Professional identity in a healthcare environment and its impact on communication amongst professionals. Can they influence patient safety and risk?

1. Introduction

Modern organisations are often seen as a hub of frantic activity. Employing large numbers of employees from many professional and cultural backgrounds, these organisations are complex entities with dynamic needs and potential. Within a healthcare context in particular, a great variety of occupations translate to a remarkably diverse composition of groups working in close proximity with one another. This paper focuses on the possible effects this rich mixture of professional backgrounds can have on patient safety and welfare. More specifically, on the effect group membership seems to have on the effective communication between healthcare employees. Research on the area has been scarce but points towards the idea that full and open communication between healthcare employees is often hindered due to individuals’ professional group membership (Soothill et al, 1995). We believe that this can cause problems to patient safety and welfare.

1.1 Patient safety

‘Patient safety’ is a relatively new area of clinical and academic interest. In particular, it emphasizes on the reporting, analysis and prevention of medical errors that may lead to adverse healthcare events. The term implies the conscious attempt to transfer into healthcare the principles used to promote safety and reduce system vulnerabilities in other industries – typically the oil industry, nuclear power, aviation and chemical engineering. These industrial safety systems of thinking have recently gained a dynamic within healthcare as a means of improving the safety of care (Kohn et al. 1999). This reflects the increasing pressure from healthcare professionals and service users alike for higher quality care and the avoidance of unnecessary risk. While this is happening, healthcare professionals often also develop a feeling of belonging to a particular professional group. Key to this is the notion of professional identity.

1.2 Professionals and group behaviour

The workplace is a key location in which our individuality (our personal identity) and the roles, attributes and characteristics attached to us by others (our social identity) meet. This results in a process of constant reconstruction of our sense of self. The workplace plays an important role in the way we perceive ourselves and others perceive us. In other words, the workplace is central to the construction of our self and identity (Haslam, 2001).

Social Identity Theory (S.I.T.) (Tajfel & Turner, 1986) and Self Categorization Theory (S.C.T.) (Turner, 1987) claim that professional groups are no different to any other type of groups. Identification with one’s work colleagues is likely to increase, provided that the ‘in-group’ is positively distinguished from other groups.

Put simply, employees will strengthen their identification with a group if it can compare favourably to other groups. In addition, there is a claim within this theoretical tradition that a strong group identity can enhance our personal identity. According to S.I.T. and S.C.T., a group that works well (maintains good in-group relations, supports its members etc.) is seen to be successful by its members and third parties alike, re-enforces its members’ willingness to maintain membership and, at the same time, allows them the feeling of self-verification and self-gratification which translates into higher self-esteem (Tajfel, 1978).

S.I.T. and S.C.T are useful to our present scrutiny for yet another reason. Categorization (social and personal), identification (with a group) and comparison (to out-group[s]) are processes that both S.I.T. and S.C.T. theorists (Tajfel, 1982; Hogg, 1988; Wetherell, 1996; Abrams, 1999; Haslam, 2001) are equally convinced succeed one another in an individual’s attempt to understand his/her environment and react to it.

Categorization refers to the process of ‘arranging’ our social surroundings in order to understand them. If we can assign people to a category then that tells us things about those people. We use social categories like doctor, nurse, etc. because they help us find out things about ourselves by knowing what categories we belong to. Identification involves the idea that we feel close to certain groups that we perceive ourselves to belong to (in-groups). Identification with a group results in two processes. Firstly, it requires us to think in terms of "us" vs. "them" (in-group vs. out-group). Another result of ‘Identification’ is the belief that members of a certain group are similar to each other in some relevant way. Social comparison (Festinger, 1954) is the idea that, in order to evaluate ourselves we engage in comparisons with similar others. Group members compare themselves and other members of their group with members of different groups.

Self-categorization theory (Turner, 1985) acknowledges the possibility of more than two levels of identity (referred to as levels of abstraction) not just the personal and social. In simple words, one category (‘healthcare worker’) can be seen as more abstract than another (‘nurse‘) to the extent that it can contain the other but not be contained by it (all nurses are healthcare workers but not all healthcare workers are nurses).

To express this, Turner used the term meta-contrast principle to describe a process of selection between groups involving similarities and differences. A nurse has to be identified as a nurse to be distinguished from a doctor, but calling her/him a ‘healthcare worker’ would suffice to distinguish him/her from a taxman. On a larger scale, a nurse would be described as ‘human’ in order to make a distinction between him/her and a poem (literature) without any change in their actual qualities/position. Put simply, a nurse can be described as ‘human’ in such a context, as this information is sufficient for this frame of reference, but needs to be identified as a nurse when talking about people and their professions.

1.3 Professional identity and Patient Safety

The formation, understanding and expression of identity (Brown, 1986) and the part played in this by our relations to others (Markus & Kitayama, 1991, Hatch & Schultz, 2004) are central themes in social psychology. There is, however, very little work on professional identity in healthcare workers either in general or specifically on the relationship between identity and notions of risk and safety. Identity influences an individual’s understanding of his/her (professional) environment, including the notions of risk and safety (Lupton, 1999). As McDonald et al (2005) argue

‘…individuals perceive and interpret risk in the context of their place in a society whose particular social forms influence what they come to perceive as risks. The implication of this approach is that challenges to risk perception represent not an appeal to individuals to adopt an alternative cognitive perspective, but a threat to existing forms of social order and, by implication, the shared values and beliefs which underpin those.’ (pp 399-400)

2.1 Methodology

We report on some of the data collected as part of a larger qualitative study. Forty eight healthcare professionals (doctors from several specialties, a wide array of nurses covering every aspect of nursing, middle managers, pharmacists, ward clerks, physiotherapists) were asked about their views on their everyday working life, working relationships and patient safety. The latter was our initial and main interest. A semi-structured interview with a few target questions was selected because it suited best the place and the time the interviews took place (at the workplace during normal working hours) providing maximum information with minimal distraction of their normal working pattern. In addition, such an interview format allows for a more flexible yet focused approach to the issues under scrutiny and is more straightforward to interpret.

2.2 Analysis

The analysis followed a Grounded theory (Strauss & Corbin, 1994; Strauss & Corbin, 1990) approach. Grounded theory is characterized by the requirement that the researcher remains 'grounded' in the empirical data. In this sense, 'theory' is understood as the identification of central individual and/or sets of concepts, along with possible relationships between these individual or sets of concepts. These relationships are used by the researcher in order to understand (and possibly explain) a particular phenomenon in the data (Strauss & Corbin, 1994; Strauss & Corbin, 1990).

The interviews were analysed in terms of the participants’ references to group membership in their everyday life. The analysis explored when and how healthcare workers describe group membership when talking about their everyday activities at work. In the interviews, participants were asked to discuss their views on patient safety within a healthcare environment. Many participants readily made references to group memberships and how that affects the understanding people have of patient safety, as well as how that affects communication between members of different professional groups.

The first author read the interview transcripts several times, and constructed a set of themes that reflected participants’ constructions of groups. In many cases these were oblique, given that a prominent focus of attention involved issues concerning patient safety in the hospital they worked. On the second and subsequent waves of analysis of each transcript, more specific themes were identified and explored further. Only once the authors had been led by the narratives provided by the respondents were the set of topics and extracts from interviews categorized into smaller, condensed topics. Then a set of meta-accounts were collated which attempted to cast how individuals discuss the kinds of contexts in which group membership becomes relevant and the role it plays in relation to patient safety.

3. Themes emerging from the interviews

Do participants think that different healthcare professionals vary in their understanding of patient safety? If so, what are the differences and how do they come about? What are the implications of this? The analysis revealed two important areas in the discussion. These have been noted in the analysis: ‘our team’ and ‘communication’.

The notion of ‘our team’ relates to the issues on group membership outlined in the Introduction, while ‘communication’ is seen as a direct result of such a membership. When we look at communication in a healthcare environment we concentrate on the ways healthcare workers interact with members of their own or different professional groups, and the implications the changing style and content of this communication has on patient safety. The data supports much of what has been written about in the ‘preferential’ and ‘multi-layered’ nature of group membership: In short, it is clear in many participants’ answers that membership to a particular professional group is a very important element of their daily working life. They explain how they identify with others coming from the same professional background, and emphasise the differences between themselves and members of other professional groups. Membership to different professional groups within the healthcare environment appears to make a difference on communication; a constraining factor that we believe has a negative impact on patients’ safety and well-being.

3.1 Our team

The notion of the team within a healthcare environment is an interesting and important issue, and one that seems to be very close to the heart of many participants. Interviewees tended to place great emphasis upon the concept of being part of a ‘team’, referring to it as an essential part of the culture healthcare workers operate in. The levels of identification participants demonstrated with a particular team or group and the way these groups were created are a central part of our scrutiny.

SCT calls this ‘the meta-contrast principle’; a notion that refers to the maximization of the ratio between inter- over intra-group differences (emphasizing the similarities between members of one group and their differences with members of other similar groups). In line with S.C.T, participants of this study demonstrated varying levels of identification to different groups. We found four different levels:

1. Departmental level

At this level respondents identified themselves with members within their own working team or specialised department. The following extract is indicative of such identification:

‘I think patient safety comes to paediatricians easily because of the nature of what we do. We’re looking after children who are vulnerable and we've got to make sure that the parents feel they can leave their children with us.’ (Female doctor)

By portraying her department as being exceedingly good concerning the work they do and their stance towards patient safety, this participant implicitly makes a comparison to other departments that might not be quite at the same standard. By doing this, she is demonstrating a strong identification with her own department, a group that in her eyes is performing better compared to similar other groups.

2. Professional level

At this level, respondents tended to accentuate the similarities between themselves and other members of a similar profession, as well as demonstrating positive distinctiveness for qualities typical or common among their in-group. Nurses, for example, tended to identify with other nurses and concentrate in their answers on things that nurses are very good at doing, and frowned upon the - according to them -less effective methods employed by their colleagues coming from a different background (e.g. doctors). This is demonstrated in the following example:

‘…our role as a nurse, whereas a doctor will just be looking at seeing the patient, treating them and sorting out the medical problems, I think nurses tend to look at things more holistically. So we all want to protect that patient overall and be looking at issues with regard to their safety more.’ (Female nurse)

The above extract suggests that this participant considers her professional group as ‘the patient’s advocate’. By doing so she portrays nursing as a central part of patient care, particularly since nurses, in her view, are more alert to patient safety than other professional groups, namely doctors.

3. Patient contact level

This level sees respondents placing themselves within a wider spectrum of healthcare professionals. Doctors, nurses etc tended to see themselves as ‘essentially doing the same job’, however, distinct differences were found between themselves and professionals whose patient contact was considerably less than their own e.g. managers, clerical workers etc. Often at this level there was an underlining antagonism between people who are ‘hands on’ (i.e. doctors and nurses), as one participant puts it, and those whose role does not involve any patient contact (e.g. managers). The following example is demonstrative of such a view. The respondent makes a comparison between nurses and doctors on one hand with managers on the other. He argues that nurses and doctors are closer together because their concern is the patient in front of them. Managers have different priorities according to this participant:

‘It's probably clearer to make it the manager and the doctor or the manager and the nurse. The nurse and the doctor I think are closer together because they are directly concerned with treating patients. A manager is concerned with managing systems and managing numbers, achieving targets, that's their job. But for the nurse and the doctor their job is the individual patients’ ( Male doctor)

Some participants went even further, suggesting that legislation, protocols and procedures devised by people with little or no patient contact (namely, managers) often become a hindrance for front line staff trying to fulfil their duties at the best they can.

4. Hospital level

This level sees participants demonstrating what S.C.T would call ‘universal’ level of identification. This is the highest (and most inclusive) group and contains all individuals employed in a healthcare environment. The following extract eloquently describes the above:

You think everybody who has been working in our hospital environment has the same priority, the same thing in his mind. I personally work thinking that everybody has this thing in his mind and so we can share the work' (Female nurse)

3.3 Communication

The four distinct levels of group identification revealed by our analysis seem to have important implications, not least because of the severity of consequence within a healthcare setting. More specifically, a common theme throughout participants’ responses involves the various conflicts that can occur with regards to the treatment or procedure a patient receives. These conflicts often occur between individuals from different departments, professionals with different background and training, or between professionals with conflicting interests and/or priorities. The participant below provides a particular explanation of this issue:

Interviewer: What about people from different backgrounds, not ethnic or cultural, but professional backgrounds? Do you see any space there for…

Participant: Yes, I do because I think this is all part of inter‑professional learning and I strongly advocate that. Again, I don’t think you should have a hospital that’s made up of lots and lots of compartments because then you don’t know what the next person's doing. (Female nurse)

This participant’s response ties in well with what has been discussed earlier with regards to the four levels of identification our data suggests that exist in a healthcare environment. In this instance, this nurse is most probably referring to the way different departments within a hospital keep communication as an internal privilege, relaying little or no information at all to other departments; hence the ‘compartmentalization’. The above extract in particular emphasized the importance of the existence of ‘teams’ in a hospital and/or department, and clearly demonstrates the problem of communication and lack of exchange of information between healthcare professionals. What is being suggested here is that ‘lots and lots of compartments’ within the hospital are creating distinct boundaries to workers knowledge and understanding. Such boundaries develop when professionals with different training and/or priorities work in close proximity, but not in accord with, each other.

The use of the word ‘compartments’ is central here as it brings to mind a machine that consists of different parts in an organic relationship with one another. When these parts work in accord with one another the ‘machine’ operates in an optimal manner. On the other hand, when the different parts work in isolation, or even worse, against one another, there is the potential for the system malfunctioning. This has obvious and potentially severe implications to the health and well-being of patients. In the next example, participants present a particular consequence of such compartmentalisation, discussing a conflict of interest between two different departments:

I think it's sometimes very difficult for us to explain why we don’t want to do something to a patient in the X‑Ray Department because we know, or we've been trained to recognise, that doing that would be potentially very hazardous. Whereas the person that wants us to do it has limited or no perception of the risk and only sees the risk associated with not doing the procedure, and therefore there's a tension between their perception that you're letting them down and letting the patient down by not doing something. Our perception is that by doing that very thing you're exposing the patient to unnecessary and avoidable risk. (Male doctor)

And

… a colleague might ask us to perform a biopsy procedure that they think is 'indicated' and therefore must be done, whereas my perception might be not in a million years would I consider a biopsy in this patient because the risk is simply too great, and the benefits to the patient of having the biopsy are debatable and not very quantifiable. It's not apparent to me that there would be a huge benefit to the patient in doing that. (Female doctor)

And finally

… I think sometimes people before they even ask for something they already have all of their arguments lined up. They're not asking you for an opinion, they're expecting you to do what they want. (Male doctor)

The above are typical examples of professional identity creating concerns with regards to the well-being of patients. Participants describe common scenarios in a patient’s daily management becoming problematic as professionals with different training and/or backgrounds are having difficulties reaching a mutual agreement as to the course of action most beneficial to a patient’s care. Doctors coming from different specialities debate –what each one of them think is- the optimal way to approach a patient’s condition. Despite the fact that both parties in question are highly trained professionals having essentially ‘the same core training’, the difference in specialisation has created a scenario whereby a conflict regarding ‘who knows best’ has arisen.

In addition to that, a breakdown on communication is implied as different professionals approach the situation unable or unwilling to exchange information that could potentially clarify their thought process and argument for their preferred course of action. Such a conflict can potentially be a dangerous one as it can lead to a shift of focus from the real issue (the effective treatment of a medical condition) to a quarrel over personal and/or professional superiority.

4. Conclusion

This paper is a first attempt to look at the important, albeit largely overlooked, issue of group dynamics within a healthcare environment, presenting interest both to social science and healthcare. We utilized techniques and theories common in social psychology in order to examine and understand an important issue in healthcare. Our data reveals that professional identity can constitute a major influence in a healthcare professional’s understanding of and behaviour towards patient care and safety. We found that many participants expressed a strong tendency to identify with several groups within their workplace. These multiple identifications took place at several levels of abstraction, each of them relevant to a specific context or situation. Participants’ accounts indicated their awareness of the existence of people’s identification with these groups and the potential implications to issues affecting the welfare and safety of patients. Communication has been identified as the single most important element in a patient’s care that could potentially be influenced by healthcare professionals’ group membership.

We argued that membership to a professional group entails from and elicits to its members behaviour, similar to that stemming from membership to any other type of group. Behaviour that typically favours the in-group and prejudices the out-group. While within a healthcare environment there might not be direct and open competition between groups since (as this paper demonstrates) healthcare professionals generally see everyone working with or near them as having the same goal (the patient’s welfare and safety), there still is privileged information reserved for members of the same group and suspicion for members of out-groups. This has the potential to indirectly harm the patient, either because vital information is not passed on to members of other teams/departments/professions, or due to lack of trust in the abilities of members of the aforementioned groups. We believe that there is an exciting prospect for future work addressing the need for closer scrutiny on group membership and its dynamics within such a sensitive and complex environment as a healthcare establishment. In doing so, ways of improving current discrepancies involving the flow of information between different professional groups may be identified.

References

Adams, K, Hean, S, Sturgis, P & Macleod Clark, J (2006). Investigating the factors influencing first-year health and social care students. Learning in Health and social care, 5, 2, 55-68

Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Huber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, end job dissatisfaction. Journal of the American Medical Association, 288(16).

Allsop, J & Mulcahy, L (1998). Maintaining professional identity: doctors’ responses to complaints. Sociology of Health & Illness Vol 20 No6 pp.802-824

Atwal, A & Caldwell, K (2002). Do multidisciplinary integrated care pathways improve interprofessional collaboration? Scandinavian Journal Caring Science; 16; 360-367

Atwal, A & Caldwell, K (2006). Nurse’s perceptions of multidisciplinary team work in acute health-care. International Journal of Nursing Practice; 12; 359-365

Beagon, B (2000). Neutralizing differences: Producing neutral doctors for (almost) neutral patients. Social science and medicine, 51, 1253-1265

Benson, L & Ducanis (1995). Nurses' perceptions of their role and role conflicts. Rehabil Nurs; 20(4):204-11

Björkström, M, Johansson, I & Athlin, E (2006). Is the humanistic view of the nurse role still alive – in spite of an academic education? Journal compilation © 2006 Blackwell Publishing Ltd

Bridges, J. M., (1990), Literature review on the images of the nurse and nursing in the media. Journal of advanced Nursing, 15,:850-854

Bucknall, T & Thomas, S (1997). Nurse’s reflections on problems associated with decision making in critical care settings. Journal of Advanced Nursing,, 25, 229–237

Burke, D, Evans, M, Cockram & A, Trauer, T (2000). Educational aims and objectives for working in multidisciplinary teams. Australasian Psychiatry; 8: 336-339

Carter, S, Garside, P & Black, A (2003). Multidisciplinary team working, clinical networks and chambers; opportunities to work differently in the NHS. Quality and Safety in Health Care; 12; 25–28

Chadwick R. & Tadd W. (1992) Ethics and Nursing Practice. Macmillan, London

Cook, T, Gilmer, M & Bess, C (2003). Beginning Students’ Definitions of Nursing: An Inductive Framework of Professional Identity. Journal of Nursing Education, Vol.42,No7

Coombs, M (2004) Power And Conflict Between Doctors And Nurses: Breaking through the inner circle in clinical care. Routledge

Department of Health (2000). The NHS Plan. A plan for investment. A plan for Reform. London: HMSO

Fagermoen, M (1997). Professional identity: values embedded in meaningful nursing practice. Journal of Advanced Nursing,25:434-441

Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7: 117–140.

Gair, G & Hartery, T (2001) Medical dominance in multidisciplinary teamwork: a case study of discharge decision making in a geriatric assessment unit. Journal of Nursing Management; 9;(1); 3-11

Hallam, J (2000). Nursing The Image: Media, Culture & Professional Identity. Routledge

Hatch, M & Schultz, M (2004). Organizational Identity. Oxford

Hogg, M. A., & Terry, D. J. (2000). Social identity and self-categorization processes in organizational contexts. Academy of Management Review, 25, 121-140.

Kohn L, Corrigan J, Donaldson ME (1999) ‘To er is human’ National Academy Press,Washington, DC

Lingard, L, Resnick, DeVito, L & Espin, S (2002) Forming professional identities on the health care team: discursive construction of the ‘other in the operating room. Medical education; 36:728-734

Lupton, D (1997). Doctors on the Medical Profession. Sociology of Health & Illness Vol.19 No.4 pp.480-497.

MacDonald, R., Waring, J. and Harrison, S. (2005) ‘Balancing risk, that is my life’: The politics of risk in a hospital operating theatre department. Health, Risk and Society, 7(4): 397-411

MacIntosh, J (2003).Reworking Professional Nursing Identity. Western Journal of Nursing Research, 25(6):725-741

Mackay, L (1993). Conflicts in Care: Medicine and Nursing. Chapman & Hall

Manias, E & Street, A (2001). A Nurse-doctor interaction during critical care ward rounds. Journal of Clinical Nursing; 10; 442-450

Marsland, L & Murrells, T (2000) Sampling for a longitudinal study of the careers of nurses qualifying from English pre-registration Project 2000 diploma course. Journal of Advanced Nursing; 31(4), 935-943

Mayer, G (1982). Guidelines for establishing joint or collaborative practice in hospitals. National Joint Practice Commission. Chicago

Nelson, G, King, M & Brodine, S (2008). Nurse-physician collaboration on medical surgical units. Medsurg Nursing 17(1), 35-40

Ohlén, J & Segesten, K (1998). The Professional identity of the nurse: concept analysis and development. Journal of Advanced Nursing, 28(4): 720-727

Parker, T & Carlisle, C (1996) Project 2000 students’ perceptions of their training. Journal of Advanced Nursing; 24; 771-778

Radcliffe, M (2000) Doctors and nurses: new game, same result. BMJ; ;320:1085

Roberts, S (2000). Development of Positive Professional Identity: Liberating Oneself from the Oppressor Within. Advances in Nursing Science;22(4):71-82

Soothill, K, Mackay, L & Webb, C (1995). Interprofessional Relations in Health Care. Edward Arnold.

Stein, L. (1967) 'The doctor-nurse game'. Archives of General Psychiatry, 16, 699-703.

Stein, L., Watts, D. T. & Howell, T. (1990) The doctor–nurse game revisited. New England Journal of Medicine, 322, 546–549.

Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage Publications, Inc.

Strauss, A. and Corbin, J. (1994). Grounded Theory methodology: An overview, In Denzin, N., K. and Lincoln, Y. (Eds.). Handbook of Qualitative Research (1-18) Sage Publications, London.

Sullivan, W (2000). Medicine under threat: professionalism and professional identity.

CMAJ;162(5) 673-5

Tajfel, H. & Turner, J. C. (1979). An Integrative Theory of Intergroup Conflict. In

Austin, W.G & Worchel, S (Eds.), The Social Psychology of Intergroup Relations.

Monterey, CA: Brooks-Cole

Tajfel, H. and Turner, J. C. (1986). The social identity theory of inter-group behavior. In Worchel, S and Austin, L.W (eds.), Psychology of Intergroup Relations. Chigago: Nelson-Hall

Trice, H & Beyer, J (1993) The Cultures of Work Organizations. Prentice Hall (Englewood Cliffs, N.J.)

Turner, J.C (1985). Social categorization and the self-concept: A social cognitive theory of group behaviour. In E.J. Lawler (Ed.), Advances in group processes (Vol.2, pp. 77-122) Greenwich, CT: JAI Press.

Turner, J.C Hogg, M.A, Oakes, P.J Reicher, S.D & Wetherell, M.S (1987). Rediscovering the Social group: A self categorization theory. Oxford, England. Blackwell

Warelow, P. (1996) Nurse-Doctor Relationships in Multidisciplinary Teams: Ideal or Real? International Journal of Nursing Practice; 2; 33-39, Blackwell Sciences

Whetten, D & Godfrey, P (1998). Identity in Organizations: Building Theory Through Conversations. SAGE Publications