Health promotion roles shaped by professional identity: an ethnographic study in the Netherlands

How frontline care professionals interpret and fulfill their health promotion roles is of great importance for the health of the vulnerable clients they work with. While the literature on health promotion is limited to describing the roles of healthcare professionals, this study examines the health promotion roles held by various frontline professionals when working with clients with combined psychosocial problems and how this is associated with professional identity. Based on ethnographic data from Dutch frontline professionals in social welfare, general healthcare and mental healthcare, this article shows how various frontline professionals promote health by reframing and customizing health problems and that this is associated with how they identify as pragmatic or holistic professionals.

Becoming active in the micro-politics of healthcare re-organisation: The identity work and political activation of doctors, nurses and managers

The changing organisation and governance of healthcare work represents a persistent focus of micro-politics. Whilst there is a developed literature describing the micro-political struggles that occur amongst healthcare occupations, there is little understanding about how, when and why actors become politically aware and active. Framed by research on political activation and the concept of identity work, this paper reports on a narrative interview study with 65 people, specifically doctors, nurses and managers, working in the English healthcare system. The narratives show that healthcare workers become increasingly aware of and engaged in micro-political activities through incremental stages based on their accumulating experiences. These stages are opportunities for identity work as actors make sense of their experiences of micro-politics, their occupational affiliations and their evolving sense of self. This identity work is shaped by actors' changing views about the morality of playing politics, the emotional implications of their engagement, and their deepening political commitments. The study shows that political socialisation and activation can vary between occupations and rather than assuming political affiliations are given or acquired the papers highlights the reflective agency of healthcare actors.

Online identities in and around organizations: A critical exploration and way forward

The construction, performance, and regulation of identities in the online world have deep implications for individuals, organizations, and society, particularly as digital technologies become increasingly omnipresent in our daily lives. In the last decades, analyses of online identities’ processes have moved from the exploration of identity play, through identity performance, toward a growing identity regulation through algorithmic management and the monetization of personal data. Despite a significant tradition of critical management and organization studies literature on identity, online identities have to date received only scant attention. This Special Issue explores what critical management and organization studies can contribute to research on online identities. Drawing on empirical analysis of virtual forums, social media, and platforms, the six papers included here highlight the struggles that accompany identity processes in the online environment and their implications for workers, activists, and other organized selves. In this introduction, we contextualize these contributions with reference to online identities studies and metaphors of the internet as a place, a tool, and a way of being. We comment on the contributions they make relating to the role of the body, and individual and collective dynamics in online identities processes. Following this, we propose critical ways forward concerning new forms of digital work, multiphrenic context collapse, and online references and sources of identity. We invite researchers to not only critically explore but also to engage with this brave new world that increasingly shapes our individual and collective selves.

Managing precarity at the intersection of individual and collective life: A Membership Categorisation Analysis of Tensions and Conflict in Identities within an Online Biosocial Community

This paper explores how individuals living within high-stakes precarious categories navigate their identity within online spaces. Using Membership Categorisation Analysis, we investigate how categorical inferences are indexed by those individuals within online biosocial communities in everyday speech, as part of their construction of identities. More specifically, we analyse online interactions of women who have been identified as carrying a BRCA gene mutation in an online biosocial community. Our findings show how (1) the online spaces participate in constituting and sustaining a form of collective responsibility, where those who are within a high-stakes precarious identity category are expected to not only support and educate each other, but also monitor the compliance to category predicates, and (2) the tensions and conflict in making sense of, belonging to, resisting and sustaining a category membership often occur when there are clashes with the socio-moral order. Overall, this paper’s contributions are twofold, first, methodologically, the use of Membership Categorisation Analysis provides an insightful analytic approach to identities, online communities and their organisation. Second, the emerging tensions identified provide insight into the complex ways in which online communities offer a forum in managing precarious identity as individual and collective life intersect.

Ontario family physicians’ perspectives about their scope of practice: what is it, what drives it and how does it change?

Background

There is little evidence to show what scope of practice (SOP) means from the point of view of family physicians, how family physicians think about their SOP as it changes over time, or what factors shape and influence their SOP. Understanding family physician perspectives on SOP and the factors that influence it can aid our understanding of how it can constrain and enable physicians’ agency and autonomy in professional practice.

Methods

Using qualitative description and incorporating constructivist grounded theory data collection and analysis techniques, four focus groups were conducted involving twenty-four Ontario-based family physicians from different contexts, at different career stages, and with different practice experiences.

Results

Participants’ SOP was highly dynamic, changing throughout their careers due to factors both within and beyond their control. Their sense of their own SOP was the product of a continuous cycle of personal and professional transitions, exposures, and experiences throughout their careers. These family physicians sought regular and sustained mentorship, support, and engagement for their SOP throughout their careers. This was particularly the case during professional transitions and for drivers of their SOP for which they felt unprepared early in their careers, such as through the first years of independent practice, and when functioning as owner-operators of medical practices. Four descriptive themes were identified focusing on the nature of their current practice, their professional preparedness and supports, practice management dynamics, and ‘doctors are people, too’.

Conclusions

The SOP of the family physicians in this study was dynamic and unique to each individual, it emerged from interactions between their personal and professional lives and identities, and it was embedded in their lived experiences. SOP was also to some extent imposed and externally driven. This study advances understanding by exploring the ‘why’ and ‘how’ of SOP rather than focusing solely on what it is.

Power through empowerment? The managerial discourse on employee empowerment

Informed by the sociology of knowledge approach to discourse, the current study explores how employee empowerment is discursively constructed as a management technique. Combing insights from labour process theory, Foucauldian approaches to governmentality and neo-Weberian interpretations of the ideological basis of capitalism, we develop an empirically informed theoretical framework that accounts for the multifaceted character of employee empowerment. Results show, first, that discourse justifies the necessity of this technique by presenting it as an efficient answer to perceived increases in competitive pressures and an ever-changing economic environment since the beginning of the 1990s. The discourse promotes advanced liberal modes of (self-)governance, which are created and maintained through a complex set of means for the control of labour. Second, although the ideological structure of the empowerment discourse is in accordance with the third spirit of capitalism, as identified by Boltanski and Chiapello, it also introduces changes by removing the neo-manager and granting the empowered employee a central role. Furthermore, our analysis suggests that empowerment is associated with strategies for reducing labour costs, such as de-layering and work intensification.

Pushing for partnership: physician engagement and resistance in primary care renewal

PURPOSE

Healthcare policymakers and managers struggle to engage private physicians, who tend to view themselves as independent of the system, in new models of primary care. The purpose of this paper is to examine this issue through a social identity lens.

DESIGN/METHODOLOGY/APPROACH

Through in-depth interviews with 33 decision-makers and 31 fee-for-service family physicians, supplemented by document review and participant observation, the authors studied a Canadian province's early efforts to engage physicians in primary care renewal initiatives.

FINDINGS

Recognizing that the existing physician-system relationship was generally distant, decision-makers invested effort in relationship-building. However, decision-makers' rhetoric, as well as the design of their flagship initiative, evinced an attempt to proceed directly from interpersonal relationship-building to the establishment of formal intergroup partnership, with no intervening phase of supporting physicians' group identity and empowering them to assume equal partnership. The invitation to partnership did not resonate with most physicians: many viewed it as an inauthentic offer from an out-group ("bureaucrats") with discordant values; others interpreted partnership as a mere transactional exchange. Such perceptions posed barriers to physician participation in renewal activities.

PRACTICAL IMPLICATIONS

The pursuit of a premature degree of intergroup closeness can be counterproductive, heightening physician resistance.

ORIGINALITY/VALUE

This study revealed that even a relatively subtle misalignment between a particular social identity management strategy and its intergroup context can have highly problematic ramifications. Findings advance the literature on social identity management and may facilitate the development of more effective engagement strategies.

Balancing altruism and self-interest: GP and patient implications

This paper explores how general practitioners (GPs) address potentially opposing motivations stemming from being altruistic and self-interested, and the implications for patients and GPs. The author finds that GPs address dual goals of patient care and profit generation. This can be challenging, while professional values (altruism) encourage a patient focus, business realities (self-interest) mandate other priorities. Viewing clinicians as altruistic in isolation of business needs is unrealistic, as is the notion that profit is the dominant motivation. A blending of interests occurs, pursuing reasonable self-interest, patients’ best interests are ultimately met. GPs need a profit focus to sustain/improve the practice, benefitting patients through continued availability and capacity for enhancement. Therefore, it is argued that GPs behave in a manner that is ‘part altruistic, part self-interested’ and mutually beneficial. These insights should be considered in designing incentive systems for GPs, raising compelling questions about contemporary understanding of the nature of professionals.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience

Background

Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various ‘new models of care’, including general practice offering ‘additional availability’ appointments during evenings and at weekends. In Greater Manchester, six ‘demonstrator sites’ were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes.

Methods

Semi-structured interviews, with the data subjected to thematic analysis.

Results

Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants.

Conclusions

The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

“Deregulation is so nineteen eighties, we’re into ‘better regulation’ now”

Purpose

The purpose of this paper is to explore how organizations operate in the absence of a clear regulatory authority in a self-regulating environment. Significant moves towards self-regulation by various political administrations, together with successive waves of deregulation raise questions about the ability and effectiveness of industries and markets to regulate their own behaviour. This is a topical political and social concern with governments often appearing to favour self-regulation as opposed to the constitution of an official regulator. The absence of a regulator and the possibility of voluntary compliance raise a number of issues for the way in which organizations operate and the consequences, both intended and otherwise for organizations and society at large.

Design/methodology/approach

Empirically the authors explore the case of an industry leader within the Passive Fire Protection industry, as it adjusts to an increasingly self-regulated market environment. The authors document how organizational members make sense of the regulatory environment and the behaviour of actors within it.

Findings

The authors find that discourses of enterprise that underpin self-regulation permit actors a choice between compliance and non-compliance. Whilst also noting the prevalence of notions of morality in terms of how actors make sense of both compliant and non-compliant behaviour. Despite common sense notions that morality is seldom clear cut or unambiguous, the case study reveals that frameworks for understanding behaviour allow participants within the industry to make very clear demarcations between moral (compliant) and amoral (non-compliant) behaviour.

Originality/value

The authors learn how those that are compliant within the industry come to question the effectiveness of the regime to which they comply, thus ultimately undermining the integrity of the regime. In the absence of a strong regulatory regime, some agents draw upon notions of enterprise to justify an individualist, economic and pragmatic approach that makes non-compliance permissible. Thus the discourse of enterprise is present in the justification of both “moral” and “amoral” behaviour, this leads the authors to question the wisdom of policy that promotes the idea of enterprise as effectively ensuring compliance.

The league of extraordinary generalists: a qualitative study of professional identity and perceptions of role of GPs working on a national after hours helpline in Australia

Background

Telephone triage and advice services (TTAS) have become commonplace in western health care systems particularly as an aid to patient access and demand management in the after hours period. In 2011 an after hours general practitioner (GP) helpline was established as a supplementary service to existing 24-h nurse-TTAS in Australia. Callers to the service in the after hours period who are triaged by a nurse as needing to see a GP immediately or within 24 h may speak with a GP on the line to obtain further assessment and advice.

While much research has been undertaken on the roles of nurses in TTAS and the professional identities and attitudes to new technology of community-based GPs, little is known of the perceptions of role and identity of GPs providing after hours advice on primary care helplines. This qualitative study explored the perceptions of professional identity and role, motivations and contributions to the health system of GPs employed on the Australian afterhours GP helpline in 2011–2013.

Methods

The study took a phenomenographic approach seeking to understand the essence of being a telephone GP, probing professional identity while also exploring role tensions. Twelve GPs, or 15 % of the helpline GP workforce participated in the qualitative study.

Results

The GPs experienced both personal and professional benefits and believed they were strengthening patient care and the Australian health system. However the role required a re-alignment of practice that challenged professional autonomy, the doctor-patient relationship and commitment to continuity of care. Some GPs made this role realignment more readily than others and were well suited to the helpline role. There was a strong collegial bond amongst the helpline GPs which facilitated the maintenance of professional autonomy.

Conclusions

Telephone GP assessment and advice does not demonstrate the same breadth as face-to-face practice and provides little opportunity for continuity of care, but this has not prevented those performing the role from identifying as a new form of generalist. The establishment of an after hours GP helpline in Australia has seen the emergence of a new generalist primary care identity as telehealth innovators.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1387-5) contains supplementary material, which is available to authorized users.

Reorganising hospitals to implement a patient-centered model of care

Purpose

– The purpose of this paper is to understand how the introduction of a patient-centered model (PCM) in Italian hospitals affects the pre-existent configuration of clinical work and interacts with established intra/inter-professional relationships.

Design/methodology/approach

– Qualitative multi-phase study based on three main sources: health policy analysis, an exploratory interview study with senior managers of eight Italian hospitals implementing the PCM, and an in-depth case study that involved managerial and clinical staff of one Italian hospital implementing the PCM.

Findings

– The introduction of the PCM challenges clinical work and professional relationships, but such challenges are interpreted differently by the organisational actors involved, thus giving rise to two different “narratives of change”. The “political narrative” (the views conveyed by formal policies and senior managers) focuses on the power shifts and conflict between nurses and doctors, while the “workplace narrative” (the experiences of frontline clinicians) emphasises the problems linked to the disruption of previous discipline-based inter-professional groups.

Practical implications

– Medical disciplines, rather than professional groupings, are the main source of identification of doctors and nurses, and represent a crucial aspect of clinicians’ professional identity. Although the need for collaboration among medical disciplines is acknowledged, creating multi-disciplinary groups in practice requires the sustaining of new aggregators and binding forces.

Originality/value

– This study suggests further acknowledgment of the inherent complexity of the political and workplace narratives of change rather than interpreting them as the signal of irreconcilable perspectives between managers and clinicians. By addressing the specific issues regarding which the political and workplace narratives clash, relationship of trust may be developed through which problems can be identified, mutually acknowledged, articulated, and solved.

Regulators, Conformers and Cowboys: The Enterprise Discourse, Power and Resistance in the UK Passive Fire Protection Industry

This article draws on industry-level research to explore the enterprise discourse in the UK passive fire protection industry. It highlights the theoretical weaknesses of the enterprise discourse by questioning the assumption that employers and managers necessarily support enterprise. It examines how employers, not just employees, may seek to resist or evade enterprise and how, far from offering a united front, employers may oppose each other. The article points towards the need for industry-level studies due to the limitations and potentially misleading insights that can flow from organization-level studies. Overall, it is argued that there may be more common ground between employees and employers in terms of opposition to enterprise than has previously been suggested.

Changes in healthcare professional work afforded by technology: The introduction of a national electronic patient record in an English hospital

This article considers changes in healthcare professional work afforded by technology. It uses the sociology of professionals’ literature together with a theory of affordances to examine how and when technology allows change in healthcare professional work. The study draws from research into the introduction of a national electronic patient record in an English hospital. We argue that electronic patient record affords changes through its materiality as it interacts with healthcare professional practice. Its affordances entail some level of standardisation of healthcare professional conduct and practice, curtailment of professional autonomy, enlargement of nurses’ roles and redistribution of clinical work within and across professional boundaries. The article makes a contribution to the growing literature advocating a cultural approach to the study of technological affordances in organisations and to studies that explore healthcare professional practice in conjunction with the materiality of technology. Two main lines of argument are developed here. First, that technological affordances do not solely lie with the materiality of technology nor with individual perceptions, but are cultivated and nurtured within a broader cultural–institutional context, in our case a professional context of use. Second, that technological affordance of change is realised when healthcare professionals’ (individual and collective) perceptions of technology (and of its materiality) fit with their sense of (professional) self. In this respect, the article shows the extent to which the materiality of technology plays out with professional identity and frames the level and extent to which technology can and cannot afford restructuring of work and redistribution of power across professional groups.

Implementing human factors in clinical practice

OBJECTIVES

To understand whether aviation-derived human factors training is acceptable and useful to healthcare professionals. To understand whether and how healthcare professionals have been able to implement human factors approaches to patient safety in their own area of clinical practice.

METHODS

Qualitative, longitudinal study using semi-structured interviews and focus groups, of a multiprofessional group of UK NHS staff (from the emergency department and operating theatres) who have received aviation-derived human factors training.

RESULTS

The human factors training was evaluated positively, and thought to be both acceptable and relevant to practice. However, the staff found it harder to implement what they had learned in their own clinical areas, and this was principally attributed to features of the informal organisational cultures.

CONCLUSIONS

In order to successfully apply human factors approaches in hospital, careful consideration needs to be given to the local context and informal culture of clinical practice.

Plural provision of primary medical care in England, 2002–2012

Objectives:

Health care reforms often include provider diversification, including privatization, to increase competition and thereby health care quality and efficiency. Donabedian's organizational theory implies that the consequences will vary according to the providers' ownership. The aim was to examine how far that theory applies to changes in English NHS primary medical care (general practice) since 1998, and the consequences for patterns of service provision.

Methods:

Framework analysis whose categories and structure reflected Donabedian's theory and its implications, populated with data from a systematic review, administrative sources and press rapportage.

Results:

Two patterns of provider diversification occurred: 'native' diversification among existing providers and plural provision as providers with different types of ownership were introduced. Native diversification occurred through: extensive recruitment of salaried GPs; extending the range of services provided by general practices; introducing limited liability partnerships; establishing GPs with special clinical interests; and introducing a wider range of services for GPs to refer to. All of these had little apparent effect on competition between general practices. Plural provision involved: increased primary care provision by corporations; introducing GP-owned firms; establishing social enterprises (initially mostly out-of-hours cooperatives); and Primary Care Trusts taking over general practices. Plural provision was on a smaller scale than native diversification and appeared to go into reverse in 2011.

Conclusions:

Although the available data confirm the implications of Donabedian's theory, there are exceptions. Native diversification and plural provision policies differ in their implications for service development.

The effort to control time in the 'new' general practice

Since the 1980s and 1990s doctors in the UK have reported a lack of time; this has been reproduced in the reorganisation of work through various contracts and regulatory mechanisms. I draw on interviews with 32 General Practitioners (GPs) in Wales about their everyday work, focusing on accounts about the limited nature of their time. I use Adams' analysis of the rationalisation of work time through the processes of commodification, compression, and colonisation, to explore tensions between traditional and new ways of doctoring. While it was possible to find evidence of traditional ways of managing time that shaped the activities of doctors and controlled those activities, the doctors were not passive participants in the rationalisation of work time. Rather they actively modified its processes using notions of professionalism that are aligned to traditional doctoring, and which offer new ways of doing and being a professional.

Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in health care

Context

One of health care's foremost challenges is the achievement of integration and collaboration among the groups providing care. Yet this fundamentally group-related issue is typically discussed in terms of interpersonal relations or operational issues, not group processes.

Methods

We conducted a systematic search for literature offering a group-based analysis and examined it through the lens of the social identity approach (SIA). Founded in the insight that group memberships form an important part of the self-concept, the SIA encompasses five dimensions: social identity, social structure, identity content, strength of identification, and context.

Findings

Our search yielded 348 reports, 114 of which cited social identity. However, SIA-citing reports varied in both compatibility with the SIA's metatheoretical paradigm and applied relevance to health care; conversely, some non-SIA-citers offered SIA-congruent analyses. We analyzed the various combinations and interpretations of the five SIA dimensions, identifying ten major conceptual currents. Examining these in the light of the SIA yielded a cohesive, multifaceted picture of (inter)group relations in health care.

Conclusions

The SIA offers a coherent framework for integrating a diverse, far-flung literature on health care groups. Further research should take advantage of the full depth and complexity of the approach, remain sensitive to the unique features of the health care context, and devote particular attention to identity mobilization and context change as key drivers of system transformation. Our article concludes with a set of “guiding questions” to help health care leaders recognize the group dimension of organizational problems, identify mechanisms for change, and move forward by working with and through social identities, not against them.

The Grit in the Oyster: Professionalism, Managerialism and Leaderism as Discourses of UK Public Services Modernization

The representation of organizational agency in UK policy discourse on public service modernization is analysed in order to disclose the legitimation of elite organizational centres and the structuring of organizational peripheries and their potential for resistance. Three discourses are identified and explored: the residual, but still potent, discourse of professionalism; the dominant discourse of managerialism; and the emergent discourse of leaderism. The emergent discourse of leaderism is shown to be linked to an imaginary of neo-bureaucratic organizing, which represents an evolution of New Public Management. As such, the analysis of leaderism, a new form of privileged agency, contributes an insight into the dynamics of public service modernization. This is developed through exploring leaderism’s tension between its strong affinity with unitarist managerialism and its weaker linkages to quasi-pluralist stakeholder networks which create potentialities for new forms of active resistance.

Are public health authorities able to "steer" rather than "row"? An empirical analysis in the Italian National Health Service

The nature of the local health authorities (LHAs) in the Italian National Health Service has been deeply reformed during the 1990s by new public management (NPM) reforms that introduced decentralization, quasi-market and managerialism. These reforms implied that the main role of LHA is to govern the production of health services in their area (steer) rather than to only directly produce services (row). After more than 15 years from these reforms of Italian healthcare, we describe how much the steering versus rowing dichotomy made an impact on LHA activity, through an analysis of the management control systems they set up for themselves and the subsequent qualitative analysis of the opinions that a diverse group of managers expressed during 8 days of group discussion. Results show that managers of Italian LHAs, when only a small part of services is produced, tend to perceive their steering role as impossible to play and focus on production, leaving therefore ungoverned a significant part of the services offered to residents. NPM, therefore, was able to influence the reform of Italian healthcare but, as suggested by a postmodernist interpretation, left managers with a rhetoric change based on inconsistent assumptions instead of actionable ideas to manage the change process.