Individual identity and organisational control: Empowerment and Modernisation in a Primary Care Trust

Authors


Ruth McDonald, National Primary Care Research and Development Certre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL e-mail: ruth.mcdonald@man.ac.uk

Abstract

The notion of empowerment has been increasingly used within management discourses in recent years. Enthusiastic supporters conceive it as an acknowledgement of the individual employee as a talented, creative being, and hence a productive resource for contributing to organisational goals. Alternatively, more critical commentators have interpreted it as another means of exercising control over employees and their identities. Although various commentators have speculated on the management of identity as a means of organizational control, there is very little empirical work from which to draw conclusions. This paper, using participant observation and interview data, represents a contribution to the small body of empirical research in the area. It focuses on an initiative aimed ostensibly at ‘empowering’ staff in an English Primary Care Trust, which may be seen as an attempt at increasing organisational control by shaping employee identities. As such, these processes can be understood more readily in terms of ethics rather than empowerment. The term ethics is used here in a Foucauldian sense and is linked to the processes of self-definition and self-constraint by which individuals train themselves to become ethical persons. The paper suggests that the outcome of attempts to manufacture particular forms of subjectivity by such methods as ‘empowerment’ programmes may be very different from those intended.

Background

Giving front-line staff and patients the opportunity to think and work differently to solve old problems in new ways is the only way to deliver the improvements set out in the NHS Plan. The changes . . . will provide a structure that supports the devolution of power to frontline staff and patients. However a change in culture and new ways of working within organisations will be needed if we are to improve the quality of the patient's experience of outcomes and improve health. A real shift in the balance of power will not occur unless staff are empowered to make the necessary change. The cultural shift needed will in many ways be more crucial to the success of the project than new management structures. Staff need to be involved in decisions which effect service delivery. Empowerment comes when staff own the policies and are able to bring about real change.

Shifting the Balance of PowerDepartment of Health 2001

The notion of empowerment has been increasingly used within management discourses in recent years. Enthusiastic supporters conceive it as an acknowledgement of the individual employee as a talented, creative being, and hence a productive resource to contribute to organisational goals (Covey 1994, Foy 1994, Peters 1992, Ripley and Ripley 1992). Walton's description of such processes as engendering commitment to organisational goals and thereby improving organisational performance provides some insight into the reasons why empowerment initiatives have proliferated in public and private sector organisations in recent years (Walton 1985). Such accounts assume that, given the option, employees will willingly participate in empowerment programmes and that participation will benefit the individual and the organisation as a whole (Brown and Brown 1994, Byham and Cox 1994, Stewart 1994). An implicit but important assumption here is that individual goals are wholly consistent with those of the organisation, although in practice there are many reasons why this might not be the case (Marchington 1995). A major problem with this literature is its failure to take account of the context in which empowerment takes place and in particular the conflict that exists within organisations (Wilkinson 1998).

More critical commentators have interpreted empowerment initiatives as another means of exercising control over employees (Sewell and Wilkinson 1992, Cunningham et al. 1996, Pickard 1993, Grey and Mitev 1995, Willmott 1995, Knights and McCabe 2000, Knights and Willmott 2000, Knights and Willmott 2002). For example, Sewell and Wilkinson's (1992) account of an empowerment initiative, which ‘on the surface’ entails job enrichment for shopfloor workers, contrasts the rhetoric of trust with the reality which involves the centralisation of power and control in the hands of senior management. Since part of this process involves ‘an intensive level of personal surveillance directed at individual members of the workforce’ (1992: 98) it is perhaps not surprising that there are no overt displays of resistance observed by the authors.

Many empowerment initiatives, however, aim to exercise control in more subtle ways. Deetz describes ‘the modern business of management’ as ‘often managing the “insides”– the hopes, fears and aspirations – of workers rather than their behaviours directly’ (Deetz 1995: 87). The promotion of a discourse of empowerment and the specification of appropriate or desirable identities in relation to ‘empowered’ individuals can be interpreted as an attempt to ‘manage the insides’ by reducing the extent of discretion and range of decision making for employees. Any acceptance of these organisational identities by employees will serve to limit their choice of alternatives to those which are compatible with affirming that identification (Tompkins and Cheney 1985) and by implication with organisational goals. Although various commentators have speculated on the management of identity as a means of organisational control, there is very little empirical work from which to draw conclusions (Alvesson and Willmott 2002). This paper represents a contribution to the small body of empirical research in the area. It focuses on an initiative aimed ostensibly at ‘empowering’ individuals in an English Primary Care Trust which, in common with Government rhetoric about empowering NHS staff, may be seen as an attempt at increasing organisational control by shaping employee identities.

Empowerment of NHS employees is depicted by Government as a key plank of its Modernisation agenda, with the process of creating Primary Care Trusts described as one of putting front line staff ‘in the driving seat’ (Department of Health 1997). In recent years, however, reforms aimed at strengthening the ability of Government to make the NHS more efficient and more responsive to the needs of its customers have been characterised as a process of command and control, emphasising the implementation of top down edicts and national standards at local level. Whilst the self-conscious use of labels such as ‘Modernisation’ may be intended to differentiate New Labour policies from those of its Conservative predecessors, the process of ‘modernisation’ represents the continuation of a set of policies initiated under previous administrations, which seek to transform the NHS from a rigid and failing bureaucracy to a system of entrepreneurial governance that will ensure its survival (Currie and Brown 2003).

The rhetoric of enterprise, which reflected the shift to the political right in OECD (Organisation of Economic Co-operation and Development) economies towards the end of the last century, underpins this new management approach (Kelly 1991, Legge 1995, Cohen and Musson 2000) and the discourse of empowerment can be seen as highly consonant with notions of enterprise culture. Under entrepreneurial government, ‘enterprise’ denotes not only the preferred model of institutional organisation and provision of goods and services, but it also refers to activities that are seen as denoting enterprising qualities such as initiative, self-reliance and the ability to accept responsibility for oneself and one's actions (du Gay et al. 1996). This new flexible mode of operation involves a redefinition of roles and competencies (Brewis 1996) with individuals taking control of their destinies and acting as an ‘entrepreneur of the self’ (Gordon 1987). For Gordon, the self becomes a project to be worked at, with the individual continuously engaged in one enterprise ‘to make adequate provision for the preservation, reproduction and reconstruction of one's own human capital’. Gordon's description of the way in which ‘economic government . . . joins hands with behaviourism’ (1991: 43) can be seen as providing an account of the ways in which ostensibly liberating ‘empowerment’ initiatives can be used to exercise control over individuals. Whilst the depiction of the individual here is of an enterprising or entrepreneurial self which may appear to be rather different from the ‘docile bodies’ observed by Sewell and Wilkinson (1992), the effect, in terms of securing compliance, it is implied, is the same.

This emphasis on the ability of management to control employees chimes with the body of literature in which self-subordination through ‘new wave management’ is seen as virtually inevitable (see Ezzamel et al. 2001 for a discussion). However, as Ezzamel et al.'s account of attempts to implement ‘lean manufacturing’ initiatives at ‘Northern Plant’ illustrates, workers can and do employ a variety of forms of resistance in the face of attempts to modernise production processes. Such resistance may be influenced at least as much by political or ideological values as considerations of one's human capital. Ezzamel et al. present a critique of labour process theory (Braverman 1974, Buroway 1979) for its characterisation of worker-management relations as recurrent struggles between sellers of labour, striving to secure meaningful employment, and senior managers intent on securing and sustaining the accumulation of capital. Labour process theory's depiction of workers as ‘passive carriers of political and ideological structures, as well as economic forces’ (2001: 1057) leads the authors to argue instead for an approach which understands motivations as part of an ongoing social formation process. ‘Considerations of identity are incorporated because they are understood to prompt employees – management as well as workers – to act in ways that address a concern to secure or enhance their sense of self-identity, yet may be counterproductive to the interests imputed to them by orthodox theory . . . [They also help] explain why values espoused by managers or ascribed to employees are not. . . . embraced or actualised when they threaten to impugn . . . their sense of self-identity’ (2001: 1057–8).

The plethora of literature on empowerment initiatives concerning ‘shopfloor’ work contrasts with the small number of studies of empowerment in the context of middle managers (Procter et al. 1999). Whilst celebratory accounts of empowerment display a tendency to classify managerial work as a technical process concerned with the co-ordination and motivation of labour to meet common goals, more critical ‘shopfloor’ studies have exhibited a tendency to portray ‘management’ as exercising power over workers so as to secure their compliance. The former approach has been criticised for ignoring ‘the many deep-rooted features of organisational life – inequality, conflict, domination, and subordination and manipulation . . . in favour of behavioural questions associated with efficiency or motivation’ (Thompson and McHugh 1995: 14). However, the latter view of managers as part of a unified whole, intent on controlling and exploiting the productive capacity of the workforce is to ignore the essentially equivocal role of managers in the labour process (Watson 1994, Wilmott 1997). Indeed, since empowerment often takes place in the context of delayering (Wilkinson 1998) and since in the NHS in recent years it has been middle management which has suffered most from this delayering process (Procter et al. 1999), a depiction of middle managers as powerful exploiters of labour is woefully misleading. Some more nuanced studies provide accounts which recognise a distinction between middle and senior management in the context of organisational change initiatives (see for example Currie and Brown's 2003 presentation of group narratives of senior and middle managers). However, the portrayal of middle managers (or indeed senior managers) as a single, univocal, homogenous entity perhaps arising from the need to generalize from complex data can, at times, leave little scope for consideration of individual difference or the diverse settings in which middle managers operate (Thomas and Linstead 2002).

The present study focuses on an initiative aimed ostensibly at ‘empowering’ employees working in a middle management capacity in an English Primary Care Trust, which may be seen as an attempt at increasing organisational control by shaping employee identities. The initiative took place against a backdrop of broader organisational changes but was specifically aimed at encouraging employees to engage in a process of self-transformation by participating in a self-development course. Brewis's (1996) account of a personal-effectiveness course draws on the writings of Michel Foucault to illustrate how the course can be seen as acting on individuals in an attempt to constitute them as self-regulating subjects, unquestioningly striving to become ‘competent’ managers. Foucault's writings also allow for an exploration of considerations of identity and difference as well as an understanding of the ways in which individuals resist empowerment processes. In this paper I draw on Foucault's work to argue that the self-development processes in which PCT employees participated can be understood more readily in terms of ethics rather than empowerment. The term ethics is used here in a Foucauldian sense and is linked to the processes of self-definition and self-constraint by which individuals train themselves to become ethical persons. For Foucault, technologies of the self permit ‘individuals to effect by their own means or with the help of others a certain number of operations on their own bodies and souls, thoughts conduct, and way of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection or immortality’ (Foucault 1988: 18). The PCT initiative described below might be seen as an example of others ‘helping’ in this process by attempting to shape subjectivity and reduce employee resistance to change. This initiative appears to be based on the naïve idea that compliant employees can simply be manufactured or that subjectivity can be wholly determined by the actions of powerful senior managers within the PCT. However, this fails to recognise the active role played by individuals in the shaping of their own identity. It also fails to take account of the differential ways in which discourses of empowerment may be read by different individuals (Findlay and Newton 1998).

What follows is divided into four main sections. The first provides a brief account of NHS modernisation and of the Foucauldian theoretical framework through which the empirical data are interpreted. The second presents contextual information about the case study site, the ‘Investing in Excellence’ (IEE) course that the PCT offered, and data collection methods. The third discusses findings from the research based on the interviews and observations conducted. The final section presents concluding remarks, which examine the implications of the research findings in the context of ethical selfhood and attempts at new forms of subordination in the guise of NHS empowerment initiatives.

Foucault, ethics and ‘Modernisation’

In the early years of the Blair Government those working in the public sector were characterised as change resistant, part of the problem rather than the solution, targets rather than agents of modernisation. This provided a rationale for imposing top-down solutions on managers who had hitherto failed to deliver. Writing in 1999, Alan Milburn, the then chief secretary of the Treasury, argued that government should import best managerial practice from the private sector (Milburn 1999).

Praise for private sector management practice and the fact that the 66-page Modernising Government white paper contained only one paragraph on ‘motivating and involving staff’ may be understood as part of New Labour's attempt to distance itself from Old Labour's ties with public sector unions. However, this willingness of Labour politicians to criticise public servants and public institutions has served only to confirm the image of public sector management as a zero-sum conflict between producer and consumer interests (Taylor 1999). More recently, however, there has been a more conciliatory approach with an emphasis, in the rhetoric at least, on empowerment and autonomy of public sector staff. Rather than simply criticising public sector workers for lacking the desired qualities of their private sector counterparts, the aim now, it appears, is to empower NHS employees to develop such qualities. At first glance the Government's desire to empower NHS employees whom it had previously held in such low regard is a surprising volte face and runs contrary to the command and control style of Government policies. The process, however, may be conceived as an attempt to reduce insubordination by influencing individual identity. The success of such a strategy is by no means guaranteed since every power relationship implies, at least potentially, a strategy of struggle (Foucault 1982). Whilst control in the context of stability may be the desired outcome of ‘empowerment’ initiatives, the achievement and maintenance of stability is never guaranteed since, as we shall see from events at Downtown PCT, insubordination and resistance are essential components of the power relations within which self-making takes place.

For Foucault, subjectivisation is a process in which ‘the individual delimits that part of himself that will form the object of his moral practice, defines his position relative to the precept he will follow, and decides upon a certain mode of being that will serve as his moral goal. And that requires him to act upon himself, to monitor, test, improve and transform himself’ (Foucault 1986: 28). In The History of Sexuality Foucault described the exercise of power, authority and liberty in the context of moral codes and techniques of the self. The former define desirable (and otherwise) behaviours and attributes and specify goals to be pursued and pitfalls to be avoided and the latter refer to the methods by which individuals act upon themselves in order to ‘transform oneself into the subject of one's ethical behaviour’ (Foucault 1986: 27).

The creation of the ethical self is seen as involving practices of freedom as opposed to merely an expression of discipline aimed at constraint. However, in the absence of ethical practices aimed at ‘excavating our own culture in order to open a free space for innovation and creativity’ (Foucault 1988: 163) freedom to create oneself may be seen less as liberation than as an obligation to aspire to a certain ethical self. Technologies of the self as practices of freedom are identified with an ethic of care for the self. These technologies of the self imply a set of truth obligations since constituting oneself as an ethical subject involves conducting oneself in accordance with the truth. Truth here signifies that which is sanctioned by prevailing moral codes and the construction of the ethical self as an act of freedom involves choosing to reject other discursive alternatives which offer marginal or illegitimate truths.

The notion of ethics as a form of freedom, as individuals choosing to adhere or aspire to certain moral codes, is taken up by Nikolas Rose. He sees irony in a state of affairs in which

the government of the soul depends upon our recognition of ourselves as ideally and potentially certain sorts of person, the unease generated by a normative judgement of what we are and could become and the incitement offered to overcome this discrepancy by following the advice of experts in the management of the self. The irony is that we believe in making our subjectivity the principle of our personal lives, our ethical systems, and our political evaluations, that we are freely choosing our freedom (1999: 11).

For Rose, freedom to create an individual self is less about choice or empowerment and may be more usefully conceived as an obligation to be free. ‘The self is not merely enabled to choose but obliged to construe life in terms of its choices, its powers, and its values’ (1999: 231).

Rose (1996) suggests that the discourse of empowerment can be seen as ‘the role of experts in the coaxing of others who lack the cognitive, emotional, practical and ethical skills to take personal responsibility and engage in self-management’. He describes how the promulgation of technologies of psychological and moral management based on psychotherapeutic discourse and practice have been focused upon ‘damaged individuals’ with the aim being to remedy their behaviour and bring it within normal (or ethical) limits. There are parallels with the ways in which individuals are encouraged to reflect on their own practice as part of empowerment processes aimed at promoting self-actualisation (Brewis 1996). The discourse of empowerment therefore assumes the existence of the damaged or deficient subject requiring what Gilbert (2001) terms ‘remedial work through reflective practice and . . . supervision in order to achieve forms of subjectivity consistent with modern forms of rule – adaptable to lighter touch forms of surveillance and capable of self-regulation’ (2001: 204).

The creation of the ethical self and the practice of certain modes of behaviour, however, should not be interpreted merely as slavish adherence to rules or prohibitions. Rather, technologies of the self, and the attainment of a certain mode of being involve individuals in making choices about behaviour, in exercising ‘their rights, their power, their authority and their liberty’ (Foucault 1986: 23). This freedom to make choices is important since it creates conditions for both the exercise of power by others, and (since where individuals are wholly determined there is no relationship of power) the exercise of resistance to that power. Freedom's refusal to submit means that attempts to exercise power will always take place in the context of resistance (Foucault 1982). What this implies is that the outcome of attempts to manufacture particular forms of subjectivity by such methods as empowerment programmes may be very different from those intended.

The case study –‘Empowerment’ in Downtown PCT

Background to the empowerment initiative

Downtown (pseudonym) PCT was created in April 2001. It was formed from two existing Primary Care Groups and one Community Health Services Trust. The latter's role was the provision of community services (such as community nursing, podiatry, speech and language therapy) while the former were involved in the commissioning of health services for the local population. In addition, staff from the Health Authority were incorporated into the PCT. The Community Trust staff formed the vast majority of the new PCT employees and were located either in clinics within the local community or in Walsingham House, a mile and a half from the PCT headquarters which housed the PCT Chairman, executive directors and some support staff (e.g. finance, human resources). This geographical separation of the senior managers from the rest of the staff exacerbated the unhappiness felt by many members of the former Community Trust when its Chief Executive was not appointed as the lead officer of the PCT. Staff at Walsingham House spoke in pejorative terms of ‘the Palace’ and its inhabitants and the Chief Executive pointed to this ‘them and us’ state of affairs in one of her briefings to the staff.

The creation of the PCT involved not merely assimilation of existing organisations but reorganisation of ways of working which involved the creation of new roles and the disappearance of old ones. Staff to be displaced were labelled ‘at risk’. The use of the label was intended to promote some sense of security since these staff would be given priority in applying for new posts, but it is not clear that labelling employees in this way was a reassuring process. Reorganisation was a constant feature during the research and this was initially justified on the basis that the PCT was a new organisation. Further processes of reorganisation included the introduction of locality teams aimed ostensibly at ‘empowering’ local staff and communities. In an addition as part of the ongoing Modernisation/service redesign agenda which/there involved building new community and hospital facilities, and was an ongoing process of redefinition of roles and pathways for patient care.

The measurement of outcomes relating to the work performed by those who deliver health services in the community has long proved a difficult task. In addition, for those PCT staff not involved in the direct provision of care, the evolving nature of the PCT, and the problems of meeting Government targets in a complex system where it is difficult to identify mechanisms for achieving desired ends, means that the precise nature of an individual's work is often uncertain and the quality of their output is difficult to assess. Under such circumstances work-related roles and identities and professional competency are actively established in interaction. This means that the likely success of attempts to persuade staff to adopt new identities and work-related roles, as desired by the Chief Executive and outlined in Modernisation documents, would be diminished if the interaction between former Community Trust staff continued as it had done. The moving of staff briefings to a neutral venue (away from ‘the Palace’) in order to encourage attendance from former Community Trust staff can be seen as an attempt to widen this sphere of interaction in order to allow new influences into the processes which shaped individual PCT identities.

A study commissioned from a third party by the PCT Chief Executive found low morale, widespread dissatisfaction with channels of communication and distrust of senior management of the PCT. Respondents reported feeling vulnerable and complained of a lack of organisational identity. In a context where their former organisations no longer existed, and the new organisation gave individuals no sense of what it was or would come to be, it is understandable that respondents did not identify with the PCT nor did they want to belong to it.

As the external consultants reported, however, many employees felt a sense of belonging in relation to the existing services they provided and in their immediate working relationships. The views expressed by interview respondents in the PCT-commissioned study were at odds with the Modernisation discourse, which permeated Government announcements and circulars and was promoted at every opportunity by the Chief Executive of the PCT. By contrast, this alternative and unofficial nature of resistant discourse had hitherto bubbled below the surface, until it was captured and articulated in print by the external consultants who summarised it in their written report. The reporting of such views in a quasi-official publication created the possibility that, once circulated throughout the organisation, such findings would lend legitimacy to the discourse of opposition. It could also negate attempts by the Chief Executive to promote identification with new organisational and individual identities. This may explain why the report, which had been circulated to senior managers within the PCT upon its receipt in June 2002, was hastily recalled and shredded.

As part of a process of organisational development the PCT Chief Executive extended an invitation to all staff to nominate people in the PCT who were ‘influencers’. These members of staff were then invited to participate in an ‘Investing in Excellence’ (IIE) programme.

Influencers were split into groups and brought together as a group for five days over the course of approximately twelve months. An external facilitator ran these events and during this time participants watched IIE videos and engaged in discussion and group and individual exercises. In addition, they worked through audio materials and work books provided as part of the IIE course during their spare time at home. They were also invited to attend an ‘influencers lunch’ at which influencers were briefed, given lunch and the chance to mingle with the Chief Executive, Chairman and other senior officers of the PCT.

The data presented here are part of a two-year participant-observation study conducted between 2001 and 2003 examining decision-making within the PCT, during which time the researcher was based within the PCT. A variety of methods were used during the conduct of the case study including formal interviewing techniques, participant observation and documentary evidence. Thirty formal interviews were conducted with employees who had participated in the IIE programme. These employees were at or below deputy director level and from a variety of functions, including the management of clinical services (e.g. nursing, podiatry), the provision of services (e.g. health visiting), training, public health and service development. A grounded theory approach to the analysis of data was used so that themes and questions that emerged in early interviews were explored and tested in subsequent interviews. Themes that emerged from interviews were compared and contrasted using the constant comparison method advocated by Glaser and Strauss (1967). Using a coding frame, the tape recordings of interviews were transcribed in full and coded into relevant categories and sub-categories. In addition to the interview transcripts, detailed notes from a field diary recording observations were coded together with documentary evidence from the PCT.

Empowerment in action – Investing in Excellence

At an open staff briefing which reported on the success of the first waves of the influencers programme the Chief Executive described the rationale for it and encouraged others to participate:

We set up an influencers group . . . we were kidding ourselves that it's the senior managers who have the most influence, but everyone knows who the managers are who have the most influence. Everyone knows who the people are with strong opinions and are opinion shapers. So we did a survey [to identify] the main influencers and people were nominated. . . . It's good to have people who challenge, but it can be quite negative if challengers see everything as half empty. . . . And recently we've been adding to the group. I use this as a way of testing the temperature of the organisation. The culture of the organisation's rarely fed back through management . . . It [influencers’ programme] can help our self-confidence, standing up and speaking publicly, our sense of self and who we are . . . some of my colleagues are gonna tell you a little bit about how the course has helped them.

What seems odd here is the notion that it is the people who are already seen to be having some influence in the PCT who are being singled out for training which will empower them. If the desire is to empower staff then why not start with those who are perceived to have little or no influence? These pronouncements raise questions about the motives for this ‘empowerment’ process and its desired effects. They also suggest that the participants are in some way deficient and in need of development. The speech is used to establish some boundaries of ethical behaviour. For example, challenge is acceptable, but within certain parameters. Freedom to act is acknowledged (‘it's good to have people challenge’), but this freedom must be exercised responsibly. Responsible selves do not choose to engage in ‘negative’ behaviours or adopt ‘half-empty’ perspectives.

The need to behave responsibly and in an ‘adult’ manner is reiterated later on in the staff meeting when the Chief Executive explains in her ‘whistle stop tour through the coming year’ that she makes ‘no apologies for not talking about everyone . . . there's always somebody saying “I'm not important”, well bloody well grow up. You cannot focus on everything in every organisation . . . some things are really high priority . . .’ The parading of those employees who have undertaken the programme and their recounting of transformations from unassertive to self-confident self, from disorganised to self-managed self, from emotional to controlled self and so on, coupled with the Chief Executive's remarks about the programme on ‘our sense of self and who we are’, further serves to underline the notion of a desired ethical self based on some transformation of the current or existing deficient self.

This theme of the emergent self-directed individual, exercising freedom of choice but behaving responsibly, runs through the IIE course as this extract illustrates:

The aims of the course are to help you as an individual and an organisation become

Unique

Self-directed

Accountable

. . . it is vital that you become self-directed . . . you have free will. You can choose [p. 3].

Although what this extract also suggests is that the organisation, as well as the individual, is engaged in a project of the self and that self-direction should be seen in the context of the moral codes which govern the organisation in which the individual is employed.

That self-direction, for the empowered individual, is a matter of choice rather than slavish adherence to rules is emphasised in the course literature as the following extract illustrates:

Locus of control: The place where control is perceived to be. This is internal for independent, self-directed, accountable people. It is external to dependent, other-directed people who have given up accountability for themselves to others, or worse, to circumstances (The Pacific Institute 1998a: 2).

Self-direction involves a recognition that ‘most of our limitations or obstacles are internal’ and can be quickly removed by affirming their opposite. However, although choosing to reject these negative thoughts is part of achieving ‘a new way of life’ or becoming a self-actualised individual, it is also important to recognise the existence of external obstacles that ‘should not be fought against’ since the ‘constraints they impose upon us will release more energy and creativity to achieve our goal’ (The Pacific Institute 1998b: 231). The freedom (or obligation in Rose's words) to make choices about ethical behaviour is in part a matter of distinguishing between what is within the control of the individual and what is not. In the context of dominant discourses on the ‘inevitable’ logic of Modernisation it may be that self-actualising individuals choose to aspire to those behaviours which are consistent with this discourse. Alternatively, those who would previously have engaged in resistance may now interpret constraints as external, recognise the ‘futility’ of resistance and choose to accept the inevitability of change. This may necessitate a degree of ‘ethical work’ (travail ethiqueFoucault 1986: 27) to bring one's conduct into compliance with the PCT rules or moral code and to attempt to transform oneself into the ethical subject of one's behaviour.

Whilst the IIE course encourages participants to recognise the existence of external obstacles which may prevent them from achieving their goals, it is stressed that the exercise of free will means that nobody can be forced to do anything against their wishes. Work processes are active choices not burdens imposed by others. A related implication is that since the possibility of resistance or departure exists for individuals, complaining about one's lot or engaging in ‘negative’ thought processes is not the behaviour to which the ethical individual aspires.

The shaping of the empowered self in Downtown PCT – identity and resistance

Participant attitudes towards the IIE course fell into three categories, with the majority of people praising the course and a small number either expressing ambivalence or being openly critical of it. Most enthusiasts saw themselves as changed and becoming more confident or content in their work as part of the process. Many of those who were critical pointed to tensions between the rhetoric of empowerment and the reality of what they saw as a top-down controlling environment. Even amongst those who were wholeheartedly in favour of the programme there were inconsistencies in the accounts presented. For example, most respondents described how as an empowered individual they enjoyed a great deal of autonomy in respect of their workload and objectives. Nevertheless, these same people also complained that, although they saw attendance at IIE sessions as extremely important, they had not been able to attend all of them due to pressure to work on ‘must dos’. This suggests that respondents are subject to pressures beyond their control and are forced grudgingly to accept the priorities which others impose upon them. Certainly, some respondents expressed resentment at having to forego what they saw as time for their development because of unreasonable demands made from ‘on high’:

A couple of occasions when something very major came up at work I had to drop everything and do this . . . it meant that I couldn't go on 2 of my days. I was furious that this important part of my personal development had to be put on hold because this big piece of work trumped it.

Resistance seemed weakest amongst those who appeared only too willing to confess to their deficiencies and make appropriate modifications to rectify these, although as the following illustrates, training the deficient self can result in tensions and a rejection of attempts at control.

The deficient self

Many respondents outlined areas of personal conduct or behaviour, which, as a result of the programme, they had become aware were in need of modification. Amongst enthusiasts, most participants reported acting upon themselves, monitoring their conduct and improving their performance in an effort to transform themselves. The responses of IIE participants serve to underline Foucault's comments on the way in which individuals decide on a mode of being that will serve as their moral goal.

Lucy was one of those who spoke enthusiastically at an open staff meeting of how the IIE programme had transformed her. She explained having learned how to look at her workload and prioritise more effectively: ‘You look at where you spend most of your time . . . If you’re organised you should be spending 80 per cent in the URGENT and IMPORTANT box. She explained how the IIE programme had helped her identify her own shortcomings ‘You realise that what you end up doing is the stuff that's not urgent’.

Lucy appears to have taken on board the IIE message about self-determination and accountability and has come to see the root of problems as located within herself rather than her environment. Problems were conceptualised in terms of deficient individuals but seen as easily resolved through the use of IIE techniques. During the research period Lucy was seconded for two years as a project manager but as her original job was not filled she was currently juggling both roles. However, although Lucy admits in my interview with her to working long hours and acknowledges that having two jobs creates tensions, her comments suggest that she perceives the problem as being located within her deficient practice: ‘you've just got to try and get your work part in control cause you could just be here 24 hours a day really so you've got to try and cut the hours down and try and be more effective’.

Comments by Lucy and other respondents who outlined progress in addressing deficiencies were often made in the context of some ideal self to which they aspired. For example Laura's comment that:

Before [the programme] I would just react to something and sometimes quite inappropriately as well maybe lose my temper and slamming and banging . . . I'm not where I want to be but I'm getting there.

is suggestive of a self in transition. The implication is that outward displays of emotion are ‘quite inappropriate’ behaviour for the ethical self to which she aspires. Similarly the tales told by other respondents about transformed selves exercising restraint and suppressing anger and resentment as a direct result of their participation in the IIE programme suggest that respondents are exercising tighter control over their feelings and behaviours in their journey to becoming their desired ethical self.

This willingness to identify and embrace development needs echoes Townley's (1995) (Foucauldian) writings on self-formation and the discourse of ‘needs’. Needs ‘become a way for individuals to understand themselves, as a means of constructing a sense of identity. Our notions of what it is to be a “self”, however, also inform how we relate to and understand others’ (1995: 279). Townley goes on to suggest that interaction with other people defined in terms of recognising, deciphering and meeting their needs ‘necessarily introduces an inherent hierarchy and subjugation’ so that recognition of the needs of others may lead to placing their needs above our own ‘soothing over potential conflict and damaged egos . . . Any legitimate anger is suppressed (1995: 281)’. Certainly, comments by Jane that the PCT managers were ‘doing a very difficult job’ and that she would not challenge their actions unless she thought them guilty of illegal activities (‘like fraud’) suggest that, in her case, the combination of an ability to perceive the needs of others and hierarchy may act to reduce the desire to resist. The emphasis in the IIE course materials on self-reliance and self-actualisation, however, may have acted to reduce the ability of some participants to take the needs of others into account. Similarly, the encouragement of the single-minded pursuit of goals appeared to contribute to a failure on the part of some course participants to acknowledge the legitimacy of the goals of others. (This is discussed in more detail below). For some, an ability to appreciate the needs of others appeared to work in ways which increased tensions, when this ability was exercised in respect of those below them in the hierarchy or indeed patients, who were outside the formal organisational hierarchy.

Several respondents reported how the IIE programme had taught them that they ‘did not have to do anything’ and that they were free to choose although non-compliance would carry consequences. For Sally, working long hours often being the only person left at the health centre when everybody else had gone home was previously a source of resentment. The realisation of her ‘freedom’ to choose had transformed her perception so that she was happy to stay, since it was her choice to do so. She was only too willing to acknowledge how she had rectified her previously deficient attitude characterised by resentment, although elsewhere in the interview she describes feeling pressured to choose certain courses of action over others:

My own director only went on one of the [IIE] courses. She never said anything but when she was also missing sessions I didn't feel strong enough to go . . . I think a few people felt like that. I suppose we should have been stronger but we weren't.

In Hirschman's terms employees who are deeply dissatisfied with an organisation may choose to leave or ‘exit’ (Hirschman 1970). Those who stay display varying degrees of ‘loyalty’ or ‘voice’. Conceptualising choices in terms of freedom to choose between loyalty or exit but not voice, closes off certain discursive options, suppressing conflicts and alternative courses of action. As Deetz writes, in choosing loyalty individuals ‘gain membership, clarity, status and specific identities, but they also re-enact a dominant set of power relations with costs’ (Deetz 1998: 170 ). Whilst the extent to which participants were willing to voice opposition or anxieties in open forums varied between individuals, it is clear that not all of those who remained were choosing loyalty, as the following section illustrates.

Conflict and self-identity

Not all participants were comfortable with the consequences of their empowered status or becoming the self to which they felt they were being encouraged to aspire, as this extract illustrates:

I've been a little bit unhappy because I've heard comments from friends that a couple of managers have commented that ‘Jackie has changed’ but yes Jackie has changed as a consequence of the programme. . . . to me that was the whole point of the programme. You do change as a person professionally and personally . . . I should have changed otherwise the programme would not have been a success . . . I realise that my comments and opinions are as valid as anybody else's in the organisation and your manager or the boss may not necessarily always be right and I've got a right to have an opinion. I’ll challenge things but the point is it's not liked if you challenge something.

Such comments suggest that an unwillingness to voice criticisms openly may be due to an awareness of the consequences of openly challenging. This may lead individuals to engage in subtler forms of resistance.

Those employees who had previously been or were currently involved in the front line delivery of services to local people reported tensions which were highlighted by the obligation to becoming an empowered ethical self with all that that implied. The picture painted by evangelistic participants of ideal selves is one of unemotional, rational, positive and self-contained individuals. Getting the potentially emotional and unruly self to behave is an important part of the IIE programme. This was illustrated by the remarks of one health visitor on what the IIE had taught her ‘it's about focusing your mind and taking away the emotion’. This highlights the emotional/rationality dualism. For those engaged in caring for patients this lack of emotionality can cause problems. One respondent had seen her ability to empathise with staff at grass roots level as a strength. She reported, when expressing anxieties about the ability to deliver safe and effective care with dwindling staffing levels, that she was instructed to ‘stop thinking like a district nurse’, since it was seen as incompatible with her status as a manager. The link between emotion and what has been seen as an irrational clinging to traditional values goes back a long way. As ten Bos and Willmott (2001) point out in their discussion on the dominance of rationalist assumptions in business ethics, such assumptions privilege reason over emotion. ‘This is not an ethics that is close to actual human beings. Indeed to be too close to actual persons risks becoming less ethical’ (2001: 775).

This sense of conflict about identity is heightened for those respondents whose sense of self is linked to the former Community Trust which no longer exists:

The impression that is given at the moment is that any old Community Trust staff are not really worth anything and the jobs that they did weren't and in all this mad rush to change everything it seems as though any good work that has been done in the past is just being ignored. . . . There are an awful lot of good things in the old organisation including. . . . [my] service.

These inconsistencies and tensions open up space for criticism or resistance, but ‘empowered’ individuals may choose other more conformist paths as this quote from the same employee illustrates:

It makes you more aware of what you can do and more aware of yourself . . . I think that I can cope with things better . . . One of the exercises we did a couple of times throughout the course was to draw pictures of what was going on in your life . . . and one of the last pictures I drew was two people sitting opposite each other smiling at each other cos it's all about thinking positive . . . and behind the figure that was me there was this huge black swirl of chaos and I said that is what's going on in the Trust at the moment and I've got my back to and I'm ignoring it. . . . rather than worrying about it . . . and not getting het up about things that are happening that I have no control over at all.

The emphasis on recognising one's own limitations and sphere of influence may have the effect of transforming disciplinary power into a benevolent aid which helps the individual to appreciate the futility of engaging in areas where they have no control. Yet securing compliance and turning one's back to the rest of the organisation does not necessarily equate to enthusiastic support for the PCT agenda or identification with its aims.

The need to remain ‘positive’ is emphasised throughout the course and was raised by many participants. The IIE audio assimilation guide compares the use of ‘positive forethought’ in efficacious people who look forward and see success with ‘negative forethought’ of inefficacious people who look forward and see the future with fear and misgivings. Given the emphasis on positive thinking in management texts, self-help books and a range of TV and radio programmes dealing with self-improvement, it is hardly surprising that employees do not readily admit to being frightened or having grave misgivings.

The picture of the self as cheerful and coping in adversity without complaint was one which was presented repeatedly. Many interviewees reported staff shortages (euphemistically, ‘capacity issues’) which placed greater burdens on employees, but almost all interviewees described themselves as ‘positive’. Part of this willingness to express a positive attitude appears to relate to norms about what is expected of managers and this may be interpreted as putting on a brave face. An hour after I interviewed Natasha, who described herself as always ‘seeing the glass as three-quarters full’, motivated and autonomous, I learned from a third party that she was unhappy in her existing role and was applying for another job at a salary of £5,000 less than her current post. Experiencing ‘negative’ emotions may result in individuals perceiving themselves as an imperfect rendition of the positive model. Engaging in a positive discourse may reflect the effort invested in self-surveillance aimed at getting the self to conform (Deetz 1998). However, expressions of allegiance to the positive ideal may be seen as dramaturgical with employees appearing to toe the line in taped interviews, but behaving differently outside those settings. For example, Charlie, who described himself as ‘positive’ and feeling ‘privileged to be doing this job’, spent much of his time bemoaning his fate and frantically searching the Health Service Journal every week for a new job outside the interview setting.

Others actively resisted the notion that being positive implied loyalty to the new order. A health visitor who reported feeling ‘positive about my outlook’ also describes feeling ‘very demoralised’ about life in the PCT. The tension between what Jenny sees as the behaviour contained in moral codes relating to the sphere of management and Jenny's own perception of an ethical self, perhaps drawn from her nursing background, is illustrated in her comment:

You've gotta care about people. You can't do it if you don't care about them and you’re thinking it's just one step up to being a manager. A lot of people have thought ‘I’ll do health visiting and then I’ll become a manager’ . . . So they've done that and they've time served. I think it's frowned upon to want to carry on in your job. I think people would say I'm an underachiever because I should be somewhere else . . . but I don't want to be where people think I should be . . . I don't feel like we’re a unified whole, that we feel part of a PCT. For us our attachment is to our community that we serve and the PCT is distant . . . that's like your employer . . . There's nobody taking a professional interest in what you do . . .

This last remark is important since selves are above all social. The making of the ethical self involves the existence of rules, but it also involves modes of subjectification; that is, the way in which individuals establish their relation to a rule and recognise themselves as obliged to conform to it. Praise for key influencers paraded at staff meetings, invitations to influencers lunches and opportunities to plan future staff communication meetings with the Chief Executive provide positive feedback and a means of encouraging some of those involved in the IIE programme to identify more closely with the values espoused by the PCT Chief Executive, and hence to comply willingly with PCT ethical codes. As Jenny's remarks illustrate, however, individuals who participate in such processes may resist attempts to shape their identity if those attempts are seen as lacking validity in terms of their view of what constitutes ethical selfhood.

Empowerment, selfhood and resistance

A small number of respondents left the course before the end and reported dissatisfaction with its messages. As one IIE evangelist explained:

I think if you look at the drop-out rates the ones who dropped out are the ones who thought the glass was half empty and the ones who have stayed are the ones who see it as half full.

Whilst judgements about the half-full or half-empty status of individuals are in the eye of the beholder, IIE dropouts were different from those who participated fully in the course inasmuch as they were far less inclined to embrace the notion of themselves as deficient or in need of empowering, as this quote illustrates:

. . . people had nominated us as people that could bring about change and so I wasn't quite sure why we were then thought to need a development programme . . . We already were [empowered] cos people were saying we were effective. It just seemed an odd thing to do to me.

Angie, who has worked in the NHS and been involved in managing change for over 25 years ‘hated every second’ of the IIE programme on the grounds of its ‘evangelical’ and ‘patronising’ manner. Her description of how her willingness to challenge the corporate line had made her unpopular with PCT management suggests that she has no regrets about her failure to conform:

If I don't agree then I will challenge . . . There was an incident where I was asked to do something that I didn't feel competent to do . . . Because I've challenged things in the past I've had senior managers come up to me and say ‘I thought you were really frightening cos you've got a terrible reputation . . . I said ‘Do you not think I was right to challenge?’ They've said yeah.

The statement also highlights tensions reported by several interviewees between complying with managerial edicts and managing risk in the delivery of care, suggesting that in the context of conflicting ethical codes, the making of the ethical self can be a tricky and uncomfortable business.

The comments by Angie and others suggest that far from conforming to a PCT norm or identifying with PCT values many respondents located their sense of self in some other constituency. For some their loyalty was to ‘the community’ or to patients; for others, the PCT identity was described in terms which conformed to the territory of selfhood which individuals had staked out as their own. Organisational goals were constructed in such a way as to prioritise the specific goals of interviewees and the descriptions of the ethical PCT selves (positive not negative, deficient but improving not static, rational not emotional, and so on) were overlaid with a veneer, which reflected the work objectives of individual respondents. This emphasis on individual goals is hardly surprising given the assumption in the IIE course that individuals are a seething mass of unfulfilled goals which they are constantly striving to achieve. These are not imposed from above but freely chosen as representing the individual's ‘true’ aspirations. What is not clear is how, when different PCT employees have goals which conflict with those of other PCT employees, these are to be prioritised or reconciled. The focus on successful outcomes with the empowered individual considering alternatives and choosing the ‘correct’ course of action may explain why interviewees see the organisation in terms of the goals which relate to their sphere of interest. In effect, employees appear to be rewriting organisational goals in terms which reflect their own values and priorities rather than conforming to some top-down notion of what counts as important. Tension arises from the subordination of individual beliefs and values in the interests of achieving short-term targets imposed by Government and prioritised by senior management. For example, the Deputy Director of Public Health was dismayed by the fact that others in the PCT choose to prioritise waiting lists rather than tackling health inequalities. Although both are the subjects of organisational targets, the timescale for achieving waiting list targets is more short term. Furthermore, the imposition of many short-term targets from central Government means that PCTs are unable to prioritise competing goals with the result that managers may perceive their department's status as marginal and undervalued. The Deputy Director of Teaching and Learning was disappointed by the way in which the PCT ‘top level’ had failed to appreciate its importance as a core function underpinning the PCT's work, ascribing to it a discrete and peripheral status. Yet training or research initiatives that may involve granting study leave or secondments, and serving long-term organisational goals, may conflict with short-term targets. Similarly, the Deputy Director of Modernisation feels frustrated that other departments do not afford appropriate recognition of the importance of her directorate ‘we are the PCT and for a long time it's felt like primary care was just that bit bolted on to the side’. With so many targets relating to hospital performance the PCT board is unlikely to be able devote as much time as it would like to the development of primary care.

Such frustrations may act to mitigate the transformational and reconstitutive effects of a discourse of empowerment (exercised responsibly as promoted by the IIE course) aimed at increasing commitment and contribution to the PCT. The emphasis in the IIE course and the empowerment discourse on individuals achieving goals, which map on to organisational goals, assumes that such goals are internally consistent and compatible. Government proclamations that staff are now in the driving seat ignores the fact that ‘empowered’ staff members may try to steer the vehicle in many directions at the same time, thereby creating tensions amongst employees. This tension appears to manifest itself in disappointment with the attitudes of others and a willingness to redefine what is important in the organisation, rather than in attempts to modify one's own notion of what is ethical behaviour.

Conclusions

The case study data suggest that participation in the empowerment programme in Downtown PCT and the observed behaviours arising from it can be understood in the context of the fashioning of the ethical self. These data, however, also illustrate that the processes of identity formation are fluid, unstable and reflexive, which means that, although the intent of empowerment initiatives might be the creation of new forms of subordination, the result might be rather different (Alvesson and Willmott 2002). Certainly, many employees reported feeling more content and less likely to complain in the context of increasing workloads and uncertainty over roles and responsibilities. For some, particularly amongst those who had been promoted by the organisation, there were clear expressions of loyalty to the new regime. For others, however, rather than actively choosing loyalty, they chose quiet resistance, engaging in criticisms with colleagues or applying for jobs outside the organisation. Some simply chose to ignore the changes and continued to work in ways which were compatible with their own ideas of ethical selfhood. Other respondents chose more open forms of resistance in the face of attempts to secure their compliance, either by opting out of the IIE course altogether or by using the techniques learned on the course to openly challenge senior managers within the PCT.

The case study suggests that individuals are actively involved in the construction of their identities bringing their own values, skills and affiliations to bear on the matter of what constitutes ethical selfhood. In addition, the rules and values (or moral code) which convey what is expected of an empowered individual in the context of Downtown PCT, far from being a systematic ensemble, are transmitted in a diffuse and contradictory manner. They can best be understood as a complex arrangement of elements that counterbalance and correct one another. At certain points they cancel each other out, providing for compromises or loopholes.

For example, there are rules which relate to the requirement for individuals to display optimism and positive attitudes. These requirements are laid out clearly in the IIE course materials and are supported by the Chief Executive's comments about the undesirable nature of those who see the glass as ‘half-empty’. There is also the public service discourse which conveys a picture of a vocational, professional, loyal, self-sacrificing and caring self for whom service is an honour and a duty rather than a chore. Management textbooks and Government policy documents are replete with images which equate rationality with calculation and lack of emotion. At the same time there are other rules, some of which are prescriptive, explicit and consistent, and which outline what constitutes the required behaviour for caring professionals. The comments made by Downtown PCT nurses suggest that such rules may conflict with other managerial codes. For example, the Nursing and Midwifery Code of Professional Conduct, paragraph 8:1, places a duty on nurses to ‘work with other members of the team to promote healthcare environments that are conducive to safe, therapeutic and ethical practice’ (NMC 2002), but staff who refuse to work in what they consider to be an unsafe environment may be seen as ‘negative’ or failing to cope in adversity. In addition, Modernisation involves attempting to deliver services with inadequate resources, to achieve at times unrealistic targets and without being permitted to engage in rationing. The unreasonable and inconsistent nature of what is being asked (exercise local freedom, but don't engage in postcode rationing, prioritise waiting lists and inequalities and access to primary care services and A & E waiting times and everything else all at the same time) means that it is not possible to provide simple messages or codes about what constitutes ethical behaviour. The fact that senior managers, as well as middle managers, occupy equivocal positions (Wilmott 1997) and possess views and values which may conflict with some aspects of the Modernisation process may serve to dilute the strength or content of the messages being passed down from on high.

The depiction of the empowered self at the heart of the IIE programme serves to buttress the comments of the PCT Chief Executive in relation to desirable ‘grown up’ behaviour. Well-behaved selves are loyal, positive and embrace change, but, as the case study illustrates, loyalty may be to other constituencies if the individual chooses to obey other ethical codes. Resistance to change may be seen by individuals as a positive stance if changes threaten such cherished values as patient safety. Whilst employees ostensibly choose ‘loyalty’ in preference to ‘exit’ the tensions created by an emphasis on personal authenticity in the context of top-down directives which require the individual to subordinate their personal priorities to those of the organisation means that conflict and resistance are always present even if not always openly voiced by employees.

For many, the obligation to render one's everyday existence meaningful as the outcome of choices resulted in frustrations emanating from the failure of others to acknowledge the legitimacy of those choices. The expression of ideas and the selection of goals by individuals represent not merely an administrative process of policy implementation, but are instead integral components of the construction and maintenance of the self. A less than enthusiastic reception for these ideas is not merely an issue on which compromise can be reached or where agreeing to disagree ensures good working relationships. Rather, many individuals are likely to perceive opposition or neglect as deeply wounding since it represents an assault on the self. The case study suggests that the shaping of ethical selves involves much more than the exercise of an empowerment discourse over inert and compliant employees. The Downtown PCT employees described here are actively involved in the shaping of their identity and for many, these assaults on the self are much more likely to provoke resistance than secure compliance. This state of affairs is likely to be exacerbated in a situation where increasing numbers of PCT staff are participating in the IIE programme, persuaded of the validity of their own opinions, but in the context of top-down directives which conflict with the way in which individuals choose to conduct themselves and with the values which they hold dear.

The paradox that presents itself is that many PCT employees now demonstrate greater loyalty to the PCT than they did before the IIE, yet this loyalty appears to be based on their own, as opposed to some shared or collective view of what constitutes the PCT. Early on in the life of the PCT, many employees described the need to create an organisational identity around which all employees could unite. This has some resonance in the words of Nikolas Rose (1999), who speculates on an alternative ethic of existence, one where ‘subjectivities are distributed, collective and oriented to action’. The Chief Executive has been at pains to break down barriers between ‘us’ and ‘them’ and create a coherent whole, perhaps in recognition that the Modernisation agenda requires co-operation from staff working across different disciplines. Despite the emphasis on collectivity and co-operation, however, this analysis suggests that an organisational identity will prove elusive, and this is partly due to the context of conflicting goals in which the PCT is forced to operate. However, the irony is that the programme of empowerment instituted by the PCT, with its focus on personal authenticity and individuality, makes compromise and consensus in the cause of organisational identity a more remote prospect than ever.

Acknowledgements

This work was undertaken whilst the author was in receipt of a Department of Health National Primary Care R and D Award. Thanks are due to participants in the study and to Nancy Harding and Mark Learmonth who made helpful comments on the draft. Two anonymous referees provided a very helpful mixture of encouragement and constructive criticism and their comments have been invaluable.

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