Kiran Veerapen FRCP(Edin) MMEd(Dundee)
Island Medical Program
Funded by CIHR

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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 out-
group 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.

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.

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
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Knowledge
Inability to prioritise, conflicting priorities
Fear of appearing incompetent
Not knowing how things work/not having the knowledge/skill
Inter/intra professional support
Too much to do
Communication
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

The team
Boundary blurring e.g. resuscitation of patient
Shared meaning
Shared accountability
The team Skill dependent

Personal
Identity
Inter-prof.
Identity
Prof.
Identity
Time to bond:
• Low workload/nights/ connect socially
• Receive empathy
• Flirting/mothering
• Social outings
Increased confidence to be
‘myself’
Shared object:
• Acute settings
• Formal team meetings
• Palliative care
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.