struggle for their members. Individuals, organizations and groups are thus players whose conduct is driven by taken-for-granted rules, or doxas, grounded in a fundamental belief in the game. Capital is socially efficient properties and resources that produce differentiation among individuals and groups and which are at stake in the field (Lamaison & Bourdieu, 1986). While each field in this way has its own capital, Bourdieu (1986) distinguishes between generic forms of capital. Of these, we emphasize cultural, social and symbolic capital as having importance for our study. Cultural capital is educational merits and knowledge, more broadly, embodied through time as socialized dispositions and thereby ‘converted into an integral part of the person’ that orients professional values (Bourdieu, 1986, p. 12; Lockett et al., 2014). Social capital consists of the effective connections of the individual and is associated with the membership of durable networks that owns collectively earned capital. Finally, building on the argument that the symbolic properties of the social have equal world-making powers as have its material characteristics, Bourdieu (1990) refers to the connotative value of capital with the concept of symbolic capital, which is the form that capitals take when they are legitimate and important in a field, yet the scale of their importance remains unseen (Bourdieu, 1986).

Being a member of an organization implies a membership of a given field in which the organization is embedded. The hospital field emerges as a particular field of forces, which is structured by the history and conditions that set it apart from other fields (Bourdieu, 1989, 1998). The field is competitive in that individual hospitals compete for funding and prestige, for example, as nominations and prizes concerning the performance of care. Moreover, each hospital constitutes a local competitive space, in which departments and staff compete for positions, legitimacy and prestige won by capital in the shape of, for example, clinical knowledge or specialization (Ernst & Jensen, 2018a), which produces differentiation and identity among staff. This is exemplified in the results section.

Hospitals are characterized by the fact that their development is tied to the development of the health professions, whose professional logics organize care (Currie et al., 2009; Forty, 1980; Wicks, 1998). Hospitals are thus institutionalized as interlaced with and dependent on the health professions. Even if recent attempts have laboured to render hospitals more market dependant and enterprising under neo-liberal transformation guises (Wallenburg, Quartz, & Bal, 2016), we believe that ‘the profession factor’ carries immense importance in relation to OI. We understand a profession as an exclusive occupational group that comes into being through its claims to extraordinary knowledge and skill (Abbott, 1988). In Bourdieu’s relational perspective, the professional and OI of a group of hospital nurses emerges through a comparison of the capital that characterizes one’s own group with that characterizing other groups. The perceived differences are distinctive features carrying symbolic significance in identity formation and claim (Bourdieu, 1991, 1998).

We link this relational understanding of the profession concept with Bourdieu’s (1990) habitus concept. Habitus is a social product consisting of dispositions for action and perception, a product of the field in which socialization takes place, where nurses become knowledgeable through their practical engagement with the social rules of the hospital field (Rehn & Eliasson, 2015). Habitus allows us to understand organizational being as an embodied state (Fleetwood, 2016), where the learned becomes institutionalized as cultural capital (Lockett et al., 2014; Tatli & Özbilgin, 2012) that establishes the representative capacity of a nursing identity. Habitus is what makes a practitioner adept at navigating and acting successfully in the field through the ‘practical sense’, which is a pre-reflexive relation to the world (Bourdieu, 1990).

Hence, for Bourdieu (1986), agents’ strategizing in practice are the everyday habitus-generated moves by which they engage in ‘social games’ (Bourdieu, 1990, p. 66). In consequence, strategizing does not result from rational choices, but from the connection between a habitus and a field, which contains the ability to assess the objective potentialities as well as the limitations of the field in relation to one’s own position in it, given by the nature and amount of capital one possesses (Bourdieu & Wacquant, 1992; Ernst & Jensen, 2018b; Inghilleri, 2005). We may refer to these strategizing moves as identity strategizing, when identity is at stake. However, with Bottero (2010), we argue that it is useful to consider identity strategizing as both dispositional and consciously mobilized, recognizing that organizational members may approach identity issues reflexively and act strategically in identity struggles as understood in the traditional sense of strategic action. As we will show, our data display several examples of both dispositional and mobilized identity work.

We see narratives as an essential part of the strategizing moves that organizational members apply to establish identity and position in the field (Bourdieu, 1991; Fleetwood, 2016). Hence, there seems to be a ‘natural’ coupling between identity and narratives, since narratives are used for creating meaning, direction and logic in life (Bourdieu, 1987), including reflexively identifying and categorizing ourselves in relation to others (Bottero, 2010). We adopt a broad definition of narratives to refer to habitus-generated thematic, sequenced accounts, which includes a sense of temporality in experience. This includes fragments and unfinished utterances that convey ongoing events, as well as more canonical narratives with temporal sequence (Carlsen, 2016; Fleetwood, 2016; Gabriel, 2004; Menary, 2008). Combining Bourdieu’s theoretical ideas with narratives provides us with a unique theoretical framework that allows us to capture the subjective experiences of organizational members, in their social and historical context. This framework enables us to ‘question, test and qualify’ the narratives told (Gabriel, 2004, p. 75). Hence, seeing narratives as social action that is rooted in social structure, we propose that narratives are the products of the principles of construction that apply to a field, yet these principles may not be visible in the discourse (Bourdieu, 1998). Narratives are in other words products of the ‘narrative habitus’ (Fleetwood, 2016). In this way, they establish a link between past and present that opens a space for reflection and agency (Gabriel, 2004). Approaching the narratives of managers and nurses as a product of their narrative habitus enables us to understand how they use narratives in their double positioning struggles – within the local organization to achieve legitimacy, and outwards in a competitive relation to other acute care departments in the country.

Research Methodology

The empirical setting: A new hospital department

We address OI within the context of a major reorganization of the Danish hospital sector, where the implementation of a number of new policy initiatives on improving the quality, efficiency and integration of care led to the establishment of 21 new acute care hospital departments across the country (Christiansen, 2012; Sundhedsstyrelsen, 2007).

In the new acute care departments, all patients are admitted in a single department across medical specialties, whereas before, they were admitted to separate departments according to pre-diagnosis and medical specialty. Medical specialization is historically institutionalized as the taken-for-granted principle that regulates work in hospitals (Abbott, 1988; Forty, 1980), which is, however, seen to create professional ‘siloes’, challenging the coordination of clinical work (Jespersen, 2013). The new departments imply a change from specialty-oriented services to process and patient-oriented services, with a focus on care integration. The attempted changes are envisioned as vast, and politicians quintessentially refer to them by the metaphor of a ‘supertanker that must be turned’, something not easily done (e.g. Danske Regioner, 2011, p. 7). The focus on care integration and efficiency means that nursing de-specialization and professional flexibility are emphasized. In consequence, acute care nurses work across medical specialties, which is unusual in the hospital organization.

We focus on the establishment of one of these new departments, department Q, initially named AAD (Acute Admission Department) in Greenwood Hospital (pseudonym). The process predominantly concerned the nurses, as the organizational model chosen in the region was to have only a few doctors employed directly in the acute care departments, and to borrow the needed additional medical expertise from the neighbouring departments of the hospital. Department Q employs nurses and doctors in the ratio 5 : 1 (see Ernst, 2017).

Data generation

Ethnography offers unique access to the lived experience in organizations through its appreciation of the humdrum of day-to-day organizational life (Pedersen & Humle, 2016). Watson (2011) recommends ethnography for the study of OI, since it enables gaining of indepth knowledge of identity-generating mechanisms. In line with Bourdieu’s theoretical ideas, the approach followed was field-level ethnography (Yanow, 2012), which connects the realist–objectivist with the constructivist–subjectivist ontological–epistemological poles, and hence it situates OI construction in a context. In the present case, it enables an in-situ perspective on how identity strategizing emerges as a process of claiming capital related to the generation of a legitimate professional identity.

The data we analyse are part of a sample of data produced for a larger study concerned with the implications of the establishment of the new acute care concept for hospital work and for practitioners. The first author, who is not trained in healthcare, undertook 13 months ethnographic fieldwork in department Q during 2013 and 2014. From a researcher position as an ‘observing participant’ (Hasse, 2015, pp. 10, 37), and dressed as the staff observed, she followed 25 nurses and nine doctors in their work. The observations were carried out in cycles of differing intensity over the year and took place in varying stretches on different days of the week including weekends and holidays. Field visits were followed by withdrawal to the office to read through and analyse data, then returning to the field after a while. Wulff (2002) terms this way of temporalizing fieldwork ‘the yoyo method’. The approach highlights issues of process, time and spatiality that enable different situations of learning in the intimate as well as the distanced relations to the observed phenomena. In total, 118 hours of day-to-day work was observed in the department during which the author took fieldnotes (Emerson, Fretz, & Shaw, 1995) on a notepad, which she carried in her uniform pocket. Besides these observations, a large number of unplanned and unregistered encounters with staff took place before and after the observations in, for example, staff rooms or offices. An important activity during observation was informal conversations with staff (Agar, 2008) during which different aspects of organizational life and work were discussed.

Besides the observations, 15 individual interviews with five nurses, five doctors and five managers were undertaken, including a manager who no longer worked in the department. Each interview lasted between 45 and 90 minutes. Moreover, two group interviews with five nurses each, each lasting around 120 minutes, were undertaken. The interviews were conducted in accordance with a thematically arranged semi-structured interview guide (Kvale & Brinkmann, 2009) containing a variety of questions concerned with the changed conditions of work enveloped in the new acute care concept. The respondents were also encouraged to take up issues on their own initiative. Possibly, this would reveal aspects of the research phenomenon that had hitherto been overlooked. All interviews were audio recorded and fully transcribed. When referring to nurses and managers, we use pseudonyms.

Additionally, the first author had access to the hospital intranet and read through internal documents relevant to the process of establishing the new department. Lastly, to understand the background for the establishment of the new acute care departments as well as their goals and purposes, a large body of textual material was studied, including policy agendas for action and government white papers. In this way, the fieldwork included both the subjective lived experience of nurses and managers in department Q and the structuring forces of the field that set the framework for their subjective constructions of OI. Bourdieu (1989, p. 14) uses the term ‘structural constructivism’ or the reverse ‘constructivist structuralism’ to explicate his belief in the significance of the dialectic between these analytical levels that bridges structuralism with constructivism and structure with agency.

Data coding and analysis

We understand coding as the process by which segments of data – phrases or sentences – are assigned meaning in relation to the research question (Saldaña, 2009). The research question of the larger study, which centred on overall organizational change and staff’s responses to change initiatives in the department, guided the initial coding. The entire dataset was first coded by the first author, with the codes deriving inductively from the data. This resulted in seven common themes or analytic categories (Saldaña, 2009) of which the themes ‘management and organization’ and ‘groups and identities’ are of interest for this study.

Subsequently, codes and categories were derived from Bourdieu’s theoretical ideas as well as from the data in an inductive-deductive combinational approach working iteratively between our data and emerging analytical understandings (Miles & Huberman, 1994; Saldaña, 2009). Through this work performed by both authors, professional identity emerged as salient for work and social life in the department. We identified the narrative constructions of nurses and managers as significant for establishing and claiming new OI, and following our approach to narratives, we acknowledged all types of statements that had narrative qualities in the sense that we see them as part of the ongoing story work (Gabriel, 2004). We used a methodological grip, called by Bourdieu (1989) ‘the construction of the research object’, which is performed in a dialectic between macro- and micro-level data, where we sought to identify the logics of differentiation (Lamaison & Bourdieu, 1986) that separated nurses, departments and hospitals in the field, and created legitimate spaces for the establishment of a socially effective identity. The concept of strategizing surfaced as a fertile analytical tool to capture the moves of nurses and managers as well as their temporal learning in relation to the construction of OI and we became attuned to the different nature of identity strategizing inside and outside the hospital, which was elicited by different interpretations of capital in the field.

Hence, articulating the concepts of field, habitus and capital in dialogue with the data provided us with ideas for theoretical advancement of the phenomenon we studied. For example, when connecting a comment by a nurse such as ‘It was a gain to win access to the other medical specialties’ with the concept of field, it testified to the ways in which the acute care nurses sought to establish an identity as ‘generalists’ rather than as ‘specialists’, and to the way in which wider field-level changes influenced the local construction of OI. Through Bourdieu’s concepts of position and positioning, the idea of double positioning struggles surfaced to explain the meeting between new capital and traditional institutionalized capital in the field, which necessitated different strategizing activities, outwards in relation to other Danish hospitals, and inwards in relation to the other departments in the organization. In this connection, we experienced a need to let strategizing comprise both pre-reflexive/embodied and mobilized/reflexive strategizing.

We saw these double positioning struggles as generating a group-based story line, where the two managers and the nurses narrated the establishment of the new department as an epic story (Frye, 1990; Gabriel, 2000) of competition, pioneering, resistance and vindication. In a drama of self-identification, they cast the head specialist doctor as the protagonist (e.g. ‘Malcolm went ahead of us as a lighthouse’), heading the double positioning struggles to victory (‘My experience was that we succeeded in creating our acute care identity’). In this, the head nurse was his committed helper, the other nurses in the department his admiring followers, and the other departments the antagonists (e.g. ‘There was always something they could criticize […] all the time we were told what we were not good at’).

Results: Strategizing for Identity and Legitimacy

In the following, we analyse identity construction in department Q through the narratives and stories told by the managers and nurses, five years after the establishment. We have arranged the story line in three temporally designated themes, identified as: (1) winning and positioning the new department in the Danish hospital field, (2) pioneering the new department, and (3) collaborative tension and the creation of a legitimate OI.

1. Winning and positioning the new department in the Danish hospital field

Winning the competition for the establishment of an acute care department would position Greenwood Hospital favourably in relation to the other hospitals in the region. This would allow Greenwood to claim capital belonging to the new progressive transformation agenda in the hospital field, which was the foundation on which the new departments were established. The capital rested on a belief in what was presented as new knowledge and best practice concerning efficient and patient-oriented organization of care and was a form of cultural capital. The hospital management, as well as the department management, engaged in several strategic moves with the aim of securing this capital. As a member of the acute care planning task force of the local region, the head specialist doctor had been heavily involved in planning the new acute care departments in the region, and as an employee at Greenwood Hospital, the doctor had been asked to head the process of winning one of the 21 new departments. When talking about his trajectory, he draws upon a narrative that is inspired by the strategic positioning attempts of the hospital.

I was employed as the head specialist doctor of the medical department in Greenwood Hospital, and the hospital management asked if I would be interested in leading a project on the establishment of an acute care unit. It was the vision of the hospital management that we should be strong in the competition for the upcoming acute care hospital, and we should be stronger than East Valley Clinic, which was the obvious candidate at that time […]. (interview)

The hospital eventually won the competition to house one of the new acute care departments and becoming an acute care hospital, which the Danish National Board of Health referred to as ‘part of a comprehensive and profound change of the hospital sector’ (Sundhedsstyrelsen, 2007, p. 5, authors’ translation from the Danish). Consequently, department Q came to represent and embody the new cultural capital that was constructed as a political project in the wider field. This capital was, however, mostly symbolic, since the virtues of the new patient- and process- oriented concept had yet to prove its material value. The new acute care departments were positioned as ‘change agents’, spearheading a better and more efficient organization of care in the entire hospital organization, where the past functioned as a negative reference point for future progress.

As the head specialist doctor had proved to be successful in the pre-establishment phase, he was now employed to manage department Q, in collaboration with a head nurse, and to lead its establishment. In the following, the head nurse explains her engagement in the department:

I was very interested in the new AAD and I believe I had the skills to become nursing unit manager of the department. I had work experience from an accident and emergency department and I had been involved in the process of designing the department […]. Eventually, I won the position and Malcolm [the head specialist doctor] and I became a very committed team. We were driven by this ‘fiery soul’ approach. (fieldnotes)

The ‘fiery soul approach’ refers to institutional entrepreneurship (Nomie & Sandor, 2015) and a surplus of work energy, which can be analysed as stemming from a harmony between a position in the field and a disposition (habitus), or a bodily being one with the world (Bourdieu, 1998). The narrative of the head nurse is thus illustrative of how the new political imperatives of the field appeal to a certain habitus, where the linguistic means employed reveal its categories of perception and appreciation. The head nurse is ready to surrender to the game of the field through a belief in the new capital it imports. This is also present in the following excerpt by the head specialist doctor, focusing on ambition and competition:

Greenwood Hospital wants to be leading within a whole range of things. We were ambitious. We had the motto that we wanted to be the best acute care department in the country, and we said that quite openly. (interview)

The local capital at stake for the managers is that of being change agents in Greenwood, which implies the ambition of achieving the position as ‘the best acute care department in the country’. All job positions in the department were posted publicly, outlining the prospects of acting as front runners in the organizational transformations. A nurse explained:

We applied for our positions here because we had the interest and the desire to be part of the new project. We were told that this was leading to the grand acute care hospital. (Simona, group interview)

Besides the possibility of claiming the cultural capital of the progressive transformation agenda, the department was a breath of fresh air in a career that perhaps had become too monotonous for many nurses. One of them, Cathryn, explained: ‘I really needed a change’ (interview).

The narratives of staff about venturing, pioneering and developing became suffused with the new cultural capital of the field that offered symbolic value to the positioning of the department in the Danish hospital field. However, it also provided the fuel for struggles internally in the hospital organization, as we will see in the following.

2. Pioneering the new department together

The managerial team was given a free hand to create the department, which they metaphorically named an ‘experimentarium’, as a way of emphasizing it as a space where the hospital management had granted the staff ample autonomy to test their ideas in realizing a progressive care organization. The nurse, Cathryn, conveys how the department management played an important role in the ‘free game’ development of the department:

There was a focus on us, and we were allowed to do things. It was development, not operation – akin to a free game, and no one knew which ideas could carry through to tomorrow. So, it was pretty cool and great to have a daring management. They had goals built on new acute care thinking […]. (interview)

This freedom released emotional energy, which was fuelled by the staff’s belief in the game, and the associated new cultural capital. For the nurses, an aspect of this capital was an opportunity for disciplinary experimentation and professional development, as new nursing roles and cross-professional collaboration were envisioned as part of the new acute care concept (Ernst, 2017, forthcoming). Cathryn’s narrative emphasizes the break with traditional care organization and professional boundaries of the past as a new access to the medical specialties and an opportunity to be included in medical tasks:

I had worked within the medical specialty for several years and it was a gain to win access to the other specialties. It was insanely exciting […] there was so much drive. Before we had these professional specialist shutters that were almost closed. So, it was a huge win […] and also a completely new way of working together with the doctors. It was a natural thing that we participated in the examinations of patients and we were good at it. (interview)

Access to medical tasks and collaboration with doctors were reinforced by the fact that the medical staffing in the department was almost exclusively covered by junior doctors, who were replaced every six months as part of their training. Therefore, important clinical decisions had to be made by the nurses, who not only outnumbered the doctors massively, but also were carriers of important clinical experience, which functioned as professional capital in day-to-day practice. Hence, the nurses were identified by the head specialist doctor as ‘immensely important’ for the department to succeed (interview).

The two managers and the nurses frequently referred to the early establishment phase as ‘times of pioneering’. ‘Pioneering’ was, for example, used by the managers to represent a democratic inclusion of the nurses in everyday decision-making. This can be seen as a strategizing move to build positive relations with them. Moreover, it was an important habitus-forming move that provided the nurses with a feeling of change agency, where a narrative of ‘creating something new together’ was constructed:

It was important for me to convey the message that we were creating something new together. Our approach was: ‘Your ideas are always welcome.’ It was immensely inspiring to work with the nurses, listen to their ideas and say ‘Yes we’ll buy it and let’s begin tomorrow.’ I mean, these prompt responses were indeed something that characterized our pioneer period. The nurses came from different cultures, and therefore, we made an effort to create various social events. We created a community by socializing. (interview, head specialist doctor)

The doctor’s reference to ‘different cultures’ concerns the different medical specialties that are seen as the main culture creators in the hospital setting, yet also as erecting professional boundaries (Wicks, 1998). The narrative also points to important aspects of the head specialist doctor’s formation of what we may term ‘leadership capital’ (Robinson & Kerr, 2009). Following Bourdieu (1998, p. 102), we conceptualize leadership capital as a form of charisma, which is built on the ‘affective enchantment’ of the supporting group, and comes into place through the belief that the leader possesses scarce and valued capital. Leadership capital then is ‘a capital of recognition’ of the leader (Bourdieu, 1998, p. 102), which permits the leader to exert symbolic effects based on the misrecognition that the social relation created between leader and followers is based on power, and thus the affective relationship created between leader and followers seems ‘pure’ (Robinson & Kerr, 2009). The head specialist doctor had acquired his leadership capital through his membership of the acute care planning task force, where he had acquired a positive reputation, which endowed him with a ‘a name’ in the field. By emphasizing democratic inclusion of the nurses and ‘socializing events’, he created affective relations with them and a feeling of group membership that functioned as capital, because it tied the staff together as a social group, united in their belief in the mission of the new department, which bolstered the department with stamina in the start-up phase.

In this, an epic story was constructed, wherein the pioneer and pioneering terms were used to represent the group’s mission in the hospital organization. Since pioneering is associated with the obstacles of metaphorically ‘paving the way’, the narrative symbolized how the group fought for a better organization of care and to naturalize the hardship and organizational chaos they had to endure. The following narrative, told by Karen, illustrates the feeling of obstacles in the shape of practical struggles:

The cabinets hadn’t arrived when we started, and the articles weren’t where they should be. The wards were not established, and we had to work out how we should work as an admissions team. We worked with everything down to the tiniest details. We created everything ourselves and we had a management who backed us up. (interview)

The head specialist doctor was seen as the pioneer role model leading the group’s way through organizational jumble as national, regional and local acute care frontrunners. The narratives by the nurse Amy and the head specialist doctor convey this feeling of pioneering, and their focus on competition, ambition and success:

Malcolm went ahead of us as a lighthouse. I was responsible for communication back then and our strategy was to catch the attention of the media, our professional journals, The Nurse and Journal of the Danish Medical Association. We succeeded completely and were seen as pioneers in the field. Other new acute care departments phoned us to ask for our advice. (field notes, Amy)

The best acute care department in Denmark, well the best of all specialist departments, is nominated each year by Dagens Medicin (a medical professional journal) […] and we were top scorers every year. I think it was the first or second year that we figured on the front page of the magazine. (interview, head specialist doctor)

The narratives convey how the strategizing moves of managers and nurses in the department included a communication strategy designed to position the department as the front runner in the national hospital field. The strategy involved the authoring of articles by the head specialist doctor and by journalists of professional journals, promoting the department. In this way, pre-reflexive and dispositional identity formation of actions stemming from embodied strategizing went hand in hand with mobilized identity formation of actions activated by explicit reflexive strategizing (Bottero, 2010). This can be expected under circumstances of major change, where the habitus has to find a new footing (Bourdieu, 1990), but may also be seen as part of mundane organizational life and conduct, when practitioners locate themselves vis-a-vis the material and symbolic location of others (Bottero, 2010). It exemplifies how the narratives of managers and nurses tied them together as a group that constituted an emotional community, fuelled by their belief in new acute care organization. The group was driven by a competitive energy that enabled them to gain the winning position among acute care departments in the country and to claim the new capital of progressive care organization.

3. Collaborative tensions and the creation of a legitimate OI

The external success of the department did, however, not impact its success within Greenwood Hospital. The collaborative climate between the acute care department and the other departments of the hospital was challenged for several reasons, where the most obvious one was the fundamental changes to well-established working procedures, which the department instigated. Second, to enhance the efficiency of patient flow, patients could stay in the new department for a maximum of 48 hours, after which they had to be transferred to one of the inpatient (bed) departments, almost irrespective of bed capacity status. In consequence, patient transfers often took place as difficult and conflict-ridden negotiations between the acute care nurses and their colleagues in the bed departments. As expressed by Amelia: ‘We have controversies with the nurses from the other departments because they don’t seem to understand that we have to transfer our patients’ (group interview).

Hence, in the narrative of the head specialist doctor, we see how he used his capital in another strategizing move to achieve acceptance of the acute care concept internally in Greenwood, by engaging in networking activities with the managements of the other departments. He thus regularly participated in morning reports of the other departments. Morning reports are important institutionalized meeting practices for medical decision-making in hospitals (Ernst, 2017).

I saw an enormous potential in networking with the other departments. I spent a lot of time visiting the other departments and participating in their morning reports during the first months. We discussed how it went and I built upon the really good personal relationships I had in the leadership circle to manage the problems that emerged. This was the way I wanted to work, to walk the talk. (interview)

The doctor’s reference to his ‘really good personal relationships’ testifies to the social capital he had built with his medical peers in the organization and beyond. This capital is closely related to the cultural capital earned through medical education, which sanctions access to field level as well as local supportive medical networks (Witman, Smid, Meurs, & Willems, 2011). His strategizing activities can be understood as nurturing and mobilizing this capital in the department’s battle for recognition in the organization. Moreover, as the narrative implies, they contributed to solving day-to-day problems.

However, department Q was confronted with further obstacles, since the acute care generalist nurses experienced their professional competence being questioned by their colleagues in the bed departments. Simona’s narrative displays the sensation of lacking professional legitimacy:

They were not satisfied with us on professional grounds […]. So, when I, who was specialized in surgery, was transferring a medical patient (to a medical department) there were always things they said I had overlooked. There was always something they could criticize. We had to find our identity, find out what we were good at when all the time we were told what we were not good at. (group interview)

According to the institutionalized medical logic that regulates the healthcare field and defines professional values, specialized clinical competence is cultural and symbolic capital in the field, and conversely, generalist competencies are associated with low capital levels (Abbott, 1988; Currie et al., 2009; Ernst & Jensen, 2018a; Lockett et al., 2014). The symbolic effects of this capital worked through the socialized and predisposed misrecognition of ‘generalization’ as a potential marker of nursing competence. Thus, the nurses of department Q lacked professional capital in the eyes of their colleagues, which made it hard to establish credibility and authority in collaboration. Consequently, department Q had difficulties in complying with the goals that had been set for it, which intensified a need to establish professional legitimacy in the organization.

Henceforth, management and nurses made an important strategizing move, in that they decided to claim organizational legitimacy through a formal training programme, which would provide the nurses with competence to handle some of the tasks traditionally taken care of by doctors. This would certify them as acute care specialists and legitimize their taking over of such tasks. The managers created their own eight days’ acute care supplementary nursing training programme, where they acted as both teachers and assessors at local exams. With this training programme, department Q saw the early emergence of the internationally recognized ‘acute care nurse practitioner’ (Norris & Melby, 2006), and a progression towards a legitimate OI:

We had to win professional recognition based on our professionalism. We shouldn’t allow other specializations to step on us and look down upon us. We needed an independent professional identity at this hospital and we made a quite comprehensive curriculum concerning the competences we wanted the nurses to acquire. We designed web pages for educational purposes, we took them to practical and theoretical exams and elevated them to a level where they could supplement the junior doctors – at least with respect to the particular acute care competences. (interview, head specialist doctor)

Interestingly, with this strategizing move, the managers constructed professional capital along the fault lines of medical specialization, having realized its sustained importance as the bedrock of competence classification in the hospital field and, as such, it was pivotal for achieving a legitimate OI. The supplementary training programme and a new narrative of an ‘acute care identity’ bolstered the professional self-confidence and motivation of the nurses. The narrative of the head specialist doctor conveys the finding of a solution:

My experience was that we succeeded in creating our own acute care identity through these courses. The courses provided very positive feedback to the nurses because they did really well. We could praise them within reasonable limits and I think it contributed to their motivation and building of self-confidence in the manner of ‘We can do it, we have something to offer, and we don’t have to crawl on our hands and knees for the (medical) specialties that look down on us. We have an individual identity at this hospital.’ (interview)

Accordingly, acute care nursing specialization became a point of differentiation, allowing the acute care nurses to claim professional cultural capital connected to their supplementary training, which allowed them a broader scope of practice in relation to the nurses of the bed departments, and thereby to establish a symbolic and material distance from them. Moreover, the training programme sustained the favourable position of the department in the wider field, because the department was the first to provide its nurses with supplementary acute care education. The programme was later adopted by other hospitals in the country, which could be the beginning of a process of institutionalization of acute care nursing as a specialty with professional recognition in the field.

Thus, the epic story of the group’s mission in the hospital organization as a pioneering journey came to include the construction of an acute care nursing identity. Despite external success, the department had to endure internal degradation, only to rise in a stronger position. This was a story, which managers and nurses alike subscribed to, and which tied them together as a group.

Discussion and Conclusion

Our analysis of the identity struggles of a group of nurses and their managers in the establishment of an acute care department has provided several interesting insights into the how, what and why of organizational identity (OI) construction. Pursuing ‘a road less travelled’ (Knights & Clarke, 2017), we have theorized the attempts to construct a new and desired identity (Croft et al., 2015) as Bourdieusian strategizing by focusing on the narratives of managers and nurses.

We have built on previous work that links OI to everyday social practice and employed an embodied narrative perspective that enables us to demonstrate the heterogeneity of OI (e.g. Carlsen, 2016; Rhodes & Brown, 2005). Our study extends the OI literature, by drawing on the interrelationship between habitus, field and capital, as subsumed in the strategizing concept, and thereby demonstrating the temporal, embodied and inherently social configuration of OI.

We propose that in order to understand OI, we must take the nature of the organization and its historical context into account, something that is rarely done (Brown, 2019). In the context of hospitals, other authors have examined the OI constructions of nurses and doctors and offered insights into identity formation and choices (e.g. Croft et al., 2015; Pratt & Rafaeli, 1997; Pratt, Rockmann, & Kaufmann, 2006). However, mainly concentrated at the micro level of analysis, none of these studies link the identity struggles of the professionals to their professional socialization and the medical logic dominating the hospital field (Abbott, 1988; Currie et al., 2009; Wicks, 1998). Pratt et al. (2006), for example, attributed an observed consensus about identity construction along medical specialization solely to circumstances inside the organization. While local factors may be of importance to OI construction, we argue that a micro perspective is unable to capture the important connection between OI and professional identity. Our study demonstrates that OI construction in the hospital organization is contingent on the institutionalized professional logics of the field, as these logics separate agents and create positions that demarcate components belonging to a legitimate OI. In this way, OI formation is a process of differentiation (Lamaison & Bourdieu, 1986), that is, of inclusion and exclusion based on kinds of knowledge and skills held, or cultural capital. Thus, in the hospital setting, OI is heterogeneous in nature, rather than a monolithic frame of reference for the members of the organization, as often suggested in the OI literature. Our study thus recognizes identity strategizing as historically and contextually embedded in a field (Knights & Clarke, 2017), and it addresses the weaknesses of integrative and traditional cognitivist frameworks, by offering an understanding of OI formation as heterogeneously connected to groups inside and outside the organization (Pratt & Rafaeli, 1997), through access to and possession of capital.

Seeing OI strategizing as both dispositional and mobilized (Bottero, 2010; Bourdieu, 1991), that is, as generated by the embodied dispositions of organizational members, as well as consciously planned, identity formation is quintessentially concerned with questions of agency and structure. Our data show how being part of the start-up was connected to a feeling of agency as a freedom ‘to do things’, and hence, establishing the department was a form of social action helped by the narratives that worked as a symbolic, emotional and practical glue that united the nurses and their managers in their struggles.

The management, and in particular the head specialist doctor, functioned as inducers of OI, which could resemble the process described by Ashforth (2016, p. 3) of ‘I think => we think => it is’, where identity originates in a strong leadership creating a causal identity effect. However, when explaining strong leadership with our concept of ‘leadership capital’, we suggest that strong leadership and emerging identity effects, rather than being ascribed to causal effects, emerge in the social relations between staff and management, and are dependent on the leader’s possession of relevant capital that defines power relations in the field. Thus, the symbolic power possessed and exercised by the leader is a socially concealed power (Robinson & Kerr, 2009). Moreover, for Bourdieu, power is not necessarily repressive, it may also be productive. This can be seen from our data, where the affective recognition by the staff allowed the head specialist doctor to form department Q as a group with stamina in the struggles encountered. However, despite the considerable social energy mobilized by the group, and the external success it obtained, our study is also an example of the complexity of translating new demands for efficient patient flow, professional flexibility and cross-professional collaboration into practice (Currie et al., 2009), since it amounts to the creation and legitimation of new capital in a field that is highly structured by (medical) specialization as symbolic capital.

Along these lines, our study makes a contribution to our understanding of OI by drawing attention to how the narratives told by managers and nurses convey a temporal and embodied learning (Menary, 2008) in OI construction that uncovers the evolution of the volume and structure of their capital over time and space (Bourdieu & Wacquant, 1992). The department represented and embodied new cultural capital, which was constructed as a political project in the wider field. In their ‘double positioning’ struggles, the staff of department Q succeeded in positioning themselves favourably outwards in the hospital field, by claiming the new cultural capital of progressive care organization. Yet, this capital had little value within the organization and nurses and managers realized that the boundaries for their OI construction was regulated by the traditional understandings of professional competence still dominant in the field and the organization. The process of exclusion and boundary demarcation by the other hospital departments had the consequence that the professional capital of the nurses, earned through education and experience, lost its value when they were employed as generalists and thereby became disconnected from the symbolic capital of the field. The department thus represented what Whetten (2006, p. 226) terms ‘unthinkable identity switching’. Interestingly, by finally providing the nurses with specialized acute care competence, the management succumbed to the institutionalized professional capital of specialization in the field, which the department intended to break with.

We propose that rethinking OI along the lines suggested here has major implications for understanding the social and political nature of OI construction and constitution. For example, understanding OI formation as a process of differentiation and legitimation relates to the idea of professional closure and professional identity (Larson, 1977). Harrits (2014) suggests that professional identity is connected to professional closure, using Bourdieu to explain professional closure as social and symbolic processes that depend on capital concentration and thus the perceived value of practitioners’ socialized knowledge and skill (Lockett et al., 2014). Moreover, professional closure is connected to social structures that demarcate the space of possible identity boundary creation (Bourdieu, 1989; Harrits, 2014). Our study illustrates the fluctuating and politically dependent institutional conditions of fields (Bourdieu & Wacquant, 1992), yet at the same time, it shows how institutionalization of new ideas in the tradition-bound hospital field is a lengthy process as new ideas representing heterodox positions in the field must seek acceptance in competition with established ideas representing doxic field positions (see Bourdieu, 1977).

While the hospital as organization embeds particular features, we believe that our study highlights some general traits concerning OI construction that apply to all organizations. Thus, paying attention to the identity constructions that are operative in all levels of the organization, and simultaneously connecting these constructions with the forces, locally and in the wider field, that define capital and restrict access to capital, provides a fruitful future avenue for understanding the multiple facets of OI, and how some OIs may be constrained, and others enabled, by seemingly inexplicable factors. As explained by Bourdieu (1986, p. 15), ‘the structure of the distribution of the different types and subtypes of capital at any given moment in time represents the immanent structure of the social world, i.e., the set of constraints, inscribed in the very reality of that world, which govern its functioning in a durable way, determining the chances of success for practices’. Our research suggests that strategies for fundamental organizational change should pay apt attention to the various forms of professional capital active in the field, but also to the logics that undergird this capital, and thus the logics that direct inclusion and exclusion and hierarchization of work and workers. This also means paying attention to how identity construction is interwoven with politics and ideology. Rather than assuming that management can command a common frame of reference for OI construction, it is imperative to understand the nature of the space for possible identity constructions.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

ORCID iD

Jette Ernst

Author biographies

Jette Ernst is Assistant Professor at the Department of Design and Communication, University of Southern Denmark. Her empirically based research focuses on how various forms of organizational change affect people in organizations, how they respond to change and how change is managed. Her current work includes themes such as professional identities in hospitals, healthcare digitalization, counter-narratives and standardization of work, company privatization, and CSR implementation. Her PhD research won the Emerald/EFMD highly commended award in Healthcare Management. Her work is published in leading peer-reviewed journals.

Astrid Jensen Schleiter is Associate Professor of Organizational Communication at the Department of Language and Communication, University of Southern Denmark. Her research interests include various aspects of organizational communication. Recent work combines theories of metaphor and narratives with a practice-based perspective on organizational change, culture and identity. Projects that she currently works on include counter-narratives in and around organizations, metaphor and narratives in mergers, strategizing and identity construction. Her work is published in leading peer-reviewed journals.

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