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Summary
Culture provides us with what we so desperately need in human life — a set of felt meanings in an orderly pattern. A group creates a culture as a way to cope with life's challenges and teach members the correct way to feel, think, and behave. No group is ever without a culture.

If culture has a built-in tendency to resist change, how does change take place at all? The process of change involves separation, chaos, and reentry — the letting go of the old and familiar and the embracing of the uncertain new.

The way to use chaos constructively is for people to return to the sacred time of their founding in order to identify, relive, and reown the heart of their creation mythology, liberated from the accidental and historical accretions that hold back creativity. For healthcare workers today, this means reidentifying with Christ's actions such as healing the sick or giving sight to the blind. Through this reidentification, healthcare givers can be fired up to form a new cultural integration adapted to changing needs.

The chaos that our healthcare ministry is experiencing today offers us unparalleled opportunities for refounding. By acknowledging the chaos of the healthcare system, we thus lock in on the healing and reconciliatory power of God, and from this comes the energy to journey through the refounding process — the process whereby we struggle to enter collaboratively into the paschal mystery with Christ for his mission of healing; thus energized, we work to challenge systems and to create responses to the most urgent needs confronting the health of the people we serve.

No one likes chaos. It is a painfully disturbing experience. But if we do not allow ourselves to experience and become familiar with chaos, we simply will not grow culturally or personally. Chaos is a hallmark of contemporary healthcare cultures, and Catholic healthcare givers must take steps to make this experience the catalyst for creating radically new healing ministries, or refounding the Catholic health ministry.

Discovering the Complexity of Culture
Culture, comprising symbols, myths, and rituals, is all about meanings, recognizable connections or relationships. Culture provides us with what we so desperately need in human life — a set of felt meanings in an orderly pattern. Once we know the meaning and significance of things, we are able to develop that comfortable sense of belonging, order, and predictability — the feeling of "being at home," a sense of identity and security.

When we lose this set of felt meanings, we are in the state of dreaded chaos, or the world of nonmeaning.¹ And that can be an intensely disturbing experience. In fact, culture is so much part of everyday life that we do not realize its power and its role until we are suddenly deprived of it, as I was in the following adventure:

Several years ago, on my first visit to Japan, I took the subway to a Tokyo hotel to visit a friend. All went well until I alighted from the train at the wrong station. Crisis! I was stunned. The signs were in Japanese, and I could not read them. I was utterly lost and panic-stricken. I became angry with everything Japanese. A law should be made, I said to myself, to require that all Japanese signs have English subtitles.

But then I noticed in a shop window woolen blankets made in my home country, New Zealand. At the bottom of each blanket was a symbol of New Zealand — a small, stylized kiwi bird. Comforting memories of my family, friends, and magnificent scenery came to me, evoking the feelings of belonging, self-worth, and security I had lost in my panic.

"How would other New Zealanders react in my situation?" I asked myself. Not with self-pity, but with resourcefulness, initiative, and courage. Energized by this discovery, I too became creative. Holding high a piece of paper on which I had written the word "help," I was quickly aided by an English-speaking Japanese man.

This incident illustrates that when our culture fails us, the resulting chaos can be the catalyst for a burst of creative energy. Notice what happened when I saw the kiwi on the blanket. I quickly experienced the power of the three elements found in all cultures: symbols, myths, and rituals.

Symbols are diverse and numerous experienced or felt meanings. Myths are narrative symbols, stories of tradition that reveal to people, in an imaginative way, a fundamental truth about the world and themselves. This truth is considered authoritative by those who accept it. Myths inspire people and tell them who they are, what is good or bad, and how they are to organize themselves and maintain their feeling of unique identity in the world.

The most powerful myth in every culture is its creation myth, since it provides people with their primary source of identity as a distinct group. In the Tokyo subway, when I asked myself how a New Zealander would react in the midst of chaos, I returned to the creation myth of my culture. The nation was founded on the other side of the world by hardy people who had to be incredibly creative to survive in a harsh terrain, thousands of miles from the world's key markets. Our heroes and heroines are stubbornly innovative people who flourish best in chaotic situations. By rediscovering this creation myth, I found myself reenergized to be creative, determined to find a way out of my paralyzing lostness. And I did. Symbols and myths evoke energy for action. Rituals, the third element in a culture, are what people visibly do because of their culture's symbols and myths. Holding up my "help" sign was a ritual.

Cultures Resist Change
Culture is not synonymous with what people are seen doing (i.e., their rituals). People may act the same, yet differ radically in their cultures, simply because they do not feel the same about what they do. Because feelings (as expressed in symbols and myths) are at the very heart of a culture, the feelings are far more difficult to name and control than the culture's visible actions or rituals.

There is a critical lesson here for healthcare administrators. If we believe culture is just what people do, not what they feel about what they do, then we assume a culture is like a machine, with parts that can be readily changed without people being affected unduly. We are accustomed to seeing entire building construction sites being destroyed and redeveloped over a short time. In a naive appreciation of the power of technology, we then conclude that the same destruction and redevelopment can occur within cultures. We decide that symbolic landscapes of peoples can be destroyed, that the familiar sights, sounds, and routines in which people are nurtured can be obliterated overnight through an administrative decision without particularly negative results for them.

This is simply not so. Symbols, myths, and rituals are neither replaced as quickly or easily as buildings nor mass produced as neatly as automobiles or toothbrushes. The uprooting of the inner framework of cultures, even when there is conscious and intellectual assent to what is happening, destroys the stable sense of belonging and people's individuality. They are bound to experience periods of intense loss, even dysfunctional behavior, as they struggle to adjust, if they ever do so. Niccolo Machiavelli was right: "It must be considered that there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things."²

Culture is not one facet of life; rather, it is the complete set of feelings affecting, most often unconsciously, in some way or other all individuals' and groups' attitudinal and structural behavior patterns (e.g., a hospital's interiorized system of authority, its modes of communication, and its felt understanding of mission and strategies).

In brief, therefore, a group creates a culture as a way to cope with life's challenges and teach members the correct way to feel, think, and behave.³ No group is ever without a culture, no matter how broken it may be at a particular time. Leaders ignore the correct understanding of culture at their peril. People may change with relative ease what they visibly do, especially under external pressure, but not their feelings and attitudes.

Some implications of this definition of culture for healthcare leaders are suggested below under the heading "Implication for Healthcare Leaders."

Change
If culture has a built-in tendency to resist change, how does change take place at all? The process of change involves three significant stages: separation, chaos (sometimes referred to as a time of liminality, a transitional period), and reentry. The process, however, is not automatic; people must commit themselves to walk through the pain of the stages.⁴

These three stages of personal and cultural change are simultaneously grieving and initiation processes — the letting go of the old and familiar and the embracing of the uncertain new. Courage is needed to let the familiar depart and to live in the in-between time, actively waiting for the new and unknown to emerge. To live in liminality requires the ability to be comfortable with ambiguity, often for long periods, and that demands faith and hope. It demands leadership support, rituals to assist in the "letting go," and a community to give courage.

Separation
In the Tokyo subway I experienced the three stages of change. Separation occurred for me when I became unable personally and culturally to cope with the strange world around me. I felt fear; anger; and the urge to flee, blame others, and insist that others solve the problem.

Chaos
Then I entered the chaos phase, feeling totally alone, vulnerable, and paralyzed. The sight of the kiwi challenged me to reclaim my nation's creation myth. Having reowned the myth, I experienced an innovative energy that surprised me. I would not allow myself to be paralyzed any longer by my inability to read Japanese. I had to let go of my dreams that suddenly the signs would change into familiar cultural symbols for me, or that a messiah would dramatically lead me out of the mess.

Reentry
A true New Zealander, I was determined to create a way out of the crisis. The reowning of the creation myth catalyzed an imaginative reaction (i.e., the holding up of the "help" sign), which is the reentry stage of the change process.

How Chaos Affects Change
The critical ingredient in personal and cultural change is the experience of chaos, that is, the cultural betwixt-and-between position that develops when familiar cultural supports cease to function. With our defenses down, we are confronted in liminal experiences with fundamental questions about, for example, the meaning of life and the purpose of society. Chaos can so stimulate our imagination with creative ideas that it becomes a highly subversive experience — no tradition or custom can be spared from evaluation.

The way to use chaos constructively is for people to return to the sacred time of their founding in order to identify, relive, and reown the heart of their creation mythology, liberated from the accidental and historical accretions that hold back creativity. For healthcare workers today, this means reidentifying with Christ's actions such as healing the sick or giving sight to the blind. Through this reidentification, healthcare givers can be fired up to form a new cultural integration adapted to changing needs.

But for this to occur, they must want to move out of chaos; conversion to a rediscovered founding myth is not automatic. In addition, healthcare givers need culture leaders who can articulate the creation story and express it in ways that relate to the changing world around them. The commitment to move out of the chaos, with a refounding vision, must be maintained throughout the reentry stage. This last stage is particularly dangerous, since people will be tempted to become disillusioned and cynical as they meet opposition to their newfound enthusiasm and insights.

Leaders to Help Us Refound
For profound, constructive cultural change to occur (e.g., in healthcare services), there must be a process of refounding, not just renewal. Refounding⁵ is the movement whereby cultures, having reowned their founding story, struggle to adapt to the realities around them through quantum-leap creativity. Renewal, on the other hand, aims to improve only a group's traditional responses to the symptoms of problems.

Refounding calls people to go to the roots of these problems, and this means inventing responses never before dreamed about. An example is local or world poverty. Renewal results in improving existing methods of poverty relief, such as speeding up the distribution of food supplies to the poor. Refounding, however, begins with the rediscovery of the myth of human dignity. Having reowned this foundational insight, we are inspired to invent, through quantum-leap innovative actions, entirely new methods that challenge the fundamental causes of poverty, such as structures of oppression and paucity of educational facilities.

For a refounding process to occur, three types of people must collaborate: authority-position, refounding, and renewal persons.

Authority-position persons, such as managers and trustees, are a group's official gatekeepers to change: By virtue of their position, they can prevent or foster change. Their primary task is to create an atmosphere that nurtures creative people committed to the group's vision. They recognize the importance of cultural disorder and instability, even encouraging chaos where organizational calcification exists.⁶

Refounding people, with their above-average gifts of imagination, innovation, collaborative skills, courage, and hope, are dreamers who do. They are able to relive the group's founding story and creatively and dramatically adapt that experience to contemporary issues.⁷ Authority-position people can be refounders, but their primary task must always be creating space and protection for refounding people to dream and innovate for the sake of the organization's mission.

Renewal people lack the outstanding gifts of refounders, but with their nuts-and-bolts skills and willing commitment to the group's mission, they are indispensable collaborators.

Refounding the Catholic Health Ministry
The cultures of Catholic healthcare, whose institutions, structures, and methods we once thought would never need radical change, are under pressures from all sides. For example, these services are being forced by circumstances, often beyond their control, to move from:

• Clear to uncertain sponsorship
• A precise to an uncertain Catholic identity
• Self-contained to collaborative systems (e.g., through mergers of former competitors and the formation of integrated networks)
• Curing to prevention
• An illness to a wellness culture

Any one of these changes would be enough to cause symptoms of cultural breakdown (e.g., fear, anger, sadness, nostalgia, blame, and denial). But all are happening simultaneously. The turmoil that the Catholic healthcare ministry is now experiencing, and will continue to experience, can only be described as chaos.

Yet the chaos that our healthcare ministry is experiencing today offers us unparalleled opportunities for refounding. By acknowledging the chaos of the healthcare system, we thus lock in on the healing and reconciliatory power of God, and from this comes the energy to journey through the refounding process. As Christians, we would express it this way: Refounding is the process whereby we struggle to enter collaboratively into the paschal mystery with Christ for his mission of healing; thus energized, we work to challenge systems and to create responses to the most urgent needs confronting the health of the people we serve.

Once we assent to walk with Christ, we must become ruthlessly honest in assessing our institutions, systems, beliefs, and attitudes in light of his mission. We must question whether these further or hinder Christ's mission. Only through ongoing assessment can we refound the ministry.

If we are open to accepting God's gifts, then we will face humanly impossible tasks, as did the founders of religious congregations and the ministry. We will search for the creative and committed people in our midst, strategically placing and supporting them. We will summon our healthcare organizational cultures to grieve over what has been lost in order to move forward to embrace what we may as yet be unable even to imagine. Through these blessings from God, which chaos disposes us to receive, and our ownership of them, we will initiate and continue the renewal and refounding of the Catholic health ministry.

NOTES

1. I approach the notion of chaos from a cultural anthropological perspective. See Gerald A. Arbuckle, Out of Chaos: Refounding of Religious Congregations, Paulist Press, Mahwah, NJ, 1988, pp. 14-45. In a complementary way, Margaret J. Wheatley looks at the relationship between chaos and leadership within the context of contemporary science in Leadership and the New Science: Learning about Organization from an Orderly Universe, Berrett-Koehler, San Francisco, 1992.
2. Gerald A. Arbuckle, Refounding the Church: Dissent for Leadership, Orbis Books, Maryknoll, NY, 1993, p. 42.
3. This is a modified definition from E. H. Schein, Organizational Culture and Leadership, Jossey-Bass, San Francisco, 1987, p. 314.
4. V. Turner, The Ritual Process: Structure and Anti-Structure, Cornell University Press, Ithaca, NY, 1977, pp. 94-203; and Gerald A. Arbuckle, Earthing the Gospel: An Inculturation Handbook for the Pastoral Worker, Orbis Books, Maryknoll, NY, 1990, pp. 62-78.
5. Arbuckle, Refounding the Church, pp. 21f.
6. R. D. Stacey, Managing the Chaos: Dynamic Business Strategies in an Unpredictable World, Kogan Page, London, 1992, pp. 189-208; Wheatley, pp. 139-151.
7. Arbuckle, Out of Chaos, pp. 29-45 and 88-111.

Fr. Arbuckle is a director of the Refounding and Pastoral Development Unit of the Catholic Theological Union, Sydney, Australia.

IMPLICATIONS FOR HEALTHCARE LEADERS

Healthcare leaders must consider the following issues of the anthropological definition of culture:

• Cultures, like individuals, have lives or unique identities of their own. Cultures can grieve or become depressed; they may be open or closed to new ideas (see Gerald A. Arbuckle, Change, Grief and Renewal in the Church, Christian Classics, Westminster, MD, 1991). Individuals influence the life of a culture, but the reverse is more powerfully the case.
• Because symbols and myths have many meanings — they are complex and have roots deep in groups' unconscious — cultures are extremely difficult to understand and describe. Leaders must approach cultures with open, patient, and listening hearts if they are ever to grasp the meanings of cultural symbols and myths. Paradoxically, one begins to be an empathic listener by first humbly struggling to sense the complexity and impact of cultural symbols in one's own personal experience. Others sense this struggle and feel at ease in sharing their experience.
• Cultures by their very nature resist change. Healthcare administrators know that employees' intellectual assent to vision and mission statements does not automatically lead to action. According to a fundamental anthropological axiom, a culture is the response to our primal need for felt order and security; it is a defense against the anxiety that disorder or the fear of chaos evokes. In other words, cultures so love order that they prefer calcification or death over life. The same people who yesterday actively supported these statements are today, at least unconsciously, resisting their implementation.
• Leaders' failure to recognize the complexity of culture is the major obstacle to successful mergers (see Gerald A. Arbuckle, "Merging Provinces," Review for Religious, vol. 53, no. 3, 1994, pp. 352-363). Rather than increased profitability, mergers are often associated with lowered morale; job dissatisfaction; unproductive behavior; sabotage; petty theft; absenteeism; and an increase in labor turnover, strikes, and accidents.

CHANGE PROCESS: PRACTICAL APPLICATIONS

The two scenarios below describe how Fr. Arbuckle's three phases of change can be applied to the healthcare ministry. Included here are leaders' reactions to the situation, the organizational response to what is happening, and activities that typically take place during each of the three phases. The first scenario is broad, representing the challenge of reorienting the healthcare delivery focus. The second scenario is more specific, dealing with staff reductions.