Transcript In the deep end: Expressions of identity and the workplace

Kiran Veerapen FRCP(Edin) MMEd(Dundee)
Island Medical Program
Funded by CIHR

Personal – a need to understand

Professional – a certain dissonance..

Topical – so what has changed and what is
unchanging?
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Exploring identity, professional identity & identification

Nurse-physician relationship and its impact

Encounters with nursing perspectives and paradigms
According to the social identity theory self concept is comprised of a personal
identity encompassing idiosyncratic characteristics and a social identity
encompassing salient group classifications. Social identification therefore is the
perception of oneness with or belongingness to some human aggregate.
Factors which predispose to a strong sense of social (professional or group) identity
are distinctiveness, prestige of the group, and its proximity to
one’s personal identity. Additionally awareness of out-groups reinforces awareness
of one’s in-group.
(Ashforth & Mael 1989, p. 21)
When group or professional identity is dominant (active), out-groups take on an
adversarial dimension and lead to the in-group being judged positively and the outgroup being devalued; such that comparisons become self enhancing (Stets &
Burke, 2000).
This results in stereotypical casting of both. “Groups have a vested interest in
perceiving or even provoking greater differentiation than exists and disparaging
the reference group on this basis” (Ashforth & Mael, 1989, p. 31).
This tendency is further accentuated when the in-group perceives a threat to its
domain or its resources. If physicians and nurses see each other as the out-group,
the workplace becomes a potential battleground.
Konner (as cited in Conrad, 1988):
I have been absorbed into the “teamness” of Medicine. During my last few months
on the wards I tried to be decent to patients, but my bonds, my emotional energy–
what psychoanalysts call cathexes–were all with doctors and medical students, and
to a lesser extent nurses. . . . Relations with patients should be smooth, cordial and
efficient but they are certainly not personal.
How do you know?
We know differently!
‘There are all kinds of sources of our knowledge but
none has authority’.
Karl Popper
Medicine is an uncertain science, yet its demand that professionals cloak themselves in
confidence and certainty, honesty and altruism, create an implicit tension and leave little
room for expressions of ambiguity or tacit knowledge.
Learning through apprenticeship (where personal knowledge is transmitted through
interaction and observation, over time) and specialized practice, all speak of the importance
of tacit knowledge or ‘pattern recognition’ if you will, but even in these situations, value is
placed on the need for description, articulation and communication in an attempt to make
the tacit, explicit, as ‘just knowing’ is seldom acceptable (Wyatt, 2001).
Creative problem solving and intuitive knowing are a prerogative of the highly skilled and
experienced; the stakes are too high for the less expert to base his decisions on his tacit
perceptions alone.
Thus when a physician is asked the question ‘how do you know’, he expects to base his
answer within a framework that can be verified.
… looking at my unconscious competence from the outside, digging to find and
understand the theories and models and beliefs that clearly, based on the looking at
what I do, now inform what I do and how I do it. These won’t be the exact same
theories and models and beliefs that I learned consciously and then became
unconscious of. They’ll include new ones, the ones that comprise my particular
expertise. And when I’ve surfaced them, I can talk about them and test them
(Baume as cited in Wikipedia 2009, para 12)
One gets the impression that explicit, empirical or positivist knowledge is considered
‘biomedical’ and in an attempt to move away from this model, tacit knowledge gained
through the various ways of knowing is considered sufficient in itself with little effort made
to unravel it and construct new knowledge.
Since personal knowledge remains tacit and contextual, it then remains for each individual
to forge out her own world view with little benefit gained from the professions collective
experience. Faced with this dichotomy several nursing scholars have exhorted the
profession towards greater objectivity and accountability. While some emphasize the need
for reflection to move this to a conscious level others are content to just claim its validity.
Purkis (2007) asks a pertinent question: ‘To what extent is nursing practice an inherent,
intuitive, artistic performance-something we’re born to engage in, versus an intellectual
endeavor, based in some form of scientific reasoning and the result of deliberate, rational
thought?’ (p 372).
To explore the ways in which narratives operate to:

Construction of professional identity in students attending medical and
nursing schools

Impact uniprofessional education on the perception of self versus the
‘other’ (physicians/ nurses).

Impact professional medical and nursing identity on the ability to work as
a team

Shift of interprofessional perceptions after transiting from professional
school to professional work.
A qualitative study using semi-structured interviews
Triangulation through non-participant observation
Analysis using a hermeneutic- phenomenological
method
To include a
mirror group
in South West
England
And so you respect what somebody with more experience or somebody who is
apparently more well read or inherently appears smarter.
And I went into to family med, my mom’s a family doc so I saw that as a very
positive role just from growing up… I mean getting Christmas cards from patients
or we were in a small town so she’d get stopped in a grocery store and people were
really appreciative.
So you’re learning just based on what your role models are. And your role models
are whoever your attending at the moment is. You pick up the people that you like,
you strive to emulate them. And you see people who, when they leave the room the
nurses breathe a sigh of relief or they curse under their breath or whatever and you
say I don’t want to be that guy. And so you evaluate what he’s doing and you take it
from there. So, it’s a lot of just interpreting people.
I thought that nurses and doctors were going to be working together. I thought nurses had a lot
more responsibility. I thought they had a lot more decision-making ability than they do…. I mean
with these TV shows, you can look at a show like Scrubs for example, and the nurses are some of the
main characters on that.
So you kind of know a little bit about yourself, who you are going in. And you pick up on the cues of
role models and you’re “who do I identify with? Do I identify with the surgeon who works 120 hours
a week and he’s the best of the best and he walks down the hall and people tremble? Is that who you
are?” Because some people are. Or are you skipping out of class to go skiing and you’re lifestyle
focused. That’s okay in modern medicine…In terms of picking a specialty or whatever, yeah, you’re
shadowed and it’s basically do you want to be like the people you’re around? Do you want their
lifestyle? Do you want their problems and their rewards? And their scope of practice? I could have
been happy doing many different things right, but –
I mean right through our medical education being taught by specialists is a pretty negative
generalist perspective out there. You hear a lot of “and then the GP missed this and then I saved the
day when I cut out the tumor.” There’s a very, it’s, there’s a difference, there’s a very big line between
generalists and specialists. And they’ve got different colleges and they’ve got different lobbying
groups and you know we start off all as med students and then we just split into different camps.
Outside practice settings:
So there’s a little bit of confusion about how this was actually supposed to be useful in the end.
And rightly so, I don’t think it really prepared us for anything. It just sort of was one of those
things to make you realize that you’re not the only one –
The general feeling was that it was not a very productive project …. A waste of time, in fact it
was sometimes counterproductive because people would identify the behavior of individuals
with the behavior of professions
Placements:
I did a few shift with physiotherapists in med school, working with the different professions is
helpful. Well anytime you can hear someone else’s point of view about the kind of cases they’re
getting or you’ll hear, “I’ll look at this referral, it just says right shoulder pain, that’s not
helpful.” So you hear their point of view, the good and the bad about what needs to be done
and it’s less important than what the actual techniques they’re using and – that kind of stuff.
It’s more just about being able to empathize with their position.
Personal experience as the other:
Working as an auxillary --
Residency is tough because you have your shitty days and you don’t have enough sleep and
you’ve not necessarily eaten properly. Often, god, sometimes you don’t have time to pee. You
know the most basic elements of self-care you don’t get to.
…but we all go home and have our nights where we just bawl. Just cry, cry and cry because it’s
hard and it sucks. Anyway, but then you have your days where you’re, “Damn, I was good
today, I was on, that was awesome.” And so, you know, sorry..
At night you’re literally getting called about kids who are quite sick and –
you’re being given tremendous responsibility to look after children and in the morning
sometimes the nurses will treat you like a child. Or the consultants will treat you like a child;
“you make sure you show up to the teaching rounds now, teaching’s really important.” And
you’re like “what?”
And when you change roles every four weeks you’re constantly making first impressions. And
you’re constantly on the defensive essentially. Because you’re never, you never have home
court advantage.
It is a pretty fantastic amount of stress – to be sleep deprived and to constantly feel stupid.
Because you’re just around specialists who know far more than you’ll ever know. And, yeah, to
constantly be on the defensive, it can be very draining
My philosophy about dealing with difficult people and in particular difficult nurses has
always been that if I can do something in a way that doesn’t compromise patient care
but allows me to sort of deal with unpleasant people to the least extent possible, I will do
that.
I’ll basically do anything up to compromising patient care.
It’s not too bad for me as a male. And the sex and gender stereotypes of medicine and
nursing are very alive and well. From my experience with nurses about half of them flirt
with me and about half of them treat me like their son.
Where as a male, I can get away with it by just smiling.
And so that’s why you have to be overly nice and you have to do your best to get in there.
And in order to do your job effectively – you need to work effectively with other team
members. And if you piss them off then they can bug you all night and you won’t get a
wink of sleep. And then you’ll hate your work.
I think it’s just anytime you’re dealing with large groups of people collaborating
and all trying to do their own separate little thing.
I don’t think the structure of hospital care is necessarily designed for true
collaboration
I find the agitated patient is a difficult one because the nurses have to sit there
all night and listen to so-and-so howl and – scream and carry on. And that’s one
where sometimes they’re trying to make themselves more comfortable and –
fair enough but giving a bunch of antipsychotics to some frail little 95 year old
lady who’s demented out of her skull, you know. It’s not necessarily best for the
patient; it’s best for the nurses.
..the nurse didn’t want the child to be poked again and I had no idea why the child
was supposed to be poked .. she wanted me to contradict the wishes of an attending
to avoid poking this child. Which I mean - obviously we don’t want to hurt the
children and I don’t have to actually physically take the blood, so there’s a big
difference there. But it did escalate quite a bit because I wasn’t comfortable
contradicting my superior for a minor inconvenience with very little potential
harm..
I like emergency medicine where the nurses will have already given the patient with
chest pain an Aspirin and gotten the ECG done before you even see them. it seems
there they’re given a little bit more Leeway to deal with certain things. I really like
that. There’s a lot of direct interaction there, because you’re not just rounding and
then gone, nurse sees that patient, you see the patient, you interact with the nurse.
and so it’s a lot of one on one, direct feedback kind of things. And you can bounce
ideas off them. You can say “man, that guy looks sick” or “I wonder if this is going to
work”. It’s very amenable to those kind of -------- As opposed to a surgery – where
you’re rounding on fifty patients in an hour and a half and it’s just running and
scribbling in charts and “oh, we’ll see you later”. Very cursory interactions.
I mean certainly as a new resident and definitely as a med student, they know a lot more than
I do, so it kind of feels a little bit silly to put on a big arrogant, superior air.
We order the nurse to do it and I think that’s such a terrible way of putting it. Of saying that,
“well you’ve written your orders”, it should be “have you written the steps of getting the
patient better” or something a little more constructive than –
It’d be very frustrating. To know that you have the ability and the knowledge to do something
but to just sit there and have to wait for somebody else to do it it’s very child-like. It’s like
you’re in grade school and until teacher says, you can’t go to the bathroom.
And that we recognize their expertise. Because yeah they are in many ways more qualified to
be making these calls than I am. And not always but for the most part when a nurse calls you
with a problem they generally know what needs to be done.
Personal, interprofessional & professional identities
+
Inability to prioritise,
conflicting priorities
Not knowing how
things work/not
having the
knowledge/skill
Knowledge
Fear of appearing
incompetent
Get the job done
Inter/intra
professional support
Communication
Too much to do
Newness
Gaining
confidence
And new again
Threat &
challenge
Knowledge, skills,
records, spaces
etc
Ostensibly,
the patient
Fragmented jobs,
separate
accountabilities
Contradictions/salience
of professional identity
Identities,
knowledge,
overwhelmed
by work
Accountability
– to whom?
Intra professional/intra
professional
Who can I ask for
help, who will
help? Whose job is
it? Interlinked
tasks
Adapted from Engestrom 2001
Boundary blurring
Shared meaning
The team
Shared
accountability
e.g. resuscitation of
patient
The team
Skill dependent
Personal
Identity
Time to bond:
• Low workload/nights/
connect socially
• Receive empathy
• Flirting/mothering
• Social outings
Increased confidence to be
‘myself’
Inter-prof.
Identity
Shared object:
• Acute settings
• Formal team
meetings
• Palliative care
Prof.
Identity
Fragmented
object/accountability
• Work overload,
spatial disparity
• Fear/uncertainty
• Being overwhelmed
• Threat response
New understanding of identity
To explore the ways in which narratives operate to:

Construction of professional identity in students attending
medical and nursing schools

Impact uniprofessional education on the perception of self
versus the ‘other’ (physicians/ nurses).

Impact professional medical and nursing identity on the ability
to work as a team

Shift of interprofessional perceptions after transiting from
professional school to professional work.