Influences of the involved factors on the process of identity reconstruction for healthcare professionals

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Influences of the involved factors on the process of

identity reconstruction for healthcare professionals

Anouk Simmes S3029948

Rijksuniversiteit Groningen Faculty of Economics and Business Master Thesis MSc BA Change Management

Supervisor: Dr. J. F. J. Vos Co-assessor: Dr. I. Maris- de Bresser

21th of March 2019 Groningen, the Netherlands

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Abstract

Purpose – This research presents a case study investigating different factors along the process of the

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Introduction

Living in a fast changing environment requires adaptations, innovations and adjustments for organizations to create a new fit. In order to establish this fit, professions need to change their way or working and new roles are required to create the ability to adapt to the demand of the changing environment (Laffin & Entwistle, 2000). There is a challenge concerning identity construction both for the individuals within the organization and organizations involved as both levels need to change their way of working, their roles and structures.

The empirical setting of this study concerns the field of rehabilitation, within healthcare. Changes occur regarding the care pathway for patients and needs of patients during the rehabilitation care and afterwards. This means that healthcare professionals need to change their current way of working to be able to fulfill these new demands of a changing or new profession. Training of healthcare professionals is needed with the aim to reconstruct their professional identity. Reconstruction of the current identity is required to create the right fit with the environment, because the healthcare professionals are in a situation where their old way of working does not longer match the needed skills and aspects to fulfill their new role. During such process of reconstructing their identity, healthcare professionals may experience various factors that play a role, such as the period of time for the reconstruction and the support of other colleagues. Due to the fact that a new role need to be embedded into the organization, the various factors that are of play might appear both at the individual and organizational level. The adaptation of organizations will generate positive results for the individuals within these organizations when going through the transition process themselves. Difficulties may occur during this transition process, as the new role which need to be added to the current professions is not yet fully established. This makes that healthcare professionals need to pioneer in creating the right identity for this role and still be able to perform their own profession. The healthcare professionals have to change their current way of working and identity even when their future identity is not yet existing, nor knowing what the future state will be.

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According to Van Offenbeek, Regts and Vos (2018) multiple challenges occur during the transition phase when adapting to a changing profession. They state that people changing to a new profession or role experience a lack of guidance, direction and approval for the new setting. These challenges can be seen as factors influencing the reconstruction of a new identity. Role models are mentioned as a potential tool for identity reconstruction. The role of ‘Others’ in this process of creating a new identity, such as a mentor or leader, is important for the protection and direction of the entrants in their new profession. This role can be seen as a validating role towards new entrants (Van Offenbeek et al., 2018).

The changes in professions and roles require healthcare professionals to adapt to a new way of working while still operating in their current position. Shifting from careers or professions can be identified as difficult according to the research of Wilson and Deaney (2010). This can create more influencing factors next to the ones specified by Van Offenbeek et al. (2018). Especially in the transition phase of the liminal process. According to Wilson and Deaney (2010) changing careers means a transition to a new profession on a later stage in your working life. They show that the important point for creating a successful mid-career transition is “instilling awareness of the need to help novices develop an awareness of their on-going sense of identity” (p. 181). This demonstrates that changing professions also include having awareness to create a new identity. Furthermore, it raises the question of how this might influence other existing identities for individuals (Wilson & Deaney, 2010).

Research focused on liminality within the area of management and organization studies, have shown a lack of understanding of the problems, tensions and factors involved in the transition process (Söderlund & Borg, 2017). Not knowing where the individual has to move to, or how the reconstruction of the identity has to go, makes this process even more difficult. Söderland and Borg (2017) have identified three themes which provide guidelines and focus points for the individuals and organizations, in order to cope with liminality and smoothen the process. It encourages organizations to focus on the appropriate points of interest for their liminality themes within the organizational setting. This might provide individuals and organizations guidance and support throughout the process of identity reconstruction.

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with and what might be supporting the transition process. Therefore, the purpose of this paper is to investigate what these factors are in the process of reconstructing the identity of healthcare professionals. Next to that, the process of how this is experienced by individuals going through changing professions will be investigated. Focusing on the different phases of liminality which have an influence on the construction of a new identity, whereby the transition phase is important for the individuals when changing to an unknown future state. Therefore this study asks the following research question:

What factors do healthcare professionals experience in the process of reconstructing their professional identity and how do these factors influence (hampering or favorable) the reconstruction process?

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Literature review

To get an understanding of possible involved factors in the identity reconstruction process and the influence concerning these factors, current literature is being investigated to see what research is already conducted and what insight this has given. First, identity (re)construction is being explained to get an insight in what this means and how this is related to liminality. Secondly, the process of liminal stages will be explained and how this might be used in management and organizational studies. Finally, a closer look is taken concerning identity adjustments in changing professions. Looking at the influence of previous skills and experiences and what kind of identities might be constructed to keep up to date within the fast changing organizational environments.

Identity (re)construction

As organizational environments change in multiple ways, so need the professions within the organization to be able to deliver the desired outcomes. To change professions, the roles, tasks and identities of individuals and organizations need to adapt to new requirements to create a fit with these changing environments. To be able to understand possible influencing factors on the whole process of identity construction, it is important to investigate what is meant by identity construction and what is included in this process. According to Ybema, Keenoy, Oswick, Beverungen, Ellis and Sabelis (2009) identity construction in organizations is to be considered as a process of co-constructive interactions between individuals and their social structures. These interactions are enacted among the synergy between the ‘self-identity’ (own understanding of who they are) of the individual and their ‘social-identity’ (the understanding of the individual in the external environment). Social identity can be described as consisting of “projections of others towards the self, projections of the self towards others and reactions to receive projections” (Beech, 2011, p.286).

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The changing environment of the healthcare professionals when adapting to their new roles influence the identification process. Whereby negative varieties of self-other talk can be seen as hampering factors to create a fit between the individual and social environment. The identity reconstruction process of the healthcare professionals, might create hampering factors on the individual level when the self-other talk turns negative and the professionals find it harder to create an image of the new role. The identity formation process is thus complex and multifaceted (Ybema et al., 2009). The process produces a negotiated outcome of interplay between internal strivings and external prescriptions. The research of Ybema et al. (2009) mentioned that the identity formation process within the organization is mostly focusing on the collective level, ignoring the identity process which goes on at the individual level. This suggests that the process for individuals is not seen as important as the collective. More attention need to be paid on the individual level in order to provide more direction concerning the identity formation process for the individuals (Ybema et al., 2009). In comparison with Ybema et al. (2009), the research of Beech (2011) highlights that introducing changes in one’s identity means changing the meaning associated with the person itself or the way in which the individual is connected to their environment. These meanings are located in the relationship between the individuals and the organization.

The research of Van Offenbeek et al. (2018) highlights different challenges for individuals when adapting to changing professions and reconstruct identities. Individuals within the new professions struggle with uncertainty and structure. During the transition or liminal process, the validating role of others plays an important role in identity reconstruction. The validating role of others within the organization might offer the individual, who is going through the liminal process, guidance and support along the way. This might create a favorable factor influencing the identity reconstruction process. However, the validating role of others also reinforces the transition process. Whereas other professions already use existing standards for their profession and roles, entrants in a new profession are mostly struggling with explaining their differences to other professions to seek for their own identity (Van Offenbeek et al., 2018). Furthermore, the relationship towards the peer group is of influence by constructing an identity. This is also emphasizes by the research of Beech (2011) showing that during identity construction support is needed in the form of a mentor or peer. However, the author emphasizes that in a lot of cases this support is missing. The validating role is of great importance for the ones reconstructing their identity. By establishing clear validating roles, the process of identity construction can be smoothened.

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Liminality

The concept of liminality arose in 1908 in the work of the anthropologist Arnold Van Gennep. In his studies of the ritual behavior and the dynamics of individual and collective life, the concept is referred to the process of transition from one social state to another (Söderland & Borg, 2017). In this study, liminality is seen as part of identity reconstruction. In the liminality literature, commonly three phases are mentioned which individuals will encounter during the transition process (Söderland & Borg, 2017; Ibarra & Obodaru, 2016). First, the pre-liminal phase, consists of the separation phase. Separation includes the detachment of the individual from their former position, social status and structure. This phase includes feelings of anxiety, frustration and chaos, which upsets normal sense making of the situation. After the separation phase comes the liminal phase. The liminal phase includes the actual transition, passing through the threshold or boundary between the former- and future position, social status and structure. During the transition phase the individual does not belong to the former nor the future position. This phase is a combination of evolutionary and natural cues where the individual need to go through. The transition phase needs active and intensive engagement to exceed continuous change. The last phase, the post liminal phase, consist of incorporation rites. This phase is marked by the event of the entrance to the new position, social status and structure. Being part of the new position offers relative stability and includes different obligations and norms than the former initial position (Söderland & Borg, 2017; Ibarra & Obodaru, 2016). Considering the process of identity reconstruction with the healthcare professionals, the explicit phases of the liminal process might help the individual to understand which phases or part of the phases she is facing and creating more clarity by knowing what is happening during the process.

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To create a better understanding of the concept of liminality and provide guidance for the individuals per phase, Söderland and Borg (2017) have identified three ways in which liminality is used in management and organization studies as related to both the individual and collective level. These ways or themes are characterized as process, position and place. After determining in which theme the liminality is positioned within the organization, the focus point will guide the transition on the individual level. Knowing in which theme the liminal process takes places at the individual level concerning the healthcare professionals, might provide guidance for the individuals along the identity reconstruction process.

Looking at the process theme, liminality is associated with passing, transitional and temporary conditions. The individual level of the process theme shows that the focus is on the sense making aspect within the liminal process and the active phase of going through the liminal phases from one stable state to another. The importance is analyzing identity formation and reformation. This is the period where multiple identity formations are taking place. For individuals the process theme includes going through the three liminal phases. In the empirical setting of this study, concerning the healthcare professionals it is associated with the separation of the current function, the transition to the new undefined role and the incorporation of this role in their current function. To tackle this stage, the focus has to be on what happens in-between the two stable states (Söderland & Borg, 2017).

The position theme shows that liminality is associated with particular roles and positions, mostly fixed conditions beyond or between organizational boundaries. The individual level of the position theme shares its importance in identity formation and re-formation located within or outside the organization. It points to the possibility of developing multiple identities and balancing these between different value and social systems. For instance, healthcare professionals may find themselves in the position theme when they are switching between roles. Changing roles between patients within the same day and even changing roles within the consultation to gain experiences for this new way of working. The main focus is on developing new or alternative identities, concerned with the ones who work in-between established structures and organizational settings (Söderland & Borg, 2017).

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individual to fall back into old habits and roles attached to the current function. The different places encourage to reflect on the everyday structure of the liminal place (Söderland & Borg, 2017).

Once an organization is going through a transition process and liminality occurs, the different themes of Söderland and Borg (2017) provide focus points to determine in which theme the liminality is taking place. Furthermore, it provides a guideline of how to act upon the different situations on the individual and collective level. This might provide favorable factors for individuals when going through a transition process, in order to create clarity for themselves and keep a hold over the situation.

Identity adjustments in changing professions

For professionals, changing professions includes the changes an individual makes to start a new profession or the adjustments within the profession itself. This includes roles, tasks and responsibilities changes when comparing to the existing profession. This process can be seen as mid-career changing as the individuals first operates in one way and now need to adjust to their new way of working (Wilson & Deaney, 2010). Mid-career entrants bring different skills and experiences into the new profession. The previous experiences of mid-career entrants often include important knowledge of supervisory, responsibilities and working in teams. The change of professions is discussed in the research of Wilson and Deaney (2010), where the experiences of mid-careers changers is explained and why the transition process of changing to a new profession is difficult. However, changing professions means changing identities, or adding an extra identity to the already existing ones (Thoits, 1992). This creates multiple identities for an individual and may rise the difficulty of switching between them (Ladge, Clair & Greenberg, 2012).

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According to Wilson and Deaney (2010) new identities are mostly created by the individual through their own interpretation of the profession in mind. Such meanings are created and based on an stereotypical role identity which is placed in the frame of reference of the individual by past experiences. Through the creation of this frame of reference, mid-career changers are going to evaluate and adapt their feelings and behavior on the standards provided by their interpretation of the profession (Wilson & Deaney, 2010).

Next to changes within professions, there is a rise of contemporary professions. The contemporary professions require individuals to work project based, meaning that they have to change their identity multiple times to fit to the different projects (Petriglieri, Petriglieri & Wood, 2017). To fulfill the identity requirement for the contemporary professions, portable selves are being created. Portable selves are identities which can be created with motives, definitions and abilities that can be used among different roles and different organizations over time. This helps individuals to keep moving around workplaces and not loose one’s roots and obligatory identity. When having this portable self, individuals have to change less within their identity to fit to the new profession requirements. To create these portable selves, the adaptive and exploratory part should be considered by the individual. The adaptive part is aligned with the instrumental ideology while the exploratory part focuses on the human ideology. Each part is focused on developing an understanding of the self in relation to the environment of the current organizational setting by keeping in mind the individuals and collectives identity. By crafting portable selves, individuals can create their identity without constantly adapting it to fit the self and the social when shifting between jobs and positions (Petriglierei, Petriglieri & Wood, 2017).

Combining the theoretical notions

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go through the liminal process, previous skills and experiences obtained might provide a solid background (Wilson & Deaney, 2010). When this is managed well, the level of success in the last process of the liminal process is marked as rewarding. Whenever a profession changes, the process of liminality begins again with the phase of separation. For the empirical setting of this study, the process of liminality is of importance to see where the healthcare professionals stand in their way of reconstruction their identity. To smoothen this process, the changes made by individuals to adapt to this new role are of great importance, where the synergy between the ‘self’ and ‘social’ identity is needed to create an understanding of the new role. To overcome any difficulties along the process as marked by Söderland and Borg (2017), which can be found in the themes in which the liminal process takes place, previous skills and experience may guide the healthcare professionals along their way in experiencing the influences of the factors associated with their individual identity reconstruction process.

Method

Research approach

This research focuses on theory development and has a qualitative approach. Qualitative research includes data gathering through interviews, observations and documents (Myers, 1997). For this research these three types of data were used to gather the needed and in depth information, therefore the research is performed as a case study. A case study investigates the ‘how’ or ‘why’ questions when developing new theories and exploring new academic fields, which in this case is of major interest (Yin, 1989; Eisenhardt, 1989).

Research site

The research is conducted concerning a project in the field of rehabilitation care, focusing on patients with acquired brain impairment (ABI). This project trains healthcare professionals to create a new role of being a coach, at the patients’ homes and of distance, for patients with ABI and their families. The project includes three different geographical areas in the Netherlands with different care facilities around the rehabilitation care. For this research the focus lies on one of these areas where five healthcare professionals go through the transition to become a coach for patients with ABI. Their current professions are speech therapist, social worker, occupational therapist, physiotherapist and acquired brain impairment coordinator. For reasons of anonymity for all professionals, the female form of addressing will be used.

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locations. The five professionals each have a combined role, they need to perform their own role as healthcare professional, in addition, they need to learn how to operate as a coach. This means that each healthcare professional has their own process of adapting to the new circumstances due to the different teams and activities they encounter. This creates a situation where every individual professional goes through a different process and needs to change different aspects within their current profession. These differences might create a situation where the professionals each need their own specific tools and support to create and perform their new role as coach.

Data collection

For this case study multiple sources are used to collect the data. According to Yin (2009) “A major strength of case study data collection is the opportunity to use many different sources of evidence” (p. 114.). In this research, triangulation is used (Gephart, 2014), consisting of documents, observations and interviews to gather all the necessary information and be able to compare between sources. The process of a case study is a iterative process which makes it possible to go back and forth within the research process. This creates the opportunity to make adjustments throughout the research (Yin, 2009).

The data collection started off with the first step of the process, gathering data from document studies. This was done to become acquainted with the current state of the research project and to be able to reflect upon the gathered information during the observations and interviews. The documents consisted of a summary of the project, concept versions of the observation and interview protocol used for previous data gathering within the project, explanations of the healthcare professionals professions and previous observations.

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during their work and change process of becoming a coach. These observations were conducted in November and December 2018. The third non-participant observation was done during a progress meeting of the five coaches with their leader and someone from the project, this was held in December 2018. During the participant observations, the coaches were observed individually during one working day. These observations were held in December 2018 and January 2019. During this day the coaches were observed during meetings with patients, with colleagues and other side activities. The last observation was again non-participant and was done during a study meeting in February 2019. This observations was schedules last to get the opportunity to see if there were any differences in their attitude, way of thinking and working comparing with the first study meetings and the interviews held. In total there were four non-participant observations and five participant observations. After the observations, the gathered data were structured to collect the important data and quotes.

To finish the data collection process, interviews were conducted to get more insight into the influences of factors experienced during the identity reconstruction process. The interviews help to collect data by a semi-structured approach with open questions, to uncover the story behind participants experiences (Gephart, 2014; Miles & Huberman, 1994). To start the interview process, an interview protocol was made prior to the interview including sub-topics to create structure and divide the interview according to the literature concepts (see Appendix 2). After the first interview conducted, the interview protocol was adjusted. Some questions were rewritten to create a better understanding for the interviewee. Before each interview, a short meeting was planned with a junior researcher from the project to discuss observed data from each professional and to see how this could be included within the specific interview. This created to some extant a personalized interview protocol with questions added related to the persons behavior and current profession. Prior to every interview, the professionals had to agree to participation, which also includes the recording of the interview and the fact that the data will be anonymously collected and used.

Data analysis

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After the coding process, each case was analyzed individually to see how the different functions influence the role as coach. Furthermore, a cross case analysis was performed to compare the cases and see if there were certain similarities, differences or patterns. Finally, the results of all the analyses were compared to the literature found regarding the research.

In the Results and Discussion sections, the healthcare professionals are referred to as, e.g. “C1” the number is added based on the order when the interviews were conducted. The term of “C…” is also used for referring to quotes or examples found during the observations. A distinction was made whereby “C..-I” will be used for quotes retrieved from the interviews and “C…-O” for quotes and examples retrieved from the observations.

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Results

The results gathered during observations and interviews are presented below. The results are presented based on the four different cases which were observed and interviewed. Furthermore, a cross case analysis compares the four cases to investigate similarities, differences and patterns. Per case the most important factors influencing the identity reconstruction process are mentioned. These factors are either hampering or favorable concerning identity reconstruction process for the individuals.

Case 1 – Speech therapist

Case one concerns a speech therapist who works in the rehabilitation care for 32 years. The most

important factors influencing the identity reconstruction process relate to previous skills and experiences obtained and the amount of time provided by her organization to invest in the coaching

project. The experiences C1 gained over the years are of great influence on the reconstruction process. Due to the fact that she worked as a speech therapist but also as some sort of coach in the past, she gained a lot of knowledge concerning multiple fields within the rehabilitation care. Her obtained knowledge and years of experiences creates a positive self-other talk (C1-I): “Because I already operate for so many years in this field, I know exactly what factors do play a part concerning cognitive matters.” Due to previous experiences both in the role as speech therapist and as a coach, C1 has shaped a clear self-identity as a speech therapist and coach. “If I should describe the role as coach I would say I am the central person in the system around the patient. The central person where someone can go to when questions arise and to keep up to date about the situation and problems. Next to that, it is someone who takes care of the communication after the rehabilitation with the care facility and the doctor and other involves parties along the way (C1-I).”

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change workplaces might act as a favorable factor in this reconstruction process, as for C1 the liminal themes do play a role. “Sometimes my role as speech therapist gets mixed up with the role as coach. Mostly when I need to operate as a coach I find it difficult to let the role of speech therapist behind (C1-O).”

Previous skills and experiences gained during other jobs helped C1 in creating a new identity as coach. “Thinking in terms of the home and place making concept is kind of the same as my previous job. It was not really that specific but more a coincidence that we talked about for example friends which are out of the picture and previous places where you normally would go to see them (C1-I)”. The self that was created during earlier experiences can be seen as a portable self that C1 took with her along the path as a speech therapist. “Previously I used to work as some sort of coach. I had my own business where I helped people who were having troubles with certain situations after the rehabilitation process. That is where I had my first coach experiences and that is something I took with me into my next job (C1-I).” Next to these favorable factors, more hampering factors became visible during the observations. “For myself I do not have a clear image about what I exactly will be doing as a coach or how my role will look like. This makes it hard to explain others within the organization what I am doing and how it will look like in the future. It is not clear what I have to offer (C1-0).” This uncertainty might hinder the reconstruction process. The support of colleagues helped in overcoming challenges and uncertainty. “A lot of times patients are assigned to me in the corridors, where colleagues come and say: Hé …, this patients might be suitable for your coaching project (C1-O).” This also made it easier for C1 to go and ask doctors about how they can help in this project. As was being said during the observations and became extra clear in the interview is the fact that C1 really likes to help the ABI patients and really sees the urge to do so. The motivation of C1 comes from the previous job as coach where she already experiences the influences of coaching at home. “I like operating as a coach. Going to people’s homes and see really wat they are doing, how their environment look like. It is easier to see how I can help them in this situation because you get to mention things you notice around the house. Otherwise you would not have all this knowledge when they only visit you in the rehabilitation center (C1-O).”

Case 2 – Physiotherapist

Case two concerns a physiotherapist who is currently working within the rehabilitation care for five years. The most important factors influencing the identity reconstruction process relate to previous

skills and experiences obtained and places where C2 executes her current position and the role as

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counter, where C2 provides information and helps people who are in need of guidance after their rehabilitation sessions have stopped. In contradiction to the office where C2 carries out the duties for the sports counter, the day to day consultations are mostly done in the practice area. During the observations, a multidisciplinary treatment with the occupational therapist was scheduled. This was arranged so the patients could get advice from both healthcare specialists. The degree of cooperation in multidisciplinary teams and the importance of it became clear by the following quote: “Working multidisciplinary is extremely important. Everyone sees the patients with their own expertise. Every three or four weeks we need to discuss how the patients are doing, during this meeting everyone gets their chance to express themselves about the treatment, what they have noticed or maybe what needs to be changed (C2-I).” During the process of identity reconstruction, C2 came across difficulties concerning the liminal themes: “It is also kind of a fight, well a fight…. There are many healthcare parties involved around the patient who all come and visit. So it is quite a search to see who takes which part and how does the GP stays up to date (C2-I).” Previous skills and experiences helped C2 in going through the liminal stages and start creating a new identity. These skills and experiences were obtained during the sports counter hours (C2-I): “At Monday mornings I work at the sports counter where I help people, guide them a bit, who stopped with the rehabilitation process after three months and need to sport on their own and need to find the right tools to do so. So with the sports counter I help people to find a solution for this via face to face meetings and phone calls.”

Next to skills and experiences, places play a part in the reconstruction process for C2. The fact that coaching is mostly executed from the patients’ homes create a favorable factor for C2. “Working in the framework of the home environment is really good. You get to see a lot more and you get more information of different fields (C2-I).” Unfortunately it is not always possible to go the home environment, sometimes coaching is done at the rehabilitation center. Which shows more difficulties, mostly at the patients side. “The hard part is that people have certain expectations from a physiotherapist. When they are going to a physiotherapist they work on themselves physically. So it is really hard to combine that with coaching and that at the end people had enough exercised. It is really hard to combine these two, due to the expectations of the people (C2-I).”

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patients about what they want to practice and achieve has changes. In contradiction to the changes, similarities between the two roles also became visible. “The listening part really stays the same, trying to figure out what they need. At the end achieving the goal someone sets for themselves that is important for both roles (C2-I).” At the end the motivation to start the project and see the urgency has not changes. “I think it already shows, I am doing more than only physiotherapist duties. I am interested in more areas. Before this I studied MER which also shows the broader field of interests. I really enjoy the part of coaching and guiding people. However now I need to find out how to combine this ( C2-I).”

Case 4 – Social worker

Case four concerns a social worker, working within the rehabilitation care for 5,5 years. The most

important factors influencing the identity reconstruction process relate to similarities between her

current function and the role as coach and the amount of time provided by her organization to invest in the coaching project. C4 has a favorable image of the self and knows how to deliver good care. “Currently I work 28 hours a week. I am able to get more hours, however, if I am going to work more I am not able to deliver the best care to all patients. This is influences by the mostly negative stories and conversations with patients. To stay focused and productive I keep my workload at 28 hours a week (C4-O).” Being a social worker includes a lot of meetings with colleagues about patients, group meetings about innovation within the rehabilitation care of social workers and conversations and consults with patients. These activities mentioned already shows that cooperation is important and working in a multidisciplinary team is the standard. “Working in a multidisciplinary way is the most important aspect. Sometimes there is overlap between different functions, so having good communication is important to receive all the information around the patient and create a better plan. (C4-I).” The role of social worker has a clear identity for C4. Due to the experiences within the rehabilitation care, the self and social identity of the role of coach already gets shape. C4 knows what is needed to become a coach and has a clear image about where the role as coach can be placed in the care pathway around patients. “As a coach you need to stand next to the patient and going through the process together instead of being someone who stands above the other….. As a coach you are a case manager. There are so many other care parties involved around the patients, so creating a clear image about what is going on will help all parties and will give the patient some peace (C4-I).” These factors are favorable for C4 concerning her reconstruction process.

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social worker you need to be able to tell why you treat the patient and what you did, this is needed for the healthcare insurance. When coaching you suddenly have all the time you want to slowly help the patient step by step without clarifying every aspect of it (C4-I).” Due of the fact that both roles includes communication and having conversations with patients, a major part is overlap between the two roles. “I think a huge part is overlap. The technique behind the conversations which is used as a social worker and as coach is the same. When being a social worker you have to deal with the team and a time frame, so that will be the difference. However, at the end, being a social worker and a coach will be closely related (C4-I).” This overlap also creates difficulties for C4. “There is so much overlap between a social worker and a coach. Sometimes I get to much focused on a goal and start to act in the resolving mode, which is not part of being a coach. […..]Relax and doing nothing is something I have to keep reminding myself of. During the lecture the last time, a situation was created to really show what was happening when I was in the resolving mode, this helped me to really think about the situation. During the lecture I started to relax again (C4-I).” To overcome these difficulties, the validating role of others is a favorable factor concerning the identity reconstruction process for C4: “We are really looking how we can include the team in this process. Last week we had a meeting in our team about the project, we shared our story with a lot of questions as response. Most of the colleagues were positive. There were some critical questions but that is part of the process, and it helps me to see what it actually will bring to the organization and to the patients.” However, the tight schedule of C4 does not always allow her to practice coaching aspects as much as she would like. Therefore, she tries to incorporate some aspects into her social work, as the time provided by her organization is not yet optimal. “Creating contact remains the most important point, whether you are a coach or a social worker. Creating contact is the start of everything, without contact you cannot proceed (C4-I).” The urgency and motivation to join the project still remains the same (C4-I): “The uncertainty after the rehabilitation process, the different parts of healthcare provided, I think we can achieve a lot in that process of care. Being part of it all really got my interest.”

Case 5 – Occupational therapist

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Next to the places where patients are seen, C5 also needs to work on her other activities concerning more administrative tasks. “I like the places where I can be alone. We have two office areas, one which can accommodate two persons, however this makes me uncomfortable. The other is our office, which accommodates eight people. It is nice but is it very annoying when you need to get your work done. So mostly I prefer to use the back office which is calm and quiet (C5-I).” Looking at places, there can already be seen that the diversity in workplaces might be a favorable factor for C5 along the identity reconstruction process. During this process, the liminal phases were visible for C5. Difficulties were noticed during the separation phase. Clear distinctions needed to be made in order to let go of the old routine or structure. “Planning related I find it very difficult to take the role as coach. Only now when I have coaching as a separate activity mentioned in my schedule I can start with the process of finding patients and seeing them as a coach. I am able to create connections with other colleagues to find patients and talk about the project (C5-I).” Later on during the transition phase it became clear that switching between occupational therapist and coach is difficult due to the similarities between the two roles. Because the functions are so close related, for C5 it is important to shift the place where operating. “So I started some coaching sessions here in the clinic and afterwards I had some telephone calls and a few house visits. However, the mapping is something I have only done in the clinic. So now I need to see if the mapping will be easier at home with the patient because than you are located in their house and familiar situation where you can also include things you see (C5-I).” To become more familiar with the role as coach, C5 has found a way to keep practicing. “I try to incorporate the way of asking questions while coaching into my current function as occupational therapist. Sometimes this is hard because as coach you have to think about places and we think about and around activities that need to be done and learned (C5-I).”

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are able to do all the activities they want to. I think at home is where everything takes place and the real rehabilitation begins (C5-I).”

Cross-case analysis

In the cross case analysis the cases are compared to see if there are any similarities, differences and patterns between the factors influencing the identity reconstruction process for the healthcare professionals. Their current functions of speech therapist, physiotherapist, social worker and occupational therapist play a role concerning the different influences of these factors. Considering the four different cases, mostly all healthcare professionals encounter the same factors regarding the process of identity reconstruction, however the influence of these factors differ per individual. The most interesting factors noticed are related to previous skills and experiences from the healthcare professionals. The time provided to invest in the coaching project and reconstruction process. The different places where the healthcare professionals can practice and execute their role as coach. The similarities between the current function and the new role and the role others have in this process, varying from colleagues to external parties.

Looking at the current way of working during the coaching project, the experiences gained within the rehabilitation care and other functions do have an influence on the reconstruction process. Experiences vary between five years till 32 years. Aspects of the current function are taken into consideration by the professionals when reconstructing their identity. This makes that the four professionals have their own input into the role as coach regarding their different functions. Based on previous experiences, the self-other talk is mainly positive and creates a favorable factor for the four healthcare professionals (C1 and C2). Looking at the creation of the self and social identity, the lack of information regarding the shape of this new role is an hampering factor for all of them. Next to not knowing how they have to shape their new identity and what to include, they do not yet know their role in the care pathway around patients and are not certain what they can offer patients, the patients’ families and also their own organization.

Concerning the reconstruction process, the healthcare professionals encounter other factors as well. Looking at the liminal phases, time is needed to pass through the stages and create a new identity. However, in the beginning of the project, time was not a factor which could be discussed or changed in favor of the healthcare professionals. The amount of time the healthcare professionals were able to invest within the project differs per individual. The professionals who had a lot of time available to experiment with this new role did experience the amount of time as a luxury and favorable factor (C1). However, professionals who did not have much time available to invest in the project, did experience the lack of time as a hampering factor (C2, C4 and C5).

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as favorable and hampering factors concerning the identity reconstruction process. Looking at the favorable aspect, the overlap that exists between some current functions and the coach role, created situations where professionals needed to adapt less (C4 and C5). They can use their knowledge obtained in their current function in aspects related to the new role as coach. This also means that the professionals have to adapt less aspects and are already familiar with some activities. However, the research show that these similarities can also be seen as a hampering factor. It can create difficult situations where professionals might fall back into old behavior (C2 and C5). When overlap occurs the switch to perform the current function instead of the coach role might become easier.

Furthermore, the validating role of others influences the reconstruction process. First of all, cooperation with colleagues and other involved parties is of influence concerning the identity reconstruction for all professionals. The importance of a multidisciplinary team in the current function becomes extra clear when working as a coach. The knowledge obtained within these teams can be taken into account when performing the role as a coach (C2 and C4). Not only cooperation plays a role, but the roles of colleagues in the reconstruction process is of influence. Some professionals encounter negativity from their colleagues, which hinders their reconstruction process and experimental phase (C5). Others experience support and help from their colleagues, this results in positive outcomes for the professionals (C1 and C2).

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Discussion and conclusion

The aim of this paper was to investigate which factors healthcare professionals encounter in reconstructing their professional identity and how these factors influence the reconstruction process. The research was conducted within a project in the rehabilitation care, where healthcare professionals had difficulties concerning their identity reconstruction. The healthcare professionals have to change their current way of working and identity, even when their future identity is not yet existing, nor knowing what the future state will be. As expressed by Söderland and Borg (2017) not enough attention is paid on the process of how individuals experience the liminal stages and what tensions are involved along the way. The research brought to the surface that during the project every individual experienced the liminal stages in a different way, also based upon their current function and previous experiences. Findings were gathered that the factors involved are more or less the same, however the influence of these factors differ per individual. The most important factors found experiences by healthcare professionals where related to skills and experiences, the provided time, places associated with the current functions and new role, role of others in the process and the similarities between the current functions and the new role.

This research shows that the healthcare professionals all had a positive self-other talk because of their previous skills and experiences, which is a favorable factor for the identity reconstruction process. The skills and experiences are obtained either in current functions or in other roles fulfilled in their past. With these findings, this research supports the research of Ybema et al. (2009) and Beech (2011) mentioning that the varieties of the self-other talk are of influence on how individuals see themselves and adapt to situations. Next to the self-other talk, the importance of previous skills and experiences from mid-career changers became visible. The interpretations and experiences obtained by previous functions and roles were taken into account by the healthcare professionals. This is in line with the research of Wilson and Deaney (2010) mentioning the influences of previous skills and experiences on how mid-career changers adapt to new roles and how they reconstruct their identity. Petriglierei et al. (2017) claim that portable selves are created to have an identity which can be used among different roles and organizations over time. This is partly supported by this research, mentioning the portable selves that are created by some professionals to take with them to different locations and into different roles within their current function.

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of time in the coaching project mentioned this as a favorable factor due to the fact that they had time to practice and experiment with their new role and identity. Next to the provided time, the places associated with identities and roles are not specifically taken into account by current literature. This research shows the importance of the influence of places while reconstructing an identity. As became visible in the research, familiar places encourage to use a familiar identity and perform familiar activities. This is both happening at the level of the healthcare professionals and at patients level. Familiar places are a hampering factor for the reconstruction process, for example, being in the practical area of the physiotherapist does encourage the patient to be engaged physically and not focus on their mental wellbeing which is a main activity while being coached. In the same way, wearing a medical uniform hampers the level of contact which is needed to be able to perform as a coach. In contradiction to the hampering factors of places, new places bring favorable factors. A new place is not yet associated with a specific role or activity, which means that a new role can more easily be practiced here. This supports the research of Manzo (2003) and Söderland and Borg (2017) mentioning that the relationship people create with places form a foundation for our being, and thus is part of our identity construction process. Including sense making of places, place attachment and place identity (Manzo, 2003). Different conditions concerning workplaces result in stimulating locations and contexts for individuals (Söderland and Borg, 2017).

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Looking at the research question: “What factors do healthcare professionals experience in the process of reconstructing their professional identity and how do these factors influence (hampering or favorable) the reconstruction process?” there can be concluded from this research that the factors that are experienced the most in the process of reconstructing a professional identity are skills and experiences, the provided time, places associated with the current functions and new role, role of others in the process and the similarities between the current functions and the new role. However, one important finding is the difference between the healthcare professionals in the experiences of the influences of these factors. The influences of the same factors might be experienced as favorable or hampering, this differs per individual. The main finding why the healthcare professionals experience the factors in a different way is the impact of the current function on the identity reconstruction process. The elements brought into the process by the current function are of influence. However, further research is needed to create a better understanding related to this finding.

The most outstanding factors are related to the places associated with the different roles, skills and experiences and validating role of others. Different locations, associated with different activities have a different influence on the reconstruction process. Familiar places are hampering because they encourage to use familiar behavior and identity. This makes it easier to fall back into old habits. New places have a favorable factor because the professionals find it more easy to execute their new role as no identity is linked to this place. Furthermore, previous skills and experiences are encountered by most professionals as a favorable factor. It provides the healthcare professionals with knowledge and more certainty about how to fulfill their new role. Last, the validating role of the colleagues closely related to the healthcare professionals are an important influence on the identity reconstruction process. However, the influence differs from favorable to hampering. Mostly it reduces uncertainty and the critical questions ask by colleagues helps the professionals to grow in their role as coach. The hampering part is associated with negative reactions retrieved from colleagues, this hinders the process of growing. Mostly the negativity is associated with slightly increasing workload for the colleagues when the professionals invest more hours in the coaching project. The degree to which the factors influence the identity reconstruction process are related to the mindset of the healthcare professional and the impact of the current function.

Theoretical implications

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became visible. The necessity of the focus points per theme are confirmed. This research showed that the liminal themes are of influence on the reconstruction process of the professionals. Last, the importance of previous skills and experiences became visible. This contributed to the study of Wilson and Deaney (2010) by adding that previous skills and experiences also helps in shaping a positive image of the individual. This research extends the literature with the influences of places regarding identity reconstruction. This research implies that places are of great influence in how the new role can fit into the current function and how this can be organized on organizational level. A new place will help in developing a new role and identity.

Managerial implications

This study also resulted in some interesting managerial implications. Changes need to be made both on individual and organizational level. This research showed that the professionals where struggling with reconstructing their identity due to the fact that the role is not yet existing, and they do not know how to fulfill this role. Mostly it creates uncertainty about where to go to and what they will provide others with their new identity. This uncertainty also reflects in delays concerning the transition process. So, if participants need to change their identity, a more established role need to be completed before starting the project. This concerns the organizational level, who need to provide more guidance along the way to create an easier transition process for the individuals. This also results as a validating role. The research already showed the importance of validating roles for the individuals. When the organizational level also supports the individuals might be more certain about themselves.

Furthermore, the time provided by the organization is of influence on the reconstruction process, going through the phases of liminality takes time, however this is not provided. On organizational level, decisions need to be made before hand about how much time the individuals may spend on the project. This will help them in accepting their new role and really start practicing. The more time each individual get to spend on the project the better the acceptance and transition.

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Limitations and further research

As each research this study has some limitations. A number of them relate to the data gathering. First, concerned cancelled appointments from patients. Leaving gaps in the schedules. Second, busy days were chosen to get the most insight, however there is for the researcher there is no knowledge about how calmer days were filled. Last, interruption of interviews or observations because of patient matters. Furthermore, not all the healthcare professionals were already able to perform their role as coach. This creates differences in their insights, opinion and experience. Another limitation became visible after analyzing case 3. It became clear that C3 had created another identity than the one for being a coach. C3 had constructed another more guiding/teaching role to be able to learn other healthcare professionals how to be a coach. This is why C3 is not taken into account in the result section as a separate case, however information obtained during the observations and interview are used to create an overview and further insight in the situation.

Further research concerning identity reconstruction can be based on multiple factors. First the places associated with identity reconstruction play a big part. As being discovered during the observations and interviews, the differences in places where to perform a current function and where to perform a new role are of influence on the reconstruction process. The current places are mostly associated with current roles, further research can be done by looking at the boundaries professionals are willing to place or overcome when working in different places. Observing the healthcare professionals in different places while executing the role as coach might create a clear overview of how the place is of influence in this process.

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References

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Appendices

Appendix 1 - Observation protocol

Observation protocol boundary work and identity reconstruction for professionals

This observation protocol focuses on the reconstruction of a professional identity as a coach. The observation focuses on saying of the professionals, their work attitude and their body language. Boundaries can exist between and inside professional groups, but also between organizations or between the profession and their new role as a coach. During the observations focus on the physical and verbal expressions related to the creation of boundaries. Don not only focus on what is being said but also pay attention to interaction with the environment and the interaction with others.

1. How and when is there an opportunity to create an identity as a coach and how does this identity creates a clear content?

What to observe:

 Moments of hesitation/doubt about the role of coach

 Ways in which this role is different than their current function

 Critical reflection on role as coach or the transition towards using this role  Interaction with others about creating the role as coach

 Discussions about the practical applications, tools/work  How often can the role as coach being seen in daily work  Open attitude toward the role as coach

 Use of role as coach in current profession

2. How and when are boundaries being set and where is this boundary placed, opened and closed?

What to observe:

 Use of professional’s jargon

 Any differences regarding old and new role  Any espoused ideas about professional values  Any characteristic about their current profession  Professional vocabulary regarding the role as coach

 Discussions about training sessions with colleagues concerning role as coach  Social gatherings with colleagues concerning role as coach

 Opinion about their role as coach and colleagues interpretation  Creation of boundaries

 Blur of boundaries is specific cases  Cooperation between boundaries

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3. Role of the home and place making concept and how this is being used?

What to observe:

 Saying about home & place making

 Example of the use of the concept during their work  Doubt about the use of the concept

 Interaction with colleagues about the concept  Comparison of concept with current way of working  Interaction with client about the concept

 Use of concept without being aware of it  Places where the concept is used more or better

 Places where there is clearly being referred to the role as coach

 Use of language including the role of coach with colleagues and clients

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Appendix 2 - Interview protocol

Interview protocol for professionals who practically experiment with coaching in home and place making

Welcome, first of all I would like to thank you for your time and participation in this research. As you know is am a student at the Rijksuniversiteit of Groningen and currently I am working on my master thesis for the study Change management. The subject of my thesis is linked to identity reconstruction and the factors including this process. You as a healthcare professional are part of the home & place making project where you guide patients who are struggling with their identity after their acquired brain impairment (ABI) and who need make their house a home again.

My research focuses on you as healthcare professional. Next to performing your current role and profession, you get an extra role as a coach. This means that you also have to change your identity because of the extra role that is being given next to your old professional status. With this research I would like to discover which factors are includes in the identity reconstruction process, positively as well as negatively.

The interview will take about one hour. I hope that you are ok with the fact of taping the interview to I can transcribe them an use the data for my research. The data will only be used for my interview and will be transcribed anonymously and the tapes will be destroyed after. The interview is confidential. If you like I can send the transcript afterward. Do you have any questions remaining before we start?

General

 Name, education, current position and organization

 How long have you been working within this organization and within this position?  What are your experiences concerning the care for ABI patients?

1. Current position and work places

 What are your current work activities?

 What is specific for you function when looking at ABI patients?

 What are important places where you exert your profession? (home client, meeting room, board room, practice area etc.)

 What do you include in other places which you visit for your daily work?  Can you describe a typical workday?

 When do you execute your work well? How do you know so? Can you give an example? (questioning about espoused believes, who decides if your work is well done?)

 What is the importance of cooperation with your current position?

 Are you part of a team? How would you describe this team? Who does what within this team? Are there any problems within the team?

 What is according to you the importance of this organization/function?

 What would you change or improve concerning the current way of working with ABI patient? Why do you think this is necessary?

2. Meaning of the role as H&P-coach concerning the care for ABI patients

 You are participating in the H&P project. How would you describe the role as H&P-coach? What are important characteristics of this role?

 How would you describe your role as H&P-coach concerning the more efficient, smarter and humane way of organizing the ABI care?

 What do you think about the idea of focusing on the story of the ABI patients and during this path leaving your old position behind and operating as a coach? What makes this easy and what makes this hard?

Influences of the involved factors on the process of identity reconstruction for healthcare professionals