Maintaining equilibrium in professional role identity: a grounded theory study of health visitors’ perceptions of their changing professional practice context

Authors

  • Alison I. Machin,

    1. Alison I. Machin MSc PhD RN Principal Lecturer School of Health Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
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  • Tony Machin,

    1. Tony Machin MSc PGCE RN Principal Lecturer School of Health Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
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  • Pauline Pearson

    1. Pauline Pearson BA PhD RN Professor of Nursing School of Health Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
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A.I. Machin:
e-mail: alison.machin@northumbria.ac.uk

Abstract

machin a.i., machin t. & pearson p. (2012) Maintaining equilibrium in professional role identity: a grounded theory study of health visitors’ perceptions of their changing professional practice context. Journal of Advanced Nursing68(7), 1526–1537.

Abstract

Aims.  This article reports the study of a group of United Kingdom health visitors’ interactions with their changing practice context, focusing on role identity and influences on its stability.

Background.  United Kingdom policies have urged health visitors to refocus their role as key public health nurses. Reduced role identity clarity precipitated the emergence of different models of health visiting public health work. An inconsistent role standard can lead to role identity fragmentation and conflict across a group. It may precipitate individual role crisis, affecting optimum role performance.

Methods.  Seventeen health visitors in two United Kingdom community healthcare organizations participated in a grounded theory study, incorporating constant comparative analysis. Direct observations and individual interviews were undertaken between 2002 and 2008.

Results/findings.  Four interlinked categories emerged: professional role identity (core category); professional role in action; interprofessional working; and local micro-systems for practice; each influencing participants’ sense of identity and self-worth. The Role Identity Equilibrium Process explains interactive processes occurring at different levels of participants’ practice.

Conclusion.  Re-establishing equilibrium and consistency in health visiting identity is a priority. This study’s findings have significance for other nurses and health professionals working in complex systems, affected by role change and challenges to role identity.

What is already known about this topic

  •  There is lack of agreement on the core nature of health visiting and its unique public health contribution within global healthcare systems.
  •  Little is known about the nature of health visiting identity as distinct from nursing identity.
  •  Lack of collective identity within a professional group can lead to role fragmentation and confusion in conveying consistent public identity.

What this paper adds

  •  The impact of role change on individual health visitors’ identity is influenced by perceived level of involvement in the change and its fit with existing identity.
  •  Feedback from peer and interprofessional interactions in their professional practice context influences the professional role identity equilibrium of individual health visitors.
  •  Individual health visitors have differing perceptions of congruence of public health work and nursing with role identity.

Implications for practice and/or policy

  •  The relationship of health visiting to nursing and public health should be reviewed and clarified to reaffirm the identity of individual practitioners in interprofessional working contexts.
  •  Peers within professions should engage in regular group interactions to foster the maintenance of equilibrium in collective professional role identity. These interactions can be facilitated face-to face, or utilizing the range of contemporary on line and remote communication media available.
  •  The Role Identity Equilibrium Model should be further tested and refined through research with other professional roles in different national and international contexts.

Introduction

Global healthcare systems are characterized by: persistent health inequalities; an international health economy under pressure; and complex inter-relationships between countries, organizations and professionals. In response, existing healthcare roles are evolving and new roles emerging which can lead to blurred practice boundaries and unclear responsibilities. To remain fit for purpose, professionals must adapt, however, working differently can challenge established role identity.

Conflicting views exist on the core nature of a public health-related, health visiting role identity (Smith 2004). Imbalance between role legitimacy, adequacy and support may impact negatively upon role performance (Machin & Stevenson 1997) leading to possible identity confusion. Left unresolved this may result in individual psychological crisis (Caplan 1961).

This article details a grounded theory study (Glaser & Strauss 1967) of health visitors’ interaction within their changing professional context. The study was conceptualized when health visitors were being urged by policy change to undertake more family orientated public health work (Home Office 1998). In local contexts some health visitors perceived existing roles to be entirely public health, perceiving no need for change and felt devalued. Others suggested public health would represent additional time burdens, negatively affecting existing service provision. It was envisaged that this research study would clarify factors influencing the health visitors’ perceptions, informing strategies to address apparent differences.

Background

United Kingdom (UK) health visitors are Registered Nurses with additional specialist education (Nurses Midwives and Health Visitors Act 1997) to work in preventative contexts with individuals, families and communities. The role shares similarities with the public health nurse or family nurse role common in other European countries and America. The nursing role in preventative family health care, working alongside community and other health professionals, is integral to World Health Organisation (WHO) strategy for improving child and family health towards achievement of health-related millennium development goals (WHO 2011). In the UK, shared health visiting identity is, theoretically, facilitated by four practice principles (CETHV 1977). However, there has been little policy consensus in applying public health concepts within health visiting roles (SNMAC 1996, Home Office 1998). Research suggests confusion continues with the emergence of different models of public health work in health visiting (Pearson et al. 2000, Carr et al. 2003, Carr 2005). A title change from Health Visitor to Specialist Community Public Health Nurse (SCPHN) [Nursing and Midwifery Council (NMC) 2004a], caused further disagreement within the profession (Cowley 2007) exacerbating this confused identity picture.

Being prerequisite for health visiting, nursing will influence practitioners’ identity. Fagermoen (1997, p. 436) determined two groupings of nursing identity values, ‘self orientated’ and ‘other orientated’. Autonomy, a key professional attribute (Macdonald 1995), was not identified as a self orientated value, despite their interviewees being senior nurses. Ohlen and Segesten (1998) studied the effect of role change on nursing identity. One nurse suggested her identity was stable and meant ‘feeling’ like a nurse, not just working as a nurse (p. 723). They concluded self-image and self-esteem are core to personal identity, the latter being the foundation for professional identity and role function.

Identity is self verifying through social interaction and dialogue (Burke 1980, Rapport & Wainright 2006). Shared role understandings facilitate role recognition. However, individuals may debate the relative value of each role aspect. Where roles are practiced inconsistently, role identity may fragment within a group (Collier 2001). Castells (1997, p. 8) suggested three types of political identity construction: ‘legitimizing’, engendering to order, predictability and perpetuation of the social structures from which it is generated; ‘resistance’, actively resisting dominant oppressive forces in society; and ‘project’, the deliberate, transformational building of identity (Godin 1996).

A common stable identity can be a vehicle for advancing practice (McDonald 2004). However, instability in healthcare systems may create ‘identity uncertainty’ (Williams & Sibbald 1999). Left unmanaged, identity confusion may leave individuals feeling disempowered (McDonald 2004), negatively affecting service provision. Health visiting has been described as a profession in crisis (Craig & Adams 2007), and processes influencing health visitors’ experiences in professional contexts are not well understood.

The study

Aim

The aim was to generate theory explaining processes by which health visitors interpreted and interacted with policy driven changes to professional practice contexts. Two research questions guided the study:

  •  How are health visitors interacting with their changing professional practice context?
  •  How have the changes influenced them and their practice?

Design

Grounded theory methodology (Glaser & Strauss 1967) is rooted in interpretivism (Hughes 1990) and a symbolic interactionist (Blumer 1969) perspective which suggests reality exists in meanings individual social actors derive from interpreted interactions. Study design was also influenced by negotiated order theory, acknowledging influences of organizational systems (Strauss 1978). A process of constant comparative analysis was undertaken, with theoretical sampling, data collection and analysis occurring concurrently during the research process (Strauss & Corbin 1990), generating theory from the data.

Sample/participants

Theoretical sampling, using a sampling matrix (Reed et al. 1997) guided selection of participants based upon relevance to the study and emerging theory. The matrix was constructed from responses to postal questionnaires sent to potential participants (N = 160) from two UK community healthcare organizations. Both were promoting the public health role of health visitors and changes to service delivery. It was anticipated participants would therefore have experience of changing professional practice contexts. Inclusion criteria for follow-up required registration as a health visitor and anticipated relevance to theoretical issues emerging from data analysis. For example, on the matrix, participant 1 suggested their work was 100% public health therefore potentially able to give rich data. Subsequent participants were selected from the matrix, seeking maximum data variation. As analysis progressed, sampling became increasingly theoretical with ‘far out’ examples chosen to challenge the emerging theory (Strauss & Corbin 1990). Following procedures for informed consent, 17 participants were selected from the matrix over the course of the study, 15 women and 2 men. The number of years since initial preparation for health visiting role varied from 2 months to 20 years. Thirteen participants held caseloads, two held specialist health visiting roles and two specialist nursing roles.

Data collection

Data were collected between 2002 and 2008, the constant comparative analysis (Glaser & Strauss 1967) extending the time spent in collecting data. Ten direct observations of participants in their usual work context were undertaken. Condensed field notes taken during observations noted factors relevant to the research question and aims. These notes were expanded afterwards (Spradley 1980, p. 69), depicting a more detailed picture of participants’ practice context. Observation data mainly informed development of a data category labelled ‘professional role in action’. After ten observations no new data emerged to augment the category concepts, therefore observations ceased. Data collection subsequently focused on interviews where the meanings participants attached to their practice could be established. Twenty individual, tape recorded interviews were undertaken, 17 initial interviews and 3 follow-up interviews, the latter used to further explore and check emerging theory. Semi-structured interviews allowed new areas of discussion to emerge whilst ensuring the interview remained relevant to the research question (Bowling 2002). A guide of six broad topics, developed from preceding and ongoing analysis, was used to frame theoretical relevance of discussion. Topics included: meanings participants afforded the term public health and how that was incorporated into practice; perceptions of preparation for the public health role and its efficacy; what they understood health visiting role to entail and its relation to previous nursing role; opinions about policy and professional changes; what their current role was; and key factors influencing feelings about their work.

Literature searching continued throughout the research, providing additional contextual data (Clarke 2005) and facilitating ongoing theoretical sensitivity, a key feature of grounded theory methodology, referring to the reflexive, interpretative relationship the researcher has with existing knowledge and theory (Glaser 1978, Strauss & Corbin 1990). Whilst this enhanced the constant comparative process, the insider position of the researcher and reflexive relationship with the research was also acknowledged (Reed & Procter 1995).

Ethical considerations

The Research Ethics Committee with ethical governance responsibility for healthcare research in the region gave permission for study, as did research and development departments in both participating organizations. Information was provided, and consent secured from participants. Confidentiality in reporting was assured, together with rights to refuse or withdraw at any time. Given the nature of public health work, other professionals and service users who were not participants were present in observation settings. They were afforded the same reassurance as participants. The NMC professional code of conduct (Nursing and Midwifery Council 2008) augmented governance.

Data analysis

Data with shared characteristics were categorized and examined for ‘fit’ with the emerging grounded theory using a range of analytical processes (Strauss & Corbin 1990). Observation field notes and interviews were transcribed verbatim and analysed line by line using ‘open’ or ‘substantive’ coding techniques. This informed selection of subsequent study participants and reflexive evolution of the interview guide. As categories consolidated, axial and variational analysis sought data which broadened properties and dimensional ranges of categories. In the final stages of constant comparative analysis, selective, theoretical, coding tested ideas and explored ‘far out’ examples, challenging or confirming proposed theory.

Rigour

Within an interpretative methodology, the canons by which quantitative studies are judged are irrelevant without adaptation (Strauss & Corbin 1990). The quantitative research term ‘validity’ is rarely used in grounded theory research, although the concept is integral to the rigour of any study. Criteria for judging grounded theory studies (Strauss & Corbin 1990) were used throughout the constant, comparative process, checking emergent theory against data and literature, for ‘accuracy’ or ‘fit’ with participants’ perceived reality (Smith & Biley 1997). Supported by processes of supervision and peer review including co-authors, the final categories and theory were affirmed as accurate reflections of data collected. Some re-interviews were undertaken, providing opportunities to recheck accuracy of interpreted data in reflecting participants’ meanings. A reflective diary enabled the researcher to note issues which may have affected research processes and data interpretation (Machin 2009).

Results

Theory developed from this study proposes that health visitor participants’ professional role identity is influenced, through a self-referent feedback process, by: other health visitors; interprofessional colleagues; and local and national policies. Through processes of ‘maintaining identity equilibrium’ (Figure 1), participants interact and interpret this feedback to establish stability and value in professional role identity. Four data categories were identified within the developed theory. The category Professional Role in Action is presented first. This captures the work of individual health visitors, forming a basis for understanding their role perceptions. The core category of Professional Role Identity is then presented, depicting meanings participants attached to their Professional Role in Action, providing foundation for the theory generated. It also reflects effects of other people and systems upon identity. This is elaborated in subsequent presentation of the remaining two categories, Interprofessional Working and Local Micro-Systems for Practice. Categories comprised a number of properties and sub properties (Table 1), each with a dimensional range (Strauss & Corbin 1990). It is not possible within the present scope to undertake detailed discussion of interrelationships between all concepts, discussion reflects only the essence of each main category, supported by data. How categories relate to the Role Identity Equilibrium Process (RIEP) (Figure 1) developed from the findings, is also identified. Participants have been coded with P and a number depicting order of selection.

Figure 1.

 Role identity equilibrium process.

Table 1. Table of categories.
Categories
Professional role identity (Core category)Professional role in actionInterprofessional workingLocal micro-systems for practice
Properties and sub properties
The essence of health visitingContext of health visiting practiceWorking with other nursesPractice maintenance systems
 Home visiting Clinic Role differentiation Specialist health visiting
 Challenging traditional practice Home Influence of manager’s background GP attachment
 Professional autonomy Drop in Working collaboratively Corporate caseload
 Influence of policy driven role change Community Role interchangeability 
  Group  
The meaning and significance of public health workCollaborationWorking with medical professionalsResource management approach
 Policy awareness Role overlap Influence of public health targets Available staff resource
 Comfort with public health role Working with others Relative autonomy Organizational priorities
 Health inequalitiesKnowledge for health visiting practice Professional hierarchy Workload equity
 Public health role in practice Nursing Lack of role awareness Management support
 Commitment to public health Social Protocols for practice
 Role adequacy Medical  Post natal depression
    Smoking cessation
    Child development surveillance
Nursing as a foundation for health visiting identityHealth visiting clientsThe interagency dimensionSystem overlap
 Adequacy of education for role Age Collaborative confidence Influence of infrastructure
 Significance of nursing knowledge Sex Managing complexity Influence of policy change
 Professional credibility Individuals Role awareness Effectiveness of information sharing systems
  Groups Conflicting values 
  Populations Power and control 
Significance of pre-defined roleFramework for practice: health visiting principlesWorking with nursery nursesPractice development approach
 Influence of stereotypes Assessing health needs Nursery nurse skills Project driven change
 Identity portability Influencing policy affecting health Professional responsibility Resource driven change
  Facilitating health enhancing activities  
  Raising awareness of health needs  

Professional role in action

Three principles of health visiting (CETHV 1977) were evident throughout participants’ professional role in action through: assessing health needs of individuals, families and populations; raising awareness of needs in home and clinic settings, through campaigns and multi agency working; and facilitating health enhancing activities. Several participants belonged to cross agency groups tackling, for example, child accident prevention, acting as liaison between services, providing a health visiting perspective. However, participants’ work influencing policy was difficult to identify except when employed in strategic leadership positions, supporting earlier research findings (Carr et al. 2003).

Participants mainly worked with individuals in home or clinical settings, assessing need and establishing relationships. However, one participant employed group approaches to smoking cessation, viewing this as an effective context for the work. Other group activities identified, such as postnatal support, aimed to facilitate social support networks. Work focused mainly, although not exclusively, on families with preschool children, reflecting policy emphasis [Department of Health (DoH) 2011]. Other work included: adults’ exercise class; healthy lifestyle work in schools; visiting older people and cardiac rehabilitation. Work with older people was less prioritized, supporting earlier research (Davidson & Machin 2003) suggesting work with older people was perceived as a ‘luxury’. Work with groups other than preschool children sometimes overlapped with other nurses:

In terms of doing health assessments ….we share that equally.. the practice nurses, see the elderly who are able to walk to the surgery, district nurses would see the ones at home that they are nursing.. I see the others (P8).

However, ‘role interchangeability’ between nurses and health visitors may precipitate blurred role boundaries, and confusion in interprofessional working (Cowley 2007, Harmer 2010) potentially affecting identity equilibrium of those involved as they seek to establish value within teams.

Knowledge underpinning practice also overlapped: within nursing and medical knowledge domains, around prescribing, smoking, obesity and hypertension; and in social domains with nursery nurses and social workers around family support and safeguarding children. This perceived variation in role may reflect role autonomy, the increasing range of healthcare contexts where health visitors practice, and influences of others in the interprofessional team. Within the individual identity dimension of the Role Identity Equilibrium Process (RIEP) (Figure 1), practitioners interpret interactions in practice seeking affirmation and stabilization of role identity through self-referent, verifying feedback (Collier 2001, Foley 2005). This process echoes processes of ‘double loop’ reflection in and on practice (Argyris & Schön 1996). Interactions over time in their professional practice setting influences identity (Blumer 1969) and the degree of perceived identity equilibrium experienced (Figure 1).

Professional role identity (core category)

Interactions with other health visitors influenced the equilibrium of the professional role identity of individuals within it (Figure 1). Several areas of consensus in data suggested a unifying, stabilizing, collective professional role identity. For example, home visiting for relationship building, an established core feature of health visiting (De La Cuesta 1994, Cowley & Frost 2006), was highly valued, with recent attempts to reduce it provoking a collective defensive response:

…… the home visiting part of health visiting was rubbished ….it wasn’t valued…the health visitors challenged it (P4).

There was also evidence of a collective resistant identity (Castells 1997), exercised through much valued autonomy, although this might be perceived as change resistance.

Reports come out like Hall 4 but some health visitors are ignoring it and doing what they’ve always done anyway (P3).

Autonomy, a core aspect of health visitors’ identity and a self orientated value, suggests differences from nursing identity as described by Fagermoen (1997).

Participants agreed on the importance of universal service provision. UK policy (DoH 2009, 2010) suggests moving towards ‘proportionate’, ‘progressive’ universalism to efficiently address health inequalities, minimum service to all, with resource reallocation on the basis of need.

However, one participant working in an area categorized as ‘affluent’, felt devalued by this and by interactions with health visitor peers suggesting that not all health visitors had the same perspective:

…I think that people [other health visitors] think that round here people don’t need health visitors! (P9).

Disagreement was evident on the meaning of a public health role and the impact of attempts to alter existing practice. Suggestions that public health was new to health visiting invoked an emotive example:

Health visitors are ‘up to here!’ at the moment, they’re sick of being told they should be doing public health when they always have been?(P2).

Implicit here is an assumption that all health visitors felt the same. However for others, public health work was additional, less prioritized than child/family caseload work:

I feel as if I’m not even doing my routine health visiting work… preventative health of families it’s very much going back seat (P8).

The child health screening function of role also engendered different responses:

[Universal developmental screening is] totally pointless… a total waste of time (P3).

Conversely:

[Developmental assessment is] bread and butter health visiting (P8).

Ambiguity around legitimacy of different role aspects (Machin & Stevenson 1997) was challenging the role identity of one participant who was considering leaving service because of the lack of support from peers:

There’s a lot of.. friction between different colleagues em, with the ones that are doing public health work and the ones that say they haven’t time to….(P4).

There was disagreement about the relationship of nursing to health visiting. Several participants felt their nursing qualification enhanced professional credibility and public identity. One participant appeared to wrestle with notions of having moved on from nursing, yet wanting to maintain role credibility:

I always say I’m a nurse and I’m not….(P4).

Another participant valued nursing identity as pre requisite for health visiting, reflected in disapproval of direct entry to education for health visiting role:

I don’t even think a newly qualified nurse could come into health visiting, you need so much experience and expertise.. to deal with the families in those situations (P16).

For another participant, the professional register change of health visitor title in favour of ‘specialist community public health nurse’ (NMC 2004a) undermined the distinctiveness of the role:

NMC, UKCC and the government who is the lead on this, have sent out a profound message to health visiting about how they’re valued ….. I think we were sold down the river (P15).

Tension in debate relating nursing to health visiting identity is captured by the following quote:

I think there’s a kind of a tension with this because [health visitors are] kind of proud to be nurses but don’t necessarily want to be grouped as nurses, they want to be grouped as health visitors (P17).

In the collective identity dimension of the RIEP (Figure 1) individuals interact with the peer group assumed to share collective role identity, which should ideally give an identity referent point for individuals. However, this study suggests collective identity cannot be assumed. Disagreement between peers evidently causes discomfort and disequilibrium, leading to identity displacement for some.

Interprofessional working

In practice environments, other professionals also influenced participants’ role identity, for example doctors. Historically, medicine entails more power than nursing in health systems (Freidson 1970), often perpetuated from within nursing (Roberts 2000) through social interaction (Riley & Burke 1995), a sign perhaps of legitimizing identity (Castells 1997):

I decide what’s the priority ….unless the GP asks me to see somebody... (P7).

There was indication this power balance might be changing:

At one time people would say ‘yes doctor no doctor’ but I think now people will say...why have I got to do that? What difference will it make? (P3)

The interprofessional nature of public health work was identified by one participant, although she questioned the adequacy of preparation for the role:

How can we [health visitors] expect to be working with other people in a public health…. if we haven’t got the skills ourselves.. other agencies aren’t going to respect our input (P3).

This reflects other findings (Pearson et al. 2000) questioning whether cross agency public health is viewed as core to health visiting role identity for which new entrants are prepared.

One participant suggested health visitors increasingly needed to defend their practice in interprofessional contexts, linking to earlier discussion on role interchangeability:

I think the spirit of health visiting has been lost ………… they’re [other professionals] trying to take over our roles well (P16).

Interprofessional team influence on participants’ professional role identity is reflected within the interprofessional, public identity dimension of the RIEP (Figure 1). One participant identified the role of health visitors in interprofessional working as providing a health visiting perspective. However, identified ‘role interchangeability’, knowledge overlaps and deficient role standards (Burke 1980), can make it difficult to articulate the unique nature and value of health visiting/This may have caused identity disequilibrium for practitioners (Hall 2003) through conflict arising from misunderstanding of expectations within interprofessional contexts.

Local micro-systems for practice

Most participants worked in practice maintenance systems within doctor-led teams, perceiving this as effective. Some participants were negative about work in increasingly common, corporate caseload systems, which fits with other research findings (Craig & Adams 2007):

I feel that I’m struggling to maintain continuity of a kind and I’m struggling to maintain effective communication…..the organisation takes a massive amount of time ….. I’m really, really stressed about it?(P11).

In discussing resource management and workload allocation systems, health visitors were clearly feeling effects of national shortage of health visitors (Craig & Adams 2007),

Where there are staffing problems …you are on your knees before you get help (P8).

They also felt devalued by the financial remuneration category in which they were placed during human resource reclassification (DoH 2004). Significantly, public health work was perceived as being de-prioritized by local redeployment of community development health visitors into caseloads.

Participants who had changed organizational roles still indicated a strong sense of ‘feeling’ like health visitors, linked to public health. For example:

I do feel as a health visitor ……..though my job title is officially specialist nurse, I always put/health visitor at the end of any communication because em, my role is public health (P16).

This suggests a degree of ‘identity portability’ within systems. However, data indicated variation in what ‘being a health visitor’ actually meant to individuals, influenced by interaction within individual changing professional practice contexts.

The public identity (structural) level of the RIEP (Figure 1) depicts processes by which variations in local practice systems such as human resource priorities, practice maintenance and local policies affect identity of individuals and others in the system. Unpredictable organizational health visiting role standards in local settings and different levels of management support influenced the professional identity of individuals through interaction and feedback. This could occur directly or indirectly. Similarly the public identity (structural and cultural) (Figure 1) illustrates how macro level policies can directly affect the identity equilibrium of individuals, for example the health visiting role title change, or indirectly through policy driven organizational change and interaction with others in change management positions in the healthcare system.

Discussion

Limitations of the study

Barbour (2000) suggests ‘theoretical generalizability’ in qualitative research derives from production of new models or ‘typologies’, such as the proposed explanatory model presented herein (Barbour 2000, p. 158) which is likely to resonate with UK health visitors sharing some history and policy context (Williams 2000). The theory generated is also relevant to other professions in the UK and internationally, experiencing similar contextual role changes and challenges. The theory developed here involves several general concepts, such as identity, role and profession, providing propositions about relationships between them. The model generated therefore represents ‘practical wisdom’ (Macnaughton 1998), providing others with insights to ‘control’ their situation (Glaser & Strauss 1967) through improved understanding.

Discussion of the findings

The grounded theory generated here is reflected in the Role Identity Equilibrium Process (Figure 1) introduced and developed alongside the findings in the previous section. It proposes health visitor participants’ professional role identity is influenced by the interpretation of feedback from social interaction in professional practice contexts. Processes of ‘maintaining identity equilibrium’ enable individuals to interpret different contextual influences relating to existing professional role identity and respond to identity threats, reaffirming value and self worth. This section develops the discussion, considering the wider relevance of findings to individual, collective and public identity.

Individual and collective identity

Findings illustrate the lack of consensus around public health role identity of UK health visitors (Pearson et al. 2000, Carr et al. 2003, Smith 2004, Cowley & Frost 2006). They also reflect diversity and apparent lack of clarity in public health nursing work in other international contexts (Philibin et al. 2010, Valaitis et al. 2011). For some participants public health work meant smoking cessation, immunizations and hypertension screening, underpinned by medical and nursing knowledge, overlapping with other nurses. For others it involved collaboration with social and voluntary sectors around homelessness and domestic abuse, preventing social isolation and working with communities, work more located in social domains, less overlapped with other nurses. The broad set of health visiting principles (CETHV 1977) supports variation in the way individuals autonomously operationalize roles. Identity is self verifying through social interaction and dialogue (Burke 1980, Rapport & Wainright 2006), reflected here in the RIEP. Shared role understandings facilitate role recognition. Inconsistency in role in action potentially contributed to apparent identity fragmentation within this study group, especially relating to public health work (Collier 2001).

Some participants experienced identity disequilibrium as public health role expectations and priorities changed. The psychological impact of these changes on individuals related to the fit with existing identity (Caplan 1961).Those considering health visiting to be intrinsically a public health role (SNMAC 1996) appeared more comfortable with reframed public health role expectations than others, whilst resenting the implication that is was a new area of practice. Those who felt ill prepared for what they perceived to be public health work or questioned the legitimacy of it, experienced greater challenges to identity equilibrium, potentially affecting optimum role performance (Machin & Stevenson 1997).

There were perceived differences in the importance of a nursing identity (Fagermoen 1997) as foundational. To maintain role identity equilibrium, it might be that those identifying more with nursing identity may be more likely to legitimize public health work linked to disease prevention. Others feeling less like a nurse might be more likely to legitimize work directed at tackling social determinants of ill health. However, with fifty per cent of role preparation carried out by health visitor community practice teachers (NMC 2004b), there is a risk that pervading role identity confusion may affect entrants to the profession, perpetuating fragmentation of a collective health visiting identity.

The suggestion from one participant that the ‘spirit’ of health visiting is lost perhaps reflects perceived demise of collective identity, leaving individuals feeling vulnerable. Efforts to collectively move health visiting forwards may be thwarted without stable role standards and sensitive approaches to change facilitation, valuing identity of individual practitioners (McDonald 2004, Higgs & Rowland 2005). Through the encouragement of personal reflection and interaction with peer identity referent groups (Burke 1980, Rapport & Wainright 2006), there are opportunities to restore equilibrium in individuals’ role identity, provided there is general agreement on the core nature of the role and a sense of collective identity.

Public identity

Having a well developed sense of professional role identity is a prerequisite for successful interprofessional working (Hind et al. 2003). This is reflected in the interprofessional, public identity level of the RIEP (Figure 1). Identity research suggests that the execution of roles differently in a professional group can engender confusion in conveying consistent public identity (Burke 1980, Collier 2001, Foley 2005), which is important for service users accessing health services. Role title is an important feature of public identity (Strauss 1959, 1997). The change of health visiting title (NMC 2004a) to specialist community public health nurse may have caused public identity confusion which may also arise where different practitioners with the same title demonstrate inconsistent roles (Collier 2001) in the local setting. Resulting interprofessional conflict may negatively affect the individual’s identity equilibrium and future interactions in local settings. The emergence of inter-professional learning in pre registration professional education represents a means of minimizing development of negative attitudes and inaccurate role perceptions (DoH 2001). This is likely to be less effective where there are conflicts around collective professional identities within a professional peer group. Uncovering collective uniqueness in health visiting is challenging. Perhaps its distinguishing feature is not specificity of knowledge, but a broad cluster of capabilities (Hurley et al. (2008), utilized contemporaneously in home visiting contexts meeting complex family needs.

The RIEP (Figure 1) places individual interaction of practitioners in the context of national policy and professional discourse. Participants evidently interacted via negotiations within structural systems impacting on self worth and identity, affirming the core premise of Negotiated Order Theory (Strauss 1978). Despite most participants having very similar job descriptions and role titles, they enacted roles in different ways influenced not only by other people, but also protocol, management arrangements and caseload organization. Intended localized commissioning processes (DoH 2010) may exacerbate this by engendering differences in role expectation across the UK, potentially reducing transferability of health visiting across the healthcare system, perpetuating role fragmentation and the formation of ‘tribes’ within the profession (Collier 2001). Synergy between national health visiting role standards and the educational preparation for the role is essential. Role clarity is also required to underpin global healthcare systems in which international and interprofessional working will be integral to the achievement of the Millennium Health Development Goals (WHO 1999, 2009).

Conclusion

Healthcare practice roles necessarily evolve, influenced by demographics, economics, research and technological advances. However, left unresolved, identity confusion within health visiting in relation to nursing and public health, threatens to compound already low morale, risking greater attrition from the role at a time when strategies to increase numbers are being implemented (DoH 2011). Health visitors should seek to stabilize collective professional role identity to enable consistent interprofessional working. In local settings this may be through face to face meetings. More widely, greater use of opportunities provided by social networking, other online resources and communication media would complement connections made at conferences and professional events, promoting and maintaining a sense of collective identity (Valaitis et al. 2011).

Further research could help to refine the RIEP model presented in this article, testing its utility in understanding situations of other groups of workers within healthcare systems, informing development of processes for managing effective role identity changes in other nursing and health professional roles across international healthcare communities.

Those charged with implementing health visiting strategies need to consider identity influences, especially those from within the profession. They also need to consider the interprofessional context of implementing strategies and the importance of clear public identity for health visitors. Actively seeking ways to foster stable collective identity through effective change facilitation (McDonald 2004, Higgs & Rowland 2005) will contribute to improved role performance of individual health visitors, minimizing identity uncertainty caused by unstable healthcare systems (Williams & Sibbald 1999).

Acknowledgements

The authors would like to thank Professor Carl May for his valuable contribution to early thinking in this study.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

AM and PP were responsible for the study conception and design, and performed the data analysis. AM performed the data collection. AM, TM and PP were responsible for the drafting of the manuscript and made critical revisions to the paper for important intellectual content. TM provided administrative, technical or material support. PP supervised the study.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers.

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