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The hospital reforms of French care institutions aim at reining in costs within the scope of the efficient management of the French public sector. These main reforms (accreditation and T2A) have generated a great upheaval within the French Healthcare institutions and more particularly have given rise to changes in organizational skills. The history of hospital management shows that a new, more organizational approach, which is of interest to management and middle managers has recently joined the more traditional approaches which were based on professional and administrative approaches to quality. In such a context, middle managers (nursing managers and hospital doctors) are encouraged to break new ground in team management by means of an instrumentation favoring local material and organizational artifacts. This type of instrumentation enables simultaneous management of skills’ development in the interest of quality, a gradual integration of management efficiency principles and prevention of an organizational crisis due to the questioning of practical skills gained thanks to hands-on experience. Oblivion appears to be mandatory when middle managers have to manage the confrontation between former practical skills and new ones triggered by T2A. An oblivion event could be defined as a temporary or final mechanism that triggers a loss of organizational memory. If one interprets this concept in terms of consolidated space management and the actor who is most involved with the daily life of each member of an organization, that which is forgotten can be understood as defective memory retention in relation to an absence of interest and strengthened by the advancement of time. 

The aim of this paper is to describe the oblivion mechanism handled by middle management in an organizational change context through the theory of conventions. In other words, the goal of the inquiry presented here consists of opening the black box of hospitals in order to understand how managers operate every day to introduce changes in daily practices and to forget some other practices. The research at hand aims to investigate the concept of oblivion within a context of organizational change. More precisely, the main question can be expressed the following way: How can the convention theory explain the memory lapse mechanism during a given phase of organizational change?

For comprehensive analysis of the oblivion mechanism, the article is organized as follows: Section 1 addresses the conceptual issue in the context of existing literature. Section 2 relates to the construct of the study with regards to case study design and its implementation. Section 3 presents and discusses the results of the longitudinal research.

Conceptual Framework

The pertinence of conventions for explaining the oblivion mechanism

The Convention Theory offers a reading template for understanding middle managers in their management space, in reflection and in interaction with their employees. It enables researchers to observe change and oblivion mechanism from a given convention when middle managers operate to replace old practices by new ones.

Application of the Convention Theory is justified by its ability to “report on several economic positions characterised by lasting interaction between players … and on the behaviour of the player in mainly productive interaction situations” (De Montmorillon, 1999: 179). It is also relevant in providing a deeper analysis of the key players in the organization in a position of uncertainty (Amblard and al, 1996). Uncertainty relates to oblivion as actors endeavour to reduce uncertainty by complying with admitted rules and forgetting those that are ambiguous and not acknowledged. According to Greish (2003), oblivion and ambiguity relate to each other; they interact. Actors try to delete ambiguous representations in order to find a tolerable order in everyday running activities. Thus, oblivion is connected to conventions: a convention comprises generally admitted rules and acts which are not always clearly conscious. Oblivion acts to take away ambiguous data from the current memory of organizations.

Pertinence of conventions for underlying structures

A group of researchers agree in thinking that the Convention Theory is suitable for describing how these organizations operate, and for diagnosing or explaining the problems encountered by specific organizations such as internal revenue services, public transport and hospitals (Batifoulier and De Larquier, 2001: 17; Amblard, 2003; Husser, 2009). Romelaer (1999: 39) also states that the Convention Theory has “many contributions that are of interest both to the organization and to the individual”. One of its most significant contributions is the endeavour to develop a universal model that can be used to explain the market and the organization, the institution and the entrepreneur, the explicit and implicit rationalisation, the management of quality and customer relations, corporate governance and organization, political and social aspects of the organization. The research in hand follows the definition given by Gomez (1996: 201): “a conventionalist analysis allows us to conceive of organizations other than as the result of agreements made by contract between autonomous individuals. It claims that the individual is socialised … and the company can therefore be seen as a space for regulation wherein the rules that govern the business are drawn up … they come together to define a series of skills and practices shared by all the players, which at the same time are given a line of conduct and a measurement of their actions”.

In other words, the theory of conventions is helpful in understanding the logic of actions taken by managers and for structuring the vision of the inquiry in the “black box”, i.e. the space of management within every service of the hospital. In this context, it is possible to shed light upon how the organization forgets practices and sometimes replaces them by others.

This current of thought has established a link between the structure and social actors (Goffman, 1974) as it focuses mainly on an organization’s “underlying structures” (Gomez and Jones, 2000), those that are not accessible in an immediate and obvious way. It forms a framework of analysis that goes above and beyond the opposition between rationality and organizational disorder, between actor and structure, routines and organizational change. Further detailed investigation of the daily operation of organizations is of undeniable interest in order to understand, through the mechanism of effort, why organizations forget certain practices tested during a period of change. The convention theory is thus relevant to understanding the phenomenon of oblivion during a particular period of change, specifically at the moment it first occurs. As a matter of fact, changing the method of the convention or changing the type of convention involves a substitution of practices, routines, and coordination between the actors of the organization. Oblivion is likely to occur during this particular period.

Oblivion Mechanism and Organizational Change

Literature regarding the oblivion mechanism is structured around 3 main theoretical currents:

The current of Organizational Learning considers the oblivion mechanism as being mandatory for creating an empty space for new knowledge in order to enable organizational change (Hedberg, 1981; Bettis and Prahalad, 1995). This current shows us that it is pertinent to contemplate inquiries when change occurs, that is to say when a new organizational change happens. The memory lapse mechanism may occur for old and new pieces of organizational knowledge. It is not relevant to consider that oblivion works only on old knowhow. Both sides must be considered. Martin de Holan and Philips (2004) have suggested 4 types of oblivion: intentional oblivion, accidental oblivion, oblivion of a new knowledge, oblivion of an old one. It is a focused and operational vision to manage inquiries. It also relates to the notion of feedback introduced by Levitt and March (1988). The empty space is more or less widespread; it depends on the former positive or negative feedback. The researcher has to investigate in new fields.

The second current points out the notion of the “experience curve” based on time’s depreciation. The stock of experience depreciates exponentially over the course of the time. According to Arthur and Huntley (2005), time affects the quantity of information, and this phenomenon is named the “decay of time”. Past information tends to diminish with time. There seems to exist a depreciation rate affecting experience (Benkard, 2000). Beyond the concept of time, change triggers spillovers, that is to say gaps of experience created when the confrontation between old and new practices occurs (Irwin and Klenow, 1994). There is here an upheaval to be managed by the organization: which items of knowledge must be integrated into the organization without altering day-to-day activities? The unlearning would be at its climax during the time of emergence, so oblivion would act intensively on practices at that specific moment. Two key factors must be considered: the pertinence of change and the confrontation between old and new practices. This current justifies a longitudinal field research to observe such decay starting from the date of the first steps of change. It is also relevant to contemplate the mechanisms of stress, accentuation, reduction, cultural assimilation within the context of consolidated space management and actors.

The third current suggests a specific analytical level. Oblivion would be grounded in everybody’s experience. The psychological field is mobilized to understand individual or group oblivion. Key actors are observed, interviewed, and analyzed to understand more precisely the decay effect as well as the tracks and marks of oblivion based on initial learning. They relate to actors’ memory (Simon, 1966; Wixted, 2004). Recent experiences do not affect grounded knowledge immediately (Rateau, 2009). Anderson (2000) underlines the fact that the most recent acquisitions are not of prime importance to favour the acquisition of new knowledge. Once old acquisitions succeed in withstanding oblivion they structure the forthcoming acquisition. This cognitive approach is completely in accordance with the theory of conventions, completing it and making it more operational. It pushes scholars to focus their attention on key actors within the organization. This was the angle chosen by Dietrich (2009) and Mahieu (2010) in opting to observe middle managers within their management space.

This last current reinforces the idea that the key moment is at the first step of change. The third current is the most pertinent one with regard to describing the oblivion process at the very first step of organizational change. It also enables a longitudinal research to be designed based on key actors such as middle managers.

From this perspective, it is possible to formulate the following research question: How does the memory lapse mechanism operates from the managers’ perspective during the first phase of organizational change?

Research Methodology

The design of the present inquiry is based on a longitudinal field research conducted over 6 months: it follows the recommendations outlined by Pettigrew (1990). The research in hand also follows the rules based on a contextualist approach defined by Brouwers and alii (1997) and Pettigrew (1985).

Case Study Design

It is a qualitative inquiry based on 6 case studies. Every case study relates to a precise service or a healthcare unit within the same hospital. By design, it favoured a large variety of different situations, following the recommendations set up by Hlady-Rispal (2002).

The case study methodology is widely discussed in literature in management science (Wacheux, 1996; Plane, 2000; Husser, 2005; Woodside, 2010) and often used in the context of hospital management (Minvielle, 1996; Grosjean and Lacoste, 1999; Husser, 2011).

The use of the case study is explained by both the newness and complexity of hospital management and by the absence of alternative models for describing longitudinal approach management. In addition, our research objective is to produce conjectures describing a phenomenon in the initial phase of implementation.

The research in hand was made up of a non participant observation strategy of the practices, semi-directive interviews dedicated to middle managers and document analysis stemming from T2A management. The following case studies are based on the work of Pettigrew (1985) which offers an original framework of research for the study of organizational change. The six selected case studies respond to issues exposed in a variety of management situations (Yin, 1994) found in a hospital’s work environment. Three dimensions are revealed: the degree of foreseeability regarding the activity, the level of professional experience, and the T2A reference system. The context is considered as part of the content, there is no possibility to separate the context from the content. The 6 case studies aim to describe a large scale of different contexts as recommended by Eisenhardt (1989). They each analyse a different aspect of the health care system, whether they differentiate by the area of expertise, type of sickness treated, environmental factors, or operational organization (staffing resources, hours of operation, scheduling, operations procedures, organizational chart, or professional development policies). The chosen cases studies are as follows:

Table 1

Case study contexts

Case study contexts

-> See the list of tables

Case Study Research

The research protocol implemented consists of the following 3 steps:

Action Plan for data collection

The six case studies include three phases: analysis of documents, semi-structured interviews and participant observations ( meetings and day-to-day activities ).

  1. Review of documents:

    During the consultation work, the researcher locates documents that relate directly or indirectly to the T2A. Documents are identified, accessed, analyzed and identified. A document database is created but does not leave the company: documents help meet the objectives of the study and guide the questioning in interviews.

  2. Interviews:

    The interviews are semi-structured. Their duration is about an hour and a half. They are recorded in notes taken in direct speech or audio recording for content analysis.

  3. Observations are made in the following contexts:

    • Department meetings which represents the “backstage”;

    • Meetings about T2A (backstage);

    • Patient reception areas which represents the “frontstage”;

    • Procedures for engineering controls (frontstage).

Resources Used

  1. Access to basic documents:

    • General Documents: Presentation of service booklets for home service, information booklets for different categories of staff.

    • T2A documents:

      T2A manual, procedures, project files (current and past).

      Specific documents for T2A implementation: introduction of T2A, self-assessment questionnaires chosen by service managers, procedures manual and technical checklists produced during self-assessment.

  2. Access to people (hospital Employees, administrators)

    The number and quality of people to meet to interview depend on the size of the service and the number of middle managers who run the service. The 6 case studies made it possible to interview 28 middle managers: health care nurses, doctors and logisticians.

    As regards these interviews, a structural analysis method was undertaken. Initiated by Barthes (1981, 1991) and implemented by Demazière and Dubar (1997), this approach offers the advantage of giving the researcher an analytical framework that is structured and coherent and helps to avoid three obstacles: 1) the illustrative stance. 2) the restorative attitude that reproduces contents in their entirety without any interpretation. 3) an absence of objectification, avoided due to the implementation of a procedure that is both standardized and systematic. Bourgeois, Nizet, and Piret (1996) offer a concise guide that gives researchers the means to broach materials constituting their object of study without projecting their own conceptions onto it. The chosen structural method seeks to apprehend the associations and contrasts interlinking the different themes found within a discourse, that is, its structure. According to Barthes (1981), all content can be analyzed on different levels corresponding to readings that vary but are necessarily articulated: the action level and the narration level. Previous sustainability research has reproduced this analytical framework: 1) The action level provides a stage for actors, individuals who act and intervene and play a role in the narrative. In this case, the three stakeholders are the employees, customers, and suppliers. 2) The narration level is identified by the presence of postulates, arguments, and proposals intended to convince the targets of the communication action and defend a point of view.

Validation

This section describes the presentation, discussion and comparison of the empirical and technical understanding of the proposals made by the researcher. A copy of the study report is available to be read by the key contributors to enable them to assess how thoroughly the facts have been considered.

The objectives are:

  1. to remedy the shortcomings of observed facts;

  2. to compare the theoretical proposals of change management to middle management representations.

Results And Discussion

The results are made up of two main parts. The first one endeavours to describe how middle managers structure the system of conventions to achieve an organizational change of type I or II. The type I implies that middle managers resort to changes within the same convention. By contrast, the type II symbolizes a complete change of convention. These results relate to the work of Argyris and Schön (1978) and more precisely to the notion of simple and double loop learning. The results are also linked to Watzlawick and Weakland (1975: 29) as they define two different changes. The first one takes place within a given system, which itself remains unchanged. The second change modifies the system itself. The results show that changes unleash a precise action of oblivion towards daily medical practices. It is also a matter of understanding the conditions to enable oblivion actions. The second part consists of proposing a theoretical framework to improve understanding of the mechanism of oblivion during the first phase of organizational change: the emergence stage.

Oblivion And Structure Of Conventions

The actors resort to previous conventions in order to run the organizational change. From the 6 case studies it was possible to observe two different types of conventions before T2A implementation: Arranged Convention and Conciliatory Convention.

Table 2

Types of conventions observed within the Hospital context before T2A implementation

Types of conventions observed within the Hospital context before T2A implementation

-> See the list of tables

One of the features of the arranged convention is its systematic approach to action: assigning the various work elements and sharing the reporting of medical, surgical and logistics’ actions carried out by the teams from the various departments. All department managers take part in working out and carrying out the accounting reporting of acts. The arranged convention is also characterised by a convergence of representations between middle management (inter- and intra- categories) that allows the integration of organizational changes in the everyday management of the department.

The conciliatory convention involves a separation of tasks. The objective of the referent middle management is to interpret the introduction of the T2A with regard to concrete reporting procedures of acts carried out within the departments. The task of the remaining middle management is, in turn, to apply to their management areas (reception, treatment rooms, medical analysis laboratories, storage facilities) the reporting criteria for acts carried out and considered to be in total compliance with the T2A.

Middle managers do not question the previous conventions during the first stage of T2A. They do not forget previous conventions as they are embedded in everyday life activity. Initially, actors will not put any changes into action; they will make use of former conventions to monitor and control future changes. Oblivion of previous practices does not appear over the first 6 months of our inquiry. While prior conventions are respected they do not pose a threat to future changes.

The interviews conducted during the first months reveal the fact that the T2A must be put on hold in order to evaluate the potential consequences on day-to-day activities before integrating it into the procedures of each department. As such, for the department head of Paediatric Emergency Services, “The T2A is one more obligation that has been imposed upon us that will need to be integrated throughout the new medical information system; I am going to have to convene specific departmental meetings in order to find out how to integrate it into the patient files, how to proceed with the transmission and management of medical records as well as to find out how to respond to an audit of our payments, and all this without jeopardizing the organization of our teams charged with actual care of the children – from the treatment of genuine emergencies to simple cuts and scrapes.’

For one of the doctors in charge of the radiology department, the most important thing is to respect the organisation of departmental activities and the management of patient transfer: “You must understand that this department is above all a support service that must meet a variety of demands in a very short amount of time. It is out of the question to challenge the structuring of tasks and responsibilities. The T2A does not ask this of us, for the time being. As a team, we must simply think over the problems caused by a new system of reporting dispensed treatment, find a new nomenclature and work out how to disseminate it. But, this cannot threaten our established organization.”

Former conventions do slow down the implementation process, however middle management utilizes and modifies them in order to apply future changes. Oblivion is rather dedicated to new processes. It is surprising to observe that oblivion does not need a lot of time to operate. It has an immediate effect on potential practices suggested by T2A, especially the one that question too much verbal practices, oral routines. The following chart goes into further details for every case study. It underlines how the mechanism of oblivion operates within every context:

Table 3

Oblivion Mechanism implementation

Oblivion Mechanism implementation

-> See the list of tables

The interviews conducted revealed an active mechanism of oblivion implemented by middle managers. The concepts of reduction and assimilation require explanation. The reduction of elements specific to the T2A occurs progressively. Because the T2A is implemented for the pricing of services, it tends to become more synthetic, restrictive, and centred around financial results. As such, in the medical analysis department, the department head declares: “At the implementation of the T2A, we considered the entirety of the modifications and negative side effects in the day-to-day management of the department, the new paperwork to be filled out and also the exact amounts for per-patient contributions. We also discussed the rules of good practice in our meetings. Additionally, we asked ourselves what the consequences would be of changing from a global allocation of funds to a fee-for-service payment system. Today, we are focused on the task of accurately recording the cost of each medical service performed each day. The rest has become secondary and we won’t discuss it much in further detail. We are very concerned about the proper organization of our department and the care we provide for our patients.”

The concept of assimilation refers to the fact that the T2A is integrated into the day-to-day operations of the departments. The details of the T2A such as pricing, reporting of medical information to the medical records services, or even the volume of activity are linked to elements from previous hospital reforms like quality control or to elements of the daily operations of the departments (staff scheduling, appointment scheduling, coordination between nursing teams and physicians.) As such, for a doctor in paediatric external consultation, the T2A is an inherent part of the service: “Basically, there hasn’t been too much of a change because it makes us maintain records of our services as we had always done. The requirements for accreditation represented a consequential change with the beginning of evaluation through the quality of care. In that respect, it was merely a question of making our daily procedures official.”

The notion of assimilation can also be described in terms of organizational anticipation. Accordingly, the head of obstetrics is integrating the T2A into the future departmental management plan: “The T2A is above all a way of distributing funding. If we can no longer cover our expenses with the revenues received, we will have to put further thought into the management of length of stays and in-patient care or even consider a Hospital at Home programme more thoroughly.

For the head of logistical services, this concept of assimilation-anticipation makes sense: “As we are a support service and the other departments have to plan ahead for their expenses and revenue, they are also looking to rein in costs. This cost control in the name of the T2A already makes us use new measures of activity to justify our own spending. Therefore, we have drawn up more precise activity-tracking charts for each department in order to anticipate future requirements in records-keeping, which is becoming inevitable.”

The research advances the assumption that the convention’s energy is fueled by symbolic interactions between key actors. Moreover, the implemented convention system is understood as a real daily management support structure used by middle management to generate daily actions and to put into play the possible changes induced by T2A. The convention system is considered as managerial support, which restricts middle management’s opposition, and supports forthcoming efforts, allowing for a resurrection of new actions maintained in the daily production of health care and services.

The convention system offers middle management two categories of change:

  • Variation of type I involves modifying some methods, which proceed from the same arranged convention or the same conciliatory convention;

  • Variation of type II involves replacing the arranged convention with the conciliatory convention. It also envisions the replacement of the conciliatory convention by the arranged convention.

The research in hand shows variations of type I for the six case studies and proposes conditions of oblivion for potential variations of type II. The conditions of oblivion rely on the routinely structured productive system of the department and on the representational system of management. These two parameters are tightly linked to the departments backgrounds (past performances in terms of quality experience, management training with regard to the formal structuring of activities, methods of integrating the T2A as an organizational value of the department and also, everyday constraints in managing production).

The emerging conditions of oblivion due to convention modification crystallize around middle management’s capacity to support it:

  • possible local coordination;

  • the degree of coherence between the service’s daily activity and the objectives to be reached in the name of T2A;

  • middle management’s personal interest and possible convergences;

  • the ability to manage organizational ambiguities that result from T2A.

There is oblivion precisely at the exact place where tracks and marks have existed in a given context. Oblivion acts to simultaneously delete data from daily practices and artefacts so that tracks and marks are erased over a few months. The key question is: How does oblivion operate? Middle managers introduce oblivion by replacing former practices and material or organizational artefacts creating at the same time. Oblivion is observed when actions and written procedures are both changed. It has never been a great upheaval as safety after operations within the units must be maintained at all costs; safety must be guaranteed if any attempts to change are to be made. The creation of artefacts is of main importance. It is a way to formalise a gradual integration which always favours the identity of the unit based on human values: the “welcome document” dedicated to patients, the “how to handle document” regarding new equipment, and the undertaking of pain. Oblivion can be considered here as a gradual modification of daily practices. Middles managers handle an assimilation of day-to-day practices in order to produce an assimilation by condensation. It is not a simple replacement of an empty space created by managers. The inquiry doesn’t confirm the proposal made by the current of Organizational Learning. The empty space doesn’t occur very often. A complete replacement of practical skills without a preparatory stage to test the new ones never happens. Middle managers prioritize actions and obviously prefer to keep a stable and safe coordination of skills rather than to test the experiment directly on patients.

In addition, the chart highlights the role of written artefacts. Oblivion appears to be most prevalent when middle managers create a new written artefact. It seems to be paradoxical because the oral tradition is grounded in daily practices and should be the favourite way to forget new or old skills. Generally speaking, writing new artefacts reinforces skills, knowledge, procedures and enables people to remember previous procedures. But it is also commonly admitted that the writing of the new procedure (regrouping new and old structured practices) replaces the previous one. Middle managers help their teams to forget the old procedure once the new one is written and drawn up in order to secure the coordination between people, teams and units within the same hospital. Within the context of medical units, the research has revealed that oral tradition acts to prevent oblivion while new written procedures enable oblivion of past skills. The two factors play a complementary role to reduce ambiguity triggered by new procedures during the first phase. Oblivion is not a simple mechanism, it does not consist in forgetting at once what is not clear in order to give the space to what is efficient, pertinent and applicable.

Figure 1

Conditions of oblivion carried out by the convention system within the context of a hospital’s work environment

Conditions of oblivion carried out by the convention system within the context of a hospital’s work environment

-> See the list of figures

The chart also suggests that oblivion intervenes as well when the values are greatly questioned. The encounter, let alone the confrontation between medical, healthcare and management values produces a great upheaveal. Middle managers’ values are greatly grounded in the healthcare field and clearly expressed by the actors all over the longitudinal research : faithfulness, kindness, honesty, professional secret, assistance, care, commitment. Human values are greatly grounded in hospital’s units. So, when new management practices included in the T2A process question original values oblivion is activated another way. New goals linked to T2A process such as efficiency, profitability, cost reduction, savings, rightsizing are analyzed, criticized, assessed, before being translated and then introduced by middle managers. If these new goals are not coherent with managers’ healthcare values they are transformed, altered in order to enhance current values. Middle managers act as translators for team members and they handle admitted and set up conventions. Oblivion occurs when there is a strong difficulty of dialogue between two different fields: the medical sphere and the managerial circle. During the first phase, managerial goals are clearly questioned and modified in terms of medical issues. The stage of emergence appears to be longer than the theoretical currents suggested in the literature. Emergence phase can last several months which is a rather long period for middle managers and not for the institution.

Figure 2

Mechanism of Oblivion

Mechanism of Oblivion

-> See the list of figures

The inquiry contemplates two different spaces handled by middle managers, the apron in front of the patients and the backstage with the team members. Oblivion has mainly worked on backstage. According to middle managers, it is the ideal place to set up oblivion. The memory lapse mechanism is made up of three times: the present of the present, the present of the past and the present of the future. Middle managers can experience several scenarios, several assumptions as regards the different ways to head up their units in the future. Bad experience coming from the past is only considered and related to requirements set up by T2A. When middle managers dread to live again potential issues similar to bad experiences already handled they take away those requirements. Oblivion works in order to produce a simplified and safe list of T2A requirements. The research has pointed out that experience is based on individual considerations. Besides, oblivion has put aside bad past experiences without cancelling them. Memory lapse mechanism appears to be positive for hospital’s units.

Conclusion

The research at hand has aimed to investigate the concept of oblivion within a context of organizational change. It has examined under which conditions oblivion is necessary as a way of renewing knowledge bases through the theory of conventions.

The conventions are more clearly defined during organisational change, which is the case with the arrival of the T2A system in hospitals. The research conducted has contributed to showing that the initial conventions in departmental hospital management have the tendency to be modified in order to adapt to the obligatory changes brought about by the implementation of the T2A. This change modifies the contents of these conventions through a phenomenon of oblivion (reductions, assimilation) within a certain number of its elements. The dismantling and total overhaul of a convention was not relevant in the hospital context in the emergent phase of change. The conditions of transition from a type I to type II variation do not work together to implement such across-the-board changes.

The research has also examined the mechanism of oblivion as such within the context of a hospital’s work environment. It did not reveal malpractices. By contrast, oblivion appears to be positive and mandatory for the effectiveness of healthcare practices. It is handled by middle managers within the backstage of daily activities. It is an important place to consider as 3 main memories confront each other here: the memory of the past, the second regarding the present and the third keeping an eye on the future. Oblivion works gradually. It takes away management practices during the first stage when they are not in accordance with middle managers’ values. It also provides a gradual integration of management requirements made on behalf of the T2A by transforming them into medical requirements.

The paper presented here has not considered the harmful consequences of oblivion. The context of emerging changes observed allows us to make the following proposal: the phenomenon of oblivion is an active process handled by middle managers and always grounded in the daily activities.

The inquiry stopped after six months of investigation which prevents from giving answers to the mechanism of oblivion over a long term period. But these considerations can lead to further longitudinal inquiries observing the oblivion mechanism on grounded practices and well-established values.