The choice of organisational ethnography as the overarching methodology for the study was rewarded by the quality, and originality of the findings. The use of SIT as a theoretical
framework for the inquiry gave focus to the design, and outcomes of the study. The case context of acute care was appropriate to the inquiry, and enabled the ethnographic methods to be applied to two core nursing activities; nursing group handover, and the MDM. The findings are limited to the assumptions, and contexts of the research design, yet they are clear, and powerful enough to have implications for further research, practice, policy, and education.
Based on the experience of using this research design I would recommend that other studies be constructed in the same way. I have been struck by the powerful data that emerged from the use of SIT in conjunction with ethnographic methods; the detailed cultural assessment of the
construction of nursing identity within the nursing activities would not have been achieved without this combination. The ethnographic framing around two activities highlights the need for similar research to be undertaken with other nursing activities; similarly different case contexts of nursing practice should be studied.
The use of the video-recording as a method was useful to ensure I did not interrupt the activity. It also provided an opportunity to observe the activities repeatedly, and gave rise to the unusual opportunity of the participants themselves participating in participant observations.
Implications
The overall implications of this research is to generate further knowledge, and that there are many questions still to be answered around professional identity, and nursing. It has been demonstrated in this project that SIT was a useful theory to study professional identity within
148 | P a g e the case environment of the nursing activities that were studied. The findings of this research project have significant implications for future policy development, education, research, and practice for nursing.
The significance of nursing to our healthcare environments cannot be underestimated, and therefore clarity of who we are, and what we do must be understood firstly by nurses
themselves. Nurses, and midwives make up 63% of all health care professionals (AIHW, 2012, p. 501). We are the largest, and most diverse of all healthcare professionals in our practices, and contexts. Yet there is limited research into how the professional identity of nurses is developed, and sustained in the working context. This research has sought to contribute to the body of knowledge on nurses’ professional identity, and the ethnographic hypotheses presented as conclusions in the previous chapter are needed to prompt further debate action, and investigation.
Social interaction is fundamentally important for the construction of professional identity. The expression of nurse identity is played out in activities where there are interactions with other health professions; this has implications for interprofessional practice. There needs to be opportunities for nurses to present their professional identity. The role of citizenship
behaviours in the interactions with other members of the healthcare team has been
understudied. This research reveals important social processes that the nurses’ offer to the interprofessional team, policy makers need to promote, and encourage the investigation, and development of these processes. Policy makers need to be conscious citizenship behaviours nurses contribute to the interprofessional team. Policy makers then need to ensure these are sustained, and maintained through enabling systems of work. Undergraduate, and postgraduate education strategies need to include the training, and analysis of the nurses’ work in
interprofessional groups, particularly the social processes that express professional identity, and goals, and behaviours that sustain good citizenship. Nurses in practice need to be aware of their contribution to citizenship behaviours, and the recognition of the role they, and their physical spaces play in the social functioning of the group. There is limited nursing research into citizenship behaviours, and their relationship to the expression of professional identity.
In order for professional identity to be constructed, and advanced by members of the profession there needs to be opportunities for nurse to nurse communication, connection, and social expression of their central work foci. There are strong findings about the construction of
professional identity from study of the nurse group handovers as revealed in the results chapter (Chapter 5), and discussed (Chapter 6). There were numerous features in nurses to nurse interaction that evidencially sustained, and advanced the construction of nurses’ professional
149 | P a g e identity. There was paucity of research that investigated nurse-nurse interactions in relation to nursing acts, and professional identity. The richness of the data, and findings gained from this study create an imperative for investment into researching this domain. Implications for policy arise from the aspects associated with group performance, social identities, and self-
categorisation. Policy makers need to be cognisant of the importance of group motivation, group goals, group norms, and group efficacy on group performance. In addition they need to
understand the importance of nested, and cross cutting identities, and identity salience to the construction of nurses professional identities. Policy needs to support nurses’ cognitive processes of self-categorisation. Education, and developers of nursing curricular need similar understanding of these constructs, and how they manifest in the context of nursing practice. Nursing educationalists need to find mechanisms to teach, and coach to strengthen the attainment of professional identity.
The investigation of nursing handover as an example of a nursing group activity in relation to SIT revealed a series of intents, and demonstrated behaviour which are important, and central to the construction of nurses’ professional identities. The findings generated new knowledge about nursing practices for their group intent. The handover specifically revealed intent related to social unification, organisation of normative behaviours, reinforcement of team conformity, the volitional control of nursing work. In addition there were intents around reinforcing the salience of collective identity to the nursing group, and achieving a functional nested identity for the oncoming shift. The combination of the social, and physical context provided the stimuli that supported, and sustained professional self-categorisation. In practice the nurses’ demonstrated behaviours such as use of humour, development of group think, storytelling, discursive
emphases on the development of we, and team processes that created expectations of social conformity, and practical respect for the experienced members of the team. Research studies into each of the aspects of professional identity need to be undertaken. Policy, and
educationalists both need to use the understandings about these social practises to inform policy development, and educational strategy.
For example educationalists would not teach group handover as a forum primarily for clinical communication if they understood the powerful social processes of professional identity construction, and maintenance of this activity. Nor would policy makers consider bed side handover as an appropriate alternative to replace private nurse-nurse group professional interactions for the construction, and expression of nursing in practice.
The results from this study indirectly suggest that the construction, and performance of nursing identity in the workplace occurs after initial academic, and professional preparation. Further
150 | P a g e research in to this is needed. Research needs to be done into the construction of professional identity within the social setting of the work space. This study has identified the significance SIT can have in revealing identification significant elements that impact on the construction of nurses’ professional identity. Rituals in ethnography are considered important arenas for investigation. Many of the rituals embedded in nursing activity have not been investigated nor are they understood in relation to how they construct, and maintain nurses’ professional
identity. Without such investigation the termination of activities that are considered rituals may have long standing negative repercussions on the profession.
The interesting finding from the application of SIT that the structure of communication in nursing handover was strongly hierarchically, and socially organised, while in the MDM the same nurses would flatten the model of professional communication to deliberately share, and create voice for the other professionals. Nursing educationalists should take note of these skills, and social processes;, and they need to be taught as a communication technique for nursing intragroup, and also interprofessional activities. Policy makers, and nurses in practice need to notice these social processes more formally, and make them explicit. Further research into other nursing activities in relation to how communication is enacted as an expression of professional identity is needed. It may be that other important models of communication have not yet been uncovered.
As stated previously the goal of normalising the complexities of practice to manage the work is an important social process that happens in nurse-nurse private spaces. The finding that this normalisation process also attunes the skill of patient advocacy to ensure patient centeredness is a significant way of holding the focus of the work while encountering it in the context of the shift. This has implications for policy, practice, and education. The literature is devoid of commentary in relation to the interplay of normalising complexities to manage work, and the socially unreal aspects of patient care. Research is needed into these aspects of professional identity, and professional work.
This project opens up future opportunities to employ SIT in the study of different nursing groups. The scope of this research does not, however, need to be limited to nurses. With the current changes in healthcare environments, and the continuing development of new ways of working within healthcare, understandings in the social dynamic within context of professional nursing groups is possibly particularly contemporary. The focus on interprofessional practice, and the need for health workers to work in teams opens up future possibilities for the findings of this project to be extended.
151 | P a g e
References
Abrams, D., & Hogg, M. A. (2008). Group Processes & Intergroup Relations 10 years on:
Development, impact and future directions. Group Processes & Intergroup Relations, 11(4), 419-424.
ACSQHC, A. C. o. S. a. Q. i. H. C. (2010). OSSIE guide to clinical handover improvement. Sydney: Australian Commission on Safety and Quality in Health Care.
ACSQHC, A. C. o. S. a. Q. i. H. C. (2012). National safety and quality health service standards. Sydney: Australian Commission on Safety and Quality in Health Care.
AHPRA, A. H. P. R. B. (2012). National Regulatory Boards.
AIHW, A. I. o. H. a. W. (2008). Australia's health 2008 the eleventh biennial report of the Australian Institute of Health and Welfare Retrieved from
http://www.aihw.gov.au/publications/aus/ah08/ah08.pdf
AIHW, A. I. o. H. a. W. (2010). Nursing and midwifery labour force 2008 AIHW bulletin, (pp. 1 v.). Retrieved from http://www.aihw.gov.au/publications/index.cfm/title/12017
AIHW, A. I. o. H. a. W. (2012). Australia's health 2012 the thirteenth biennial health report of the Australian Institute of Health and Welfare (pp. xv, 625 p.). Retrieved from
http://www.aihw.gov.au/publication-detail/?id=10737422172
Andrew, N. (2012). Professional identity in nursing: Are we there yet? Nurse Education Today, 32(8), 846-849.
Apker, J., & Eggly, S. (2004). Communicating professional identity in medical socialization:
considering the ideological discourse of morning report. Qualitative Health Research, 14(3), 411-429. doi: 10.1177/1049732303260577
Apker, J., Ford, W. S., & Fox, D. H. (2003). Predicting nurses' organizational and professional identification: the effect of nursing roles, professional autonomy, and supportive communication. Nursing economic$, 21(5), 226-232, 207.
Apker, J., Propp, K. M., & Ford, W. S. (2009). Investigating the effect of nurse-team communication on nurse turnover: relationships among communication processes, identification, and intent to leave. Health Commun, 24(2), 106-114.
Apker, J., Propp, K. M., & Ford, W. S. Z. (2005). Negotiating Status and Identity Tensions in Healthcare Team Interactions: An Exploration of Nurse Role Dialectics. Journal of Applied Communication Research, 33(2), 93-115.
Aranda, K., & Law, K. (2007). Tales of sociology and the nursing curriculum: Revisiting the debates. Nurse Education Today, 27(6), 561-567.
Ashforth, B. E., & Mael, F. (1989). Social Identity Theory and the Organization. The Academy of Management review, 14(1), 20-39.
Atkinson, P. (2004). Performing Ethnography and the Ethnography of Performance. British Journal of Sociology of Education, 25(1), 107-114.
Atkinson, P. (2007). Handbook of ethnography (New ed.). London ; Thousand Oaks, Calif.: SAGE. Atkinson, P. (2008). Manual of Ethnography – Edited by Marcel Mauss. The Sociological Review,
152 | P a g e Atkinson, P., Coffey, A., & Delamont, S. (1999). Ethnography. Journal of Contemporary Ethnography,
28(5), 460-471. doi: 10.1177/089124199028005004
Atkinson, P., & Pugsley, L. (2005). Making sense of ethnography and medical education. Medical Education, 39(2), 228-234. doi: 10.1111/j.1365-2929.2004.02070.x
Baldwin, M. (2003). Patient advocacy: a concept analysis. Nursing standard, 17(21), 33-39.
Barratt, M., Choi, T. Y., & Li, M. (2011). Qualitative case studies in operations management: Trends, research outcomes, and future research implications. Journal of Operations Management, 29(4), 329-342. doi: 10.1016/j.jom.2010.06.002
Benner, P. E. (2001). From novice to expert : excellence and power in clinical nursing practice (Commemorative ed.). Upper Saddle River, N.J.: Prentice Hall.
Betts, C. E. (2006). Assuming practice amid the culture wars: a response to James P. Smith 28 years later. Journal of advanced nursing, 54(5), 633-634.
Bonner, A. T., Gerda. (2002). Insider-outsider perspectives of participant observation. Nurse researcher, 9(4), pp.7-19.
Boxer, M. M., Vinod, S. K., Shafiq, J., & Duggan, K. J. (2011). Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer, 117(22), 5112-5120.
Brewer, J. D. (1994). The ethnographic critique of ethnography: Sectarianism in the RUC. Sociology : the Journal of the British Sociological Association, 28(1), 231.
Burger, J. L., Parker, K., Cason, L., Hauck, S., Kaetzel, D., O'Nan, C., & White, A. (2010). Responses to work complexity: the novice to expert effect. Western journal of nursing research, 32(4), 497-510.
Cameron, C. (1996). Patient advocacy: a role for nurses. European journal of cancer care, 5(2), 81-89. Cameron, F., & Brownie, S. (2010). Enhancing resilience in registered aged care nurses. Australasian
journal on ageing, 29(2), 66-71.
Carper, B. (1978). Fundamental patterns of knowing in nursing. ANS Adv Nurs Sci, 1(1), 13-23. Cartwright, D., & Zander, A. (1968). Group dynamics : research and theory (3rd ed.). New York:
Harper & Row.
Chaboyer W, M. (2009). Bedside handover: quality improvement strategy to "transform care at the bedside". Journal of nursing care quality, 24(2), 136-142.
Chaboyer W, M., McMurray, A., & Wallis, M. (2008). Bedside handover and whiteboard communication. [Public report].
Chaboyer, W., McMurray, A., & Wallis, M. (2010). Bedside nursing handover: a case study. International journal of nursing practice, 16(1), 27-34.
Chang, E. D., J. (2008). Tranistions in Nursing (2nd ed.): Churchill Livingstone.
Chiesa, M., & Hobbs, S. (2008). Making sense of social research: how useful is the Hawthorne Effect? European Journal of Social Psychology, 38(1), 67-74. doi: 10.1002/ejsp.401
Chinery, W. (2007). Alleviating stress with humour: a literature review. The Journal of Perioperative Practice, 17(4), 172-179 passim.
Clarke, C. M., & Persaud, D. D. (2011). Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. Journal of patient safety, 7(1), 11-18.
153 | P a g e Clouder, D. L., Davies, B., Sams, M., & McFarland, L. (2011). “Understanding where you're coming
from”: Discovering an [inter]professional identity through becoming a peer facilitator. Journal of interprofessional care, 26(6), 459-464. doi: 10.3109/13561820.2012.706335 Clouder, L. (2003). Becoming professional: exploring the complexities of professional socialization in
health and social care. Learning in Health and Social Care, 2(4), 213-222. doi: 10.1046/j.1473-6861.2003.00052.x
Cioffi, J., & Ferguson, A. (2009). Team nursing in acute care settings: nurses' experiences. Contemporary Nurse : a Journal for the Australian Nursing Profession, 33(1), 2-12. Cook, R. (2011). Patient advocacy is still at nursing's core. Independent Nurse.
Corbin, J. (2008). Is caring a lost art in nursing? International Journal of Nursing Studies, 45(2), 163- 165.
Cribb, A. (2011). Integrity at work: managing routine moral stress in professional roles. Nursing philosophy, 12(2), 119-127.
Cunliffe, A. L. (2010). Retelling Tales of the Field. Organizational Research Methods, 13(2), 224-239. doi: 10.1177/1094428109340041
D'Antonio, P. (2006). History for a practice profession. Nurs Inq, 13(4), 242-248.
Daly, J., Speedy, S., & Jackson, D. (2004). Nursing leadership. Sydney: Churchill Livingstone. Deacon, M. (2013). The reality of teamwork in an acute mental health ward. Perspectives in
Psychiatric Care, 49(1), 50-57.
Deschamps, J., & Doise, W. . (1978). Crossed category membership in intergroup relations. . In H. Tajfel (Ed.), Differentiation between social groups (pp. 141-158). Cambridge: Cambridge University Press.
Devitt, B., Philip, J., & McLachlan, S. A. (2010). Team dynamics, decision making, and attitudes toward multidisciplinary cancer meetings: Health professionals' perspectives. Journal of oncology practice, 6(6).
Drew, D. (2011). Professional identity and the culture of community nursing. British journal of community nursing, 16(3), 126-131.
Duchscher, J. E. (2009). Transition shock: the initial stage of role adaptation for newly graduated registered nurses. J Adv Nurs, 65(5), 1103-1113.
Duffield, C. M. (1986). Nursing in Australia comes of age! International Journal of Nursing Studies, 23(4), 281-284.
Edgar, A., & Pattison, S. (2011). Integrity and the moral complexity of professional practice. Nursing philosophy, 12(2), 106.
Emeghebo, L. (2012). The image of nursing as perceived by nurses. Nurse Education Today, 32(6), 49- 53.
Emerson, R. M. (1987). Four Ways to Improve the Craft of Fieldwork. Journal of Contemporary Ethnography, 16, 69.
Emerson, R. M. (2004). Introduction. Annals of the American Academy of Political and Social Science, 595(ArticleType: misc / Issue Title: Being Here and Being There: Fieldwork Encounters and Ethnographic Discoveries / Full publication date: Sep., 2004 / Copyright © 2004 American Academy of Political and Social Science), 8-13.
Emerson, R. M. (2009). Ethnography, interaction and ordinary trouble. Ethnography, 10(4), 535-548. doi: 10.1177/1466138109346996
154 | P a g e Emerson, R. M., & Shaw, L. L. (1984). New Ethnographies. Journal of Contemporary Ethnography,
13(1), 103-108. doi: 10.1177/0098303984013001007
Emmerson, R., Fretz, R., & Shaw, R. (2011). Writing Ethnographic fieldnotes.
Evans, A. M. (2008). Discourses of anxiety in nursing practice: a psychoanalytic case study of the change-of-shift handover ritual. Nursing Inquiry, 15(1), 40-48.
Evans, A. M., Pereira, D. A., & Parker, J. M. (2008). Discourses of anxiety in nursing practice: a psychoanalytic case study of the change-of-shift handover ritual. Nursing Inquiry, 15(1), 40- 48. doi: 10.1111/j.1440-1800.2008.00387.x
Fagermoen, M. S. (1997). Professional identity: values embedded in meaningful nursing practice. Journal of advanced nursing, 25(3), 434-441.
Fairbrother, G., Jones, A., & Rivas, K. (2010). Changing model of nursing care from individual patient allocation to team nursing in the acute inpatient environment. Contemporary Nurse : a Journal for the Australian Nursing Profession, 35(2), 202-220.
Fairchild, R. M. (2010). Practical ethical theory for nurses responding to complexity in care. Nursing Ethics, 17(3), 353-362.
Fairman, J., & D'Antonio, P. (2008). Reimagining nursing's place in the history of clinical practice. J Hist Med Allied Sci, 63(4), 435-446.
Farrell, C., James, N., & Kirkbride, P. (2012). Are multidisciplinary meetings good value or poor use of time? Cancer nursing practice, 11(2).
Fetterman, D. M. (2010). Ethnography : step-by-step (3rd ed.). Los Angeles: SAGE. Fights, S. (2007). I'm just a nurse. Med-Surg Matters, 16(3), Jun.
Fitzgerald, M., Pearson, A., Walsh, K., Long, L., & Heinrich, N. (2003). Patterns of nursing: a review of nursing in a large metropolitan hospital. Journal of Clinical Nursing, 12(3), 326-332. doi: 10.1046/j.1365-2702.2003.00782.x
Flatley, M., & Bridges, J. (2008). Promoting the art of caring for older people. International Journal of Nursing Studies, 45(3), 333-334.
Fraser, K. (2011). Team work at the heart of perioperative nursing. Kai tiaki, 17(7), 2. Freidson, E. (2001). Professionalism : the third logic. Chicago: University of Chicago Press. Gamlen, C. (2012). Managing Organizational Complexity. Measuring Return on Investment in
Complex Healthcare Systems. Journal of Nursing Administration, 353-Aug. Geertz, C. (1973). The interpretation of cultures : selected essays. New York: Basic Books. Giddens, A. (2010). Sociology, sixth edition. Cambridge: Polity.
Goar, C. (2007). Social Identity Therot and the reducation of inequality: Can cross-cutting categorization reduce inequaltiy in mixed-race groups? Social Behavior and Personality, 35(4).
Gobo, G. (2008). Doing ethnography. Los Angeles, Calif. ; London: SAGE.
Golafshani, A. (2003). Understanding Reliability and Validity in Qualitative Research. The Qualitative report, 8(4), 597-607.
Gordon, S. (2005). An end to angels. American journal of nursing, 105(5), 62-69.
155 | P a g e Grealish, L., & Trevitt, C. (2005). Developing a professional identity: student nurses in the workplace.
[Research Support, Non-U.S. Gov't]. Contemporary Nurse, 19(1-2), 137-150. Greenwood, E. (1957). Attributes of a Profession. Social Work, 2(3), 45-55.
Grice Robinson, S. (2013). The unique work of nursing. Nursing, 43(3), 42-43.
Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park, Calif.: Sage Publications.
Haigh, C., & Hardy, P. (2011). Tell me a story--a conceptual exploration of storytelling in healthcare education. Nurse Education Today, 31(4), 408-411.
Haslam, S. A. (2003). Social identity at work developing theory for organizational practice. New York: Psychology Press.
Haslam, S. A. (2004). Psychology in organizations : the social identity approach (2nd ed.). London ; Thousand oaks, CA: Sage Publications.
Haslam, S. A., Reicher, S. D., & Reynolds, K. J. (2012). Identity, influence, and change: rediscovering John Turner's vision for social psychology. British Journal of Social Psychology, 51(2), 201- 218.
Healy, P. (2004). Speak up for nursing. Nursing standard, 18(33), 14-16.
Helman, C. (2000). Culture, health and illness (4th ed.). Oxford: Butterworth-Heinemann.
Hogg, M. A., & Abrams, D. (2001). Intergroup relations : essential readings. Philadelphia, Pa. ; Hove: Psychology Press.
Hogg, M. A., Abrams, D., & Marques, J. (2005). The social psychology of inclusion and exclusion. Hove, U.K.: Psychology Press.
Hogg, M. A., & Knippenberg, D. v. (2003). Leadership and power identity processes in groups and organizations. London: SAGE.
Hogg, M. A., & Reid, S. A. (2006). Social identity, self-categorization, and the communication of group norms. Communication Theory, 16(1), 7-30.
Hogg, M. A., & Terry, D. J. (1998). Attitudes, behavior, and social context the role of norms and group membership. Mahwah, N.J.: L. Erlbaum Associates.
Hogg, M. A., & Terry, D. J. (2000). Social Identity and Self-Categorization processes in organizational contexts. Academy of Management Review, 25(1), 121-140.
Hogg, M. A., & Terry, D. J. (2001). Social identity processes in organizational contexts. Philadelphia, Pa. ; Hove: Psychology Press.
Hopkinson, J. (2002). The hidden benefit: the supportive function of the nursing handover for qualified nurses caring for dying people in hospital. Journal of Clinical Nursing, 11(2), 168- 175.
Horton, K., Tschudin, V., & Forget, A. (2007). The value of nursing: a literature review. [Review]. Nursing Ethics, 14(6), 716-740. doi: 10.1177/0969733007082112
Hughes, R. G., & Clancy, C. M. (2009). Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses. Journal of nursing care quality, 24(3), 180-183. Hutchinson, S. A. (1990). Responsible subversion: a study of rule-bending among nurses. [Journal
Article
156 | P a g e Ickes, W., & Knowles, E. S. (1982). Personality, Roles and Social Behavior ed by W.Ickes &
E.S.Knowles. New York: Springer.
ICN, I. C. o. N. (2010). International Council of Nurses Conseil international des infirmieres = Consejo internacional de enfermeras (pp. 1 CD-ROM). Retrieved from http://www.icn.ch
Johnson, J. A. (2012). Storytelling...A tool for education, leadership, and team building. Journal for nurses in staff development, 28(5), 255-Oct.
Kalisch, B. J. (1982). Improving the image of nursing. American journal of nursing, 83(1), 48-52. Kane, B. (2007). Multidisciplinary team meetings and their impact on workflow in radiology and
pathology departments. BMC Medicine, 5 (2007), 15-15.
Katrinli, A., Atabay, G., Gunay, G., & Guneri, B. (2009). Exploring the antecedents of organizational identification: the role of job dimensions, individual characteristics and job involvement.