DO THE MEDICAL AND NURSING PROFESSION EVEN WANT TO
COLLABORATE? PROFESSIONAL IDENTITY, OUT-GROUP
THREAT AND WILLINGNESS TO COLLABORATE: THE
MODERATING ROLE OF PERCEIVED STATUS DIFFERENCES
University of Groningen Faculty of Economics and Business
Human Resource Management & Organizational Behavior Department Master Thesis
July 10th 2016
Ilse M. Vos
Gedempte Zuiderdiep 32, 9711 HH Groningen E-Mail: i.m.vos@student.rug.nl
Student Number: 2032031
Supervisor: Prof. dr. F. A. Rink
Acknowledgment. I would like to thank Floor Rink for her helpful feedback and effort throughout the process. I also would like to thank Jan Pols (UMCG) for his helpful thoughts
Abstract
A satisfactory quality of healthcare is very important for society, and is partly derived from a good collaboration between medical specialist and nurses. However, a majority of medical specialists and nurses indicate that their collaboration could be strongly improved. Therefore it is particularly meaningful to look at antecedents of their willingness to collaborate and possible causes. This current study investigated how out-group threat affected the relation between the professional identity of medical and nursing students and their willingness to collaborate. Furthermore, it was investigated whether perceived status differences moderated that relation. Though, the results did not indicate any significant relations. However, interestingly, perceived status differences did moderate the relation between social inclusion, out-group threat and willingness to collaborate, such that this relation was only negative and significant under high perceived status differences.Further implications for healthcare organizations and future research directions are discussed.
Do the Medical and Nursing Profession Even Want to Collaborate? Professional Identity, Out-Group Threat and Willingness to Collaborate: the Moderating Role of Perceived Status
Differences
According to the vast majority of nurses and doctors, their collaboration with another could be highly improved (Oosterhof, 2008). This is a popular subject within the medical world. Particularly, since a good collaboration between medical professionals is likely to enhance health outcomes for patients (Baggs, et al., 1999; Hughes & Fitzpatrick, 2010; Messmer, 2008; Rose, 2011).
The tasks doctors and nurses perform are by definition highly complex (Molleman, et al., 2008), because one patient often has multiple notably interrelated problems. Task
A key problem in interdisciplinary collaboration is that doctors do not understand the professional role of nurses and vice versa. One possible reason for this could be that both parties identify highly with their own professions’ values and norms and feel a high sense of belonging to their profession. Such strong feelings of identification with a profession
generally shapes an employee’s cognition, feelings and behaviours (Tajfel & Turner, 1979) and causes him/her to feel threatened when an out-group member, here another physician or a nurse, is critical or negative about their profession (Walton & Cohen, 2007). This feeling of being threatened often results in uncooperative behaviour, reducing the willingness to collaborate (Helmreich & Schaefer, 1994).
Yet another underlying reason for why nurses and specialists do not collaborate well may be that these professions differ in perceived status. Both physicians’ and nurses’ indicate that the perceived status of the medical profession is higher than nursing professional’ status. Given that in healthcare settings, task complexity is often high (Molleman, et al., 2008) - leading to higher chances of decision making disagreements between nurses and physicians, it can be expected that these differences in status further strengthen feelings of threat (Bigley & Roberts, 2001). Research shows that in such circumstances, large status differences will enhance differentiation and deviance among team members (Harrison & Klein, 2007) and enhance chances of interpersonal clashes due to unfairness perceptions (Anderson & Brown, 2010). As a result, the degree to which nurses and specialists experience status differences among them may further aggravate perceptions of outgroup threat and hence, may reduce their willingness to collaborate (McNeil, Mitchell & Parker, 2013).
that these relations hinge on the perceived equality in status by both parties, such that greater perceived status differentiation between doctors and nurses will strengthen these relations whereas lower perceived status differentiation between doctors and nurses will weaken these relations. This would mean that little status differences between nurses and doctors may alleviate the negative impact of their professional identities on the perceptions of outgroup threat, and, as a result, their willingness to collaborate with each other.
This research contributes to the literature in a number of important ways. As shown previously, a medical specialists’ and nurses’ professional identity strengthens the
collaboration within their own profession (Pratt, et al., 2006). But unfortunately there is a dark side to this development, as a strong professional identity tends to decrease the willingness to collaborate with another profession, who show another professional identity. When nurses and medical specialists are not willing to collaborate, chances of medical errors will increase, particularly in complex patient situations (Matziou, et al., 2014). A greater understanding of the relationship between the degree to which nurses and medical specialists identify to their profession and their willingness to collaborate will thus strengthen the quality of the
healthcare process, whilst providing solutions and strengthening the interdisciplinary collaboration.
setting, since reducing such status differences may offer a solution to strengthen the quality of interdisciplinary healthcare collaborations.
Professional Identity
According to social identity theory, one’s self-view is not only determined by interpersonal relations or personality, but an important part is determined by group
membership (Tajfel & Turner, 1979). Social identity in the workplace can be referred to as one’s professional identity. In the medical world, employees tend to identify strongly to their medical or nursing specialty.
Physicians and nurses are likely to identify strongly with their own profession and perceive significant differences with other professions (Coyle, et al., 2011). According to Goldie (2012), the most important part of medical education is to help students form their professional identities. Medical and nursing students go through an intensive socialization period, during which they are taught to adopt values, norms and common professional behaviors (Pratt, et al., 2006). Students are clinically trained to become professionals,
amongst other health professionals, students and patients (Monrouxe, 2010). During that time, their professional identity is constructed. Moreover, job tasks of physicians and nurses are highly complex, so extensive knowledge and skills are needed to perform the job. Therefore, doctors and nurses have to invest a lot of time and cognitive ability in their job. Research has shown that these investments will increase professional identification (Pratt, et al., 2006; Weaver, et al., 2011).
Two variables constitute a strong professional identity: professional inclusivity and social exclusivity. Professional inclusivity is the feeling one belongs to the profession and feels treated as such (Weaver, et al., 2011). According to Molleman (2010a) a strong
(Haslam, et al., 2003). Holding a shared professional identity results in identifying with other members of the profession and in incorporating team goals as one’s own performance
objectives (Faraj & Yan, 2009). Furthermore, research showed that a strong professional identity is positively related to meeting those performance goals (Sethi, 2000). As a result, professional identification will trigger members to engage in professional tasks and efforts for the profession (Ellemers, de Gilder & Haslam, 2004). Moreover, professional identity
enhances professional satisfaction, professional extra-role behavior and profession climate (Riketta & Van Dick, 2005). Additionally, sharing unique professional knowledge is an important attribute of professional identity. As such, a strong professional identity will motivate one to uniquely engage in a particular professional task, using that specific
knowledge (Gao & Riley, 2010). Professional identification is positively related to learning and performance within a profession (Van der Vegt & Bunderson, 2005). Subsequently, a shared professional identity increases the degree to which one accepts and uses professional knowledge shared by a fellow profession member (Kane, 2010).
Yet, a strong professional identity also leads to larger perceptions of social separation from other professions, or, social exclusivity (Wackerhausen, 2009). Higher levels of social exclusivity will lead to the feeling that one is isolated from other medical disciplines, decreasing ones’ openness to another profession (Coyle, Higgs, McAllister & Whiteford, 2011). This might lead to outgroup threat as well, as I will now continue to argue in this paper.
Professional identity and willingness to collaborate
Scholars generally assume that interprofessional collaboration is necessary and desirable, because no profession has yet obtained the highest level of skills, knowledge and competences about a particular healthcare problem. Indeed, research confirms that
2009). Although both nurses and medical specialists with a strong professional identity are inclined to participate in multidisciplinary collaborations because they see it as an opportunity to demonstrate their own expertise to others (Gaertner & Dovidio, 2009) and because being able to help solve complex tasks increases one’s proudness of the profession (Molleman, 2010b), there are often to many serious barriers to successful interdisciplinary collaboration.
Research stated that multidisciplinary collaborations in a healthcare setting can lead to oversimplification and misinterpretation of out-group members’ task roles and intentions, especially in complex, tense communication (Lingard, Reznick, DeVito, and Espin, 2002). Moreover, nurses and medical specialists are often in competition with one another. For example, when a new, prestigious and valuable job task can be obtained, both professions will ‘fight’ to make it theirs. ‘Winning’ the job task might feel important, since adding a new, high status task to their job tasks will strengthen their professional identity. Obtaining this job task, will confirm that the profession is important and it will enhance in-group members’ feelings of being proud of their profession (Wackerhausen, 2009). Paradoxically, this often also happens in complex multidisciplinary collaborations in healthcare because different parts of a complex case tend to interfere with one another (Molleman & Rink, 2014). Because the different professions then have competing opinions, they respond negatively towards each other and devalue the multidisciplinary collaboration (Ferlie, et al., 2005; Molleman, et al., 2010a).
Accordingly, it is a logical preposition that a stronger professional identity leads to a lower willingness to cooperate.
Hypothesis 1. The joint degree to which nurses and medical specialists identify with their profession is negatively related to their joint willingness to cooperate.
Ultimately, I argue that outgroup threat explains why there is a negative relation between the joint degree to which nurses and medical specialists identify with their profession and their joint willingness to cooperate. By positively evaluating one’s own profession, one tries to satisfy the desire for a positive self-concept (Tajfel & Turner, 1979). This positive evaluation is determined in reference to specific other groups through social comparison and enhances identification to one’s own profession (Tajfel & Turner, 1979). So, in essence, a professional identity results from separating an out-group from one’s in-group. As a result, highly identified in-group members have difficulties understanding thoughts and emotions of out-group members, which could be threatening. Accordingly, a strong identification to the profession, tends to result in outgroup threat, which might hinder or frustrate goals within the profession. (Hewstone, Rubin & Willis, 2002). Consequently, mental states of in-group members are easily perceived, increasing levels of empathy within the profession. However, it is relatively difficult to recognize emotions and minds of the out-group, a different profession. This results in less understanding of, and less empathy towards the out-group (Hackel, Looser & Van Bavel, 2014). A strong professional identity therefore increases chances of negative reactions or criticism towards other professions (Zhong, et al., 2008). Research indeed confirms that under high levels of out-group threat, expertise diversity will decrease the effectiveness of an interdisciplinary team (Mitchell, Parker & Giles, 2011).
To conclude, multidisciplinary collaborations can be seen as a threat, as one feels that their profession is negatively evaluated or not immediately positively valued by the other profession. Both the medical and nursing profession will show defence mechanisms under this kind of circumstances (Walton & Cohen, 2007). A diverse composition of a healthcare team, in this case, nurses and physicians, can provoke group members to categorize others as in-group or out-group, which in turn could impair group processes like collaboration
conflicts and dominance of physicians over nurses, the intergroup anxiety, and thereby out-group threat is high (Blue and Fitzgerald, 2002). The research presented above leads to the second hypothesis.
Hypothesis 2a. The joint degree to which nurses and medical specialists identify with their profession is positively related to their joint feeling of out-group threat.
As threatening perceptions of roles and values of the other profession tend to result in being harsh, unfair and uncooperative towards this profession (Helmreich & Schaefer, 1994), it generally causes withdrawal in interdisciplinary collaborations or the withholding of important task information (Amason, 1996). As such, outgroup threat results in a lower willingness to collaborate, which in turn is a barrier to providing high quality care (Kvarnstrom, 2008).
To conclude, although medical specialists and nurses have to work together in order to deliver the best care possible, they feel threatened by the other profession and as a result, do not want to collaborate together. Leading to the following hypotheses:
Hypothesis 2b. The joint feeling joint feeling of out-group threat is negatively related to their willingness to collaborate.
Hypothesis 3. The joint degree to which nurses and medical specialists perceive out-group threat mediates the direct relation between the joint degree to which they identify with their profession and their joint willingness to cooperate.
Perceived status differences
Now we know that a strong professional identity is negatively related to the
willingness to collaborate, because of outgroup threat. However, it is very important to know how this relationship could be weakened or changed in a positive way. A key factor might be the degree to which there are status differences between nurses and physicians. When
situation in which outgroup threat is high, and the willingness to collaborate is low. In
conclusion, lowering the perceived status differences could be the solution of problems within the collaboration between nurses and physicians.
Status is ‘the prominence, respect and influence individuals enjoy in the eyes of others’ (Anderson, et al., 2006, p. 1094). Influence and deference in teams arise from both perceived merit, based on expertise and experience, and from formal authority (Bunderson, 2003). Traditionally, the medical profession has been traditionally perceived as the most dominant profession in healthcare (Hallinan & Mills, 2009; Benoit, et al, 2010). Both
physicians’ and nurses’ perceive the status of the medical profession higher than the status of the nursing profession.
Research demonstrates that clear status differences will have different implications for collaborations between physicians and nurses working on simple versus complex tasks
same level status nurses (Long, et al., 2008; Nugus, et al., 2010; Reeves, et al., 2009). And finally, a great degree of status inequality can lead to more competition, differentiation and deviance among the lowest status profession due to unfairness perceptions (Harrison & Klein, 2007).
In contrary, when status differences are relatively low among nurses and medical specialists both professions might be less threatened and less hesitant to communicate to each other about how to solve complex patient cases. Moreover, there will be less competition and differentiation between the two professions. Most important is that different task perspectives will be more integrated, leading to a more comprehensive approach to solving problems (Greer et al., 2014). Eventually, this should result in a higher healthcare quality.
Leading to the expectation that perceived status differences moderate the relation between professional identity and willingness to collaborate.
Hypothesis 4. Perceived status differences moderate the relationship between the joint degree to which nurses and medical specialists identify to their profession and their feelings of outgroup threat, such that when perceived status differences are large, the relationship will be strengthened
Figure 1. Conceptual model
Method
The purpose of this research was to investigate how the joint degree to which nursing and medical students identify to their profession influenced their willingness to collaborate with another profession, and whether out-group threat mediated this relation. Furthermore, this research examined how perceived status differences moderated this relationship. Data from medical students were collected in the University Medical Centre Groningen (UMCG) and its affiliated teaching hospitals. Data from nursing students were collected in the UMCG and in general hospitals.
Participants and design
A questionnaire was sent to 1200 medical students and 953 nursing students. There were 154 respondents, 83 medical students (72.3% female, mean age = 24.15, SD = 2.01) and 71 nursing students (67.6% female, mean age = 26.66, SD = 1.81). All participants were enrolled in the master programme of the University Medical Centre Groningen School of Medicine or in the Nursing Academy (Hanzehogeschool Groningen) in the Netherlands. Medical students were involved respectively in their first (41.0%), second (36.1%), and third year (22.9%). The nursing students group consisted of 40.8% third year, and 40.8% fourth year students. Ninety-nine percent were Dutch.
Procedure
Participants took part in this research on a voluntary basis, all data were anonymously collected.
Measurement
All full scales are presented in Appendix A.
Professional identity. Professional identity was measured using the Professional
Identity Scale (Adams, et al., 2006). This scale, consisting of 9 items, was scored on a five-point Likert scale (1 = strongly agree, 5 = strongly disagree). Example items are “I feel I have strong ties with members of my profession” and “Being a member of this profession is
important to me”. All items were combined to one reliable scale (α = .84).
Outgroup threat. Outgroup threat was measured using an adapted version of the
Primary Appraisal of Identity Threats (PAIT) scale (Berjot, et al., 2006). This scale, consisting of 15 items, was scored on a five-point Likert scale (1 = strongly agree, 5 = strongly disagree). Example items were ‘I feel like I am often considered as a nobody’, and ‘Physicians often judge me as a typical nurse’. All items were combined to one reliable scale (α = .88).
Willingness to collaborate. Physicians’ and nurses’ willingness to collaborate with
Perceived status differences. Perceived status differences were measured using a
self-constructed scale. This scale, consisting of 3 items, was scored on a five-point Likert scale (1 = never, 5 = always). An example item was ‘I perceive it as normal that physicians and nurses differ in status’. All items were combined to a reliable scale (α = .73).
Control variables
Several control variables were used: dominance and task complexity. Dominance was used as a control variable, because people who score higher on dominance are inclined to perceived more out-group threat, and could thus respond differently to the mediator (Sidanius & Pratto, 1999). Task complexity was used as a control variable to check whether the results remain even when the unique hospital work context is controlled for (Molleman, et al., 2010).
Dominance. Dominance was measured using the Dominance Circumplex Scale. This
scale, consisting of 11 items, was scored on a seven-point Likert scale (1 = Strongly disagree, 7 = Strongly agree). Example items were ‘In general, I try to exceed other’s achievements’ and ‘In general, I put people under pressure’. All items were combined to a reliable scale (α = 72).
Task complexity. Task complexity was measured with four items adapted from the
job complexity scale (Morgeson & Humphrey’s, 2006). This scale, consisting of 4 items, was scored on a seven-point Likert scale (1 = Strongly disagree, 7 = Strongly agree). Example items were ‘My job is simple and uncomplicated’, and ‘My job consists of relatively uncomplicated tasks’. All items were combined to a reliable scale (α = .78).
Factor analysis
making process and sharing patient information. The factor loadings of these scales can be found in Table 1. Importantly, however, the factor analysis also revealed that three items did not load on any specific factor, and that several items did not load on their original factor or had high cross loadings with another factor. Consequently, these items were deleted. The remaining items, which loaded on one of the three factors, often scored moderate on both ‘sharing patient info’ and ‘joint participation in the cure/care decision making process’, the three subscales were analysed as one highly reliable scale (α = .88).
Results Descriptive statistics
Descriptive statistics and correlations, such as means, standard deviations (SD) and Pearson correlations can be found in Table 2. First, I aggregated the scores medical and nursing students to overall combined scores for all variables involved. Surprisingly, professional identity was not significantly related to out-group threat and willingness to collaborate (respectively, r = -.10, n.s.; and r = .04, n.s.). As expected, out-group threat was negatively related to willingness to collaborate (r = -.57, p < .01). However, perceived status differences was not significantly related to professional identity, out-group threat and
collaboration (r = -.08, n.s.; r = -.04, n.s.; and r = -.08, n.s., respectively). Results showed that dominance was negatively correlated to out-group threat (r = -.16, p < .05), and educational background (r = -.30, p < .01). Furthermore, the results showed negative relations between task complexity and professional identity (r = -30, p < .01); and between task complexity and educational background (r = -.29, p < .01). Moreover, educational background was
significantly related to out-group threat and willingness to collaborate (r = .19, p < .05; and r = -.20, p < .05, respectively).
Subgroups. Table 2 showed that educational background was significantly correlated
statistics for the subgroups. Descriptive statistics and correlations of the subgroups; medical and nursing students, such as means, standard deviations (SD) and Pearson correlations can be found in Table 3.
Medical students. Remarkably, the results of medical students did show a significant
negative relation between professional identity and out-group threat (r = -.22, p < .05), and between out-group threat and the willingness to collaborate (r = -.42, p < .01). However, professional identity was not significantly related to their willingness to collaborate with nurses (r = .02, n.s.) As expected, perceived status differences was significantly related to out-group threat and willingness to collaborate (r = .30, p < .01; and r = -.27, p < .05,
respectively). Furthermore, dominance was positively related to out-group threat (r = .26, p < .05). Lastly, task complexity was negatively related to professional identity (r = -.26, p < .01).
Nursing students. The results of nursing students showed a strong negative relation
between out-group threat and willingness to collaborate (r = -.66, p < .01). However, professional identity was not significantly related to out-group threat and willingness to collaborate (r = -.04, n.s.; and r = .11, n.s., respectively). Remarkably, perceived status differences was positively correlated to the willingness to collaborate (r = .27, p < .05). Lastly, task complexity was negatively related to professional identity (r = -.27, p < .05).
Hypothesis Testing
of out-group threat, such that when perceived status differences are large, the relationship will be strengthened.
To test my hypotheses I conducted a multiple regression analysis (Table 4). In the first step of the analysis, the control variables were entered (i.e., dominance, task complexity, and educational background: model 1). In the second step of the analysis, the main independent variables were entered (i.e., their joint levels of professional identity, and their jointly
reported levels of perceived status differences; model 2). In the third step of the analysis, the interaction between their joint professional identity and the moderator (i.e., perceived status differences) was added to the equation (model 3). Finally, I ran bootstrap process models of Hayes (2007) to test the mediation hypothesis.
Willingness to collaborate. Hypothesis 1 stated that both professional identities
would be negatively related to their joint willingness to collaborate. As results show in Table 4, these variables were not significantly related (B = .06, SE = .09, n.s.), meaning that the first hypothesis is not supported by the results.
Interaction. I predicted that perceived status differences would moderate the
relationship between professional identity and out-group threat, such that when perceived status differences were large, the relationship would be strengthened. However, as Table 4 showed, the interaction coefficient for professional identity * perceived status differences was non-significant (B = .04, SE = .69, n.s.). Meaning that, contrary of what was expected, there is no prior evidence for a moderating effect of perceived status differences. Therefore, I can conclude that hypothesis 4 is not supported.
Mediation. Considering that there is no significant moderation effect, I conducted a simple mediation analysis (Hayes, 2013, model 4, 1000 bootstraps) to test whether out-group threat would mediate the relationship between professional identity and willingness to
a mediator, and willingness to collaborate as a dependent variable. Dominance and task complexity were entered as covariates. Firstly, the results (Table 5) showed that professional identity and out-group threat were not significantly associated (B = -.10, SE = .09, n.s.). Meaning, that hypothesis 2a is not supported. Second, in contrary with hypothesis 3, the results showed that out-group threat did not significantly mediate the relation between professional identity and willingness to collaborate (B = .05, SE = .04, n.s.). The confidence interval did include zero (-.03, .14). In conclusion, Hypothesis 3 is not supported.
However, out-group threat was positively associated with willingness to collaborate (B = -.57, SE = .07, p < .01), disconfirming Hypothesis 2b. Initially, out-group threat was
expected to relate negatively to willingness to collaborate.
Supplementary Analyses
Subgroups. Because there were significant correlations between educational
backgrounds of the participants, so either their medical or nursing background, and some of the model variables, I conducted one-way ANOVAs (Table 6) to test whether these group responses differed systematically and significantly. Medical students experienced
significantly less out-group threat (M = 4.07, SD = .53, F = 5.69, p < .05), more perceived status differences (M = 3.39, SD = .82, F = 14.88, p < .01), and more willingness to
collaborate (M = 3.38, SD = .43, F = 6.02, p < .05) than the nursing students (respectively M = 2.66, SD = .66; M = 2.81, SD = 1.00; and M = 3.19, SD = .53). I therefore also tested my conceptual model for each group separately (by conducting two additional multiple regression analyses (see Tables 7 and 8).
Medical students. Results of the multiple regression analysis (Table 7) show that no
The results show that there is no significant relation between the interaction coefficient professional identity x perceived status differences, and willingness to collaborate (B = -.38, SE = .93, n.s.). Meaning that there is no initial support for a moderating effect of perceived status differences.
Considering that there is no significant moderation effect, I conducted a simple mediation analysis (Hayes, 2013, model 4, 1000 bootstraps) to test whether out-group threat would mediate the relationship between professional identity and willingness to collaborate. Bootstrap analysis confirmed that out-group threat mediated the relation between professional identity and willingness to collaborate with nurses (B = .08, SE = .04, CI = [.01, .19]).
Nursing students. Results of the multiple regression analysis (Table 8) show that no
significant relation can be found between professional identity and willingness to collaborate (B = .18, SE = .15, n.s.). Interestingly, however, perceived status differences was positively related to willingness to collaborate (B = .27, SE = .13, p < .05), as opposed to the results of medical students.
Again, the results showed no initial support for a moderating effect of perceived status differences (B = -.22, SE = 1.10, n.s.).
Considering that there was no significant moderation effect, I conducted a simple mediation analysis (Hayes, 2013, model 4, 1000 bootstraps) to test whether out-group threat would mediate the relationship between professional identity and willingness to collaborate. However, in this group, bootstrap analysis disconfirmed that out-group threat mediated the relation between professional identity and willingness to collaborate with physicians (B = .02, SE = .09, CI = [-.16, .21]). The confidence interval did contain zero.
Social inclusion. This research was part of a larger study, in which social inclusion
him/her with a sense of belonging (Otten & Jansen, 2014). As mentioned before, a large part of professional identity is professional inclusivity, the feeling that one belongs to the
profession and feels treated as such (Weaver, et al., 2011). Therefore, I have conducted a supplementary analysis in which I have tested whether my conceptual model would be significant, when professional identity would be replaced with social inclusion.
In line with previous hypotheses, I expect that both social inclusion, and out-group threat will decrease the willingness to collaborate with the other profession; and that social inclusion will enhance feelings of out-group threat. I further propose that out-group threat will mediate the relation between social inclusion and willingness to collaborate. Lastly, I propose that perceived status differences will moderate the relation between social inclusion and out-group threat, such that larger perceived status differences will strengthen that relation.
In contrary to my expectations, the analysis showed that social inclusion was
positively associated to willingness to collaborate with the other profession (B = .38, SE = .08, p < .01).
Discussion
In this current research, it was hypothesized that professional identity was negatively related to willingness to collaborate with the other profession. Further, it was predicted that out-group threat would mediate this relation. Lastly, perceived status differences was predicted to moderate the relationship between professional identity, out-group threat and willingness to collaborate, such that larger differences would strengthen that relation.
The results of this current study disconfirmed all hypotheses. However, there were some interesting differences between medical and nursing students. Within the medical students group, perceived status differences was negatively related to willingness to collaborate. Though, within the nursing students group, perceived status differences was positively related to willingness to collaborate. Lastly, when focusing on social inclusion instead of professional identity, there were some significant findings. Results indicated that social inclusion is positively related to willingness to collaborate. Furthermore, perceived status differences moderated the relationship between social inclusion and out-group threat, such that this relation was only negative and significant under high perceived status
differences. In other words, medical and nursing students were less willing to collaborate with each other, when they were both highly socially included in their own group and perceived large status differences.
Theoretical Implications
There are alternative explanations for the findings regarding the unsupported
However, for the nursing students, there might be another explanation. Professional identity in nursing is complicated, since nurses struggle to define their work as opposed to the medical profession. This lack of clarity could cause a devaluation of their work (Willetts & Clarke, 2012). Public image of nurses is diverse and incompatible, partly due to their invisibility and lack of public discourse. This negative image has a negative influence on their self-concept and development of their professional identity. Nurses derive their professional identity from their public image, work values, education and values. Professional aspects of their job remain invisible, partly due to the dominant position of the medical profession (Ten Hoeve, Jansen and Roodbol, 2014).
Secondly, out-group threat did not mediate the relation between professional identity and the willingness to collaborate. Yet, there was no significant relation between professional identity and out-group threat as well. The social identity theory argues that professional identification is constituted of in-group favoritism and out-group threat (Tajfel, 1979). However, an explanation might be that this is only the case when the situation under analysis is a clear intergroup context (Turner, 1999). Medical students commonly report high levels of social exclusivity, while they tend to report a strong sense of intra-discipline care unit team inclusivity as well (Weaver, et al., 2011). So, an unclear intergroup context might have contaminated the results.
threat, but those variables can be relatively independent (Allport, 1954). Professional identity can be constructed easily, only by affirming that the in-group is relatively better than the out-group (Voci, 2006). Therefore, the students might have been identified to their profession, whilst they did not perceive any out-group threat.
However, interestingly, nursing students were significantly more threatened by the out-group (medical students), and were significantly less willing to collaborate with doctors. On the other hand, medical students were significantly less threatened by nursing students, whilst they were significantly more willing to collaborate with nurses. These results did form a little support for our mediation hypothesis.
Thirdly, perceived status differences did not moderate the relation between professional identity, out-group threat and willingness to collaborate. As stated before, deference in work teams arises from both perceived merit, based on expertise and experience and from formal authority (Bunderson, 2003; Hansson, et al., 2009). A possible explanation could be that medical and nursing students are not yet experienced and do not have a formal authority yet. In that case, deference can only be derived from their expertise, their
educational background. Therefore, it might have been the case that perceived status
differences were rather small and did not serve as a moderator. However, the results indicated significant relations between perceived status differences and willingness to collaborate. The absence of a relation between professional identity and willingness to collaborate might be the cause.
towards nurse-physician collaboration than medical students do (Brown, et al., 2015; Wang, et al., 2015). Nurses are more likely to view collaboration as being important for a good healthcare quality, and have more interests in a good collaboration than physicians do (Hojat, et al., 2003; Hughes & Fitzpatrick, 2010; Thomson, 2007). On the other hand, the medical profession possesses more power, so physicians do not perceive nurse-physician collaboration as necessary to enhance healthcare quality (Hansson, et al., 2009). These different perceptions might be derived from nurses’ and physicians’ different educational background and training (Hughes & Fitzpatrick, 2010). Nurses are trained in developing interpersonal skills with patients and other healthcare professionals, like physicians, furthermore they learn to make decisions interdependently with physicians (Hughes & Fitzpatrick, 2010). Furthermore, nurses want to collaborate with physicians to be able to share their valuable perspectives during the decision-making process. Nurses’ perspectives are more focused on patient care, including social and psychological well-being (Dougherty & Larson, 2005). This might explain the positive relation between perceived status differences and willingness to collaborate in the nursing students group. In contrast, physicians are trained to develop technical skills and find the best cure possible to treat diseases. As a result, the medical
profession is more focused on disease management and therefore is more satisfied by working autonomously. (Hughes & Fitzpatrick, 2010; Sirota, 2007). Furthermore, physicians dominate the power hierarchy, therefore they possess more power in the decision-making process. This might lead them to have less interest in an effective collaboration (Hansson, et al., 2009, Hojat, et al., 2003). This might explain why the medical students were less willing to collaborate with nurses.
words, medical and nursing students were less willing to collaborate with each other, when they were both highly socially included in their own group and perceived large status differences.
Again, out-group threat did not mediate the relation between social inclusion and willingness to collaborate. This result adds to our previous arguments about the lacking effect of out-group threat.
Practical Implications
There are some interesting practical implications following from the results of this study. First, this research shows that larger perceived status differences of medical and nursing students have negative implications for their willingness to collaborate. Since a lower level of willingness to collaborate is a precedent for other negative consequences like an increasing chance of medical errors (Matziou, et al., 2014), nurses that are prohibited to demonstrate task knowledge, resulting in less integration of their unique and valuable perspectives (Alexander, et al., 2009, Greer et al., 2014), and more importantly decreasing quality of care. However, social inclusion within both professions is very important as well, since it enhances collaboration within professions (Pratt, et al., 2006). Specifically, hospitals could take steps to shield medical and nursing staff from large status differences. For instance, organizations could create a working atmosphere in which status differences are less
important. This might not be easy, since a lot of status differences are created during their studies, or in society itself. Therefore, it is advised to all parties involved to realize that a greater understanding of another’s tasks and more communication eventually leads to greater medical successes and less medical errors.
better collaboration (Hawkes, Nunney & Lindgvist, 2013). Furthermore, this does not affect professional identity or social inclusion within the profession. This is important, because professional identity has important benefits for collaborating with members of your own profession. According to Turrentine, et al. (2016), interprofessional training on the work floor enables students to learn about, from and with each other, better preparing them to integrate into interdisciplinary teams. This is important, because a better understanding of tasks and responsibilities of the other profession will increase the willingness to collaborate with the other profession. Yet, this interprofessional training could add to a so-called ‘interprofessional identity’ (Bleakley, 2011). As the dual identity model argues, the collaboration between physicians and nurses could be improved when physicians and nurses feel like they belong to their profession and that they belong to the interprofessional care unit team (Caricati, et al., 2015). Therefore, an important advice to hospitals is to provide interprofessional training or education. Eventually, this will lead to a higher quality of care.
Potential Limitations
Like all research, this study is not without its limitations. Due to the correlational design, internal validity is lacking as we measure and not manipulate our variables. That is, we cannot draw causal inferences from the present study (McLeod, 2008).
In addition, this present study lacks external validity as well. Meaning that this current research comprised a very small sample of medical and nursing students. Known is that means, Pearson correlations and other sample findings could be imprecise estimates of the population when sample sizes are rather small (Baguley, 2012). Yet, a small sample size tend to result in a very limited statistical power for detecting population differences and relations of interest (Leppink, Winston & O’Sullivan, 2016).
(Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). We did so, because our focus was on participant’s subjective experience of our variables. The use of self-reports can possibly have affected social desirability, which in turn might have exaggerated our findings.
Another important limitation is that we asked medical and nursing students about their group, while measuring social inclusion. This results in a lack of knowledge about what they perceive as being their group. They might have perceived their team as only the medical or nursing team, or they might have perceived their team as it is a student team. Another option could be that they perceive it as their healthcare department team, so an interprofessional group. However, literature states that medical students are made to feel part of the medical team (Weaver, et al., 2011). According to Bleakley (2011), it is more likely that this means that students feel part of the medical team, than the wider health care team.
Lastly, another important limitation is that we asked medical and nursing students to fill in a questionnaire about the extent to which they collaborate with the other professional group. Although, third year medical master students and fourth year nursing students actually do collaborate with nurses and medical specialists, respectively, younger students do not. So, the scale might not represent their real willingness to collaborate, but more their expectations of the collaboration.
Directions for Future Research
Further, I would recommend to validate the Dutch version of the Nurse-Physician Collaboration Scale (Ushiro, 2009). Although, the results of this current study are based on a small sample size, they indicate that it is a good scale. I recommend to retest the scale with the use of a sample of third year medical students, fourth year nursing students or healthcare professionals.
In light of the results of this current research, it seems important to think about ways to reduce status differences and increase collaboration. Although this is not easy and a certain amount of status differences will be inevitable. One important question for future research is how medical and nursing students respectively develop their professional identity and thus how they are prepared to their future collaboration. This study is a cross-sectional study, which means that data is collected from a sample at one specific point in time due to time constraints. However, it would be very interesting to investigate how students develop their professional identity over the years, especially when results could be measured for the same individual both in low and high status difference settings on the work floor, for instance in different departments like geriatrics (lower status differences) and cardiology (higher status differences). It is important to know which departments are most troublesome in the light of interdisciplinary collaboration, and how to solve these problems.
Another interesting direction for future research would be to test the moderating role of status differences on the relation between professional identity, in-group favoritism and willingness to collaborate. Meaning that, research will be more focused on the positive side of professional identity, instead of the dark side.
Conclusion
that out-group threat still does not mediate the relationship. Further, status differences moderate the relation between social inclusion, out-group threat and willingness to
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Table 1.
Factor analysis Nurse-Physician Collaboration Scale (Ushiro)
Component Cooperativeness Sharing
patient info
Joint
participation Verpleegkundigen en artsen overleggen
met elkaar over hoe medische fouten kunnen worden voorkomen
.452
Verpleegkundigen en artsen praten gemakkelijk met elkaar over andere onderwerpen dan werk
.738
Verpleegkundigen en artsen delen makkelijk informatie en meningen over dingen die met hun werk te maken hebben
.669
Verpleegkundigen en artsen bekommeren zich om elkaar als ze erg moe zijn
.691
Verpleegkundigen en artsen helpen elkaar .700 Verpleegkundigen en artsen groeten elkaar
elke dag
.563
Verpleegkundigen en artsen houden rekening met elkaars roosters wanneer ze een gezamenlijk behandelmoment plannen
.612
Wanneer een patiënt wordt ontslagen uit het ziekenhuis, overleggen artsen en verpleegkundigen met elkaar waar de behandeling van een patiënt moet worden voortgezet en over de leefregels die een patiënt moet volgen
.432
Verpleegkundigen en artsen overleggen gezamenlijk over de verandering die zij in de organisatie van de patiëntenzorg willen realiseren
.405
Wanneer een patiënt een zorgverlener niet meer vertrouwt, proberen verpleegkundigen en artsen om de situatie samen met de patiënt op te lossen
Verpleegkundigen en artsen zijn op de hoogte van de informatie die aan de patiënt is verstrekt over zijn/haar aandoening of behandeling
.553
Verpleegkundigen en artsen wisselen informatie uit over het verloop van een behandeling
.575
Verpleegkundigen en artsen gaan bij elkaar na of er bij de patiënt tekenen zijn die wijzen op bijwerkingen of complicaties
.704
Verpleegkundigen en artsen vertellen elkaar over de reactie van een patiënt op uitleg over zijn/haar aandoening en behandeling
.526
Verpleegkundigen en artsen delen
informatie over de zelfredzaamheid van een patiënt op ADL gebied
.610
Verpleegkundigen, artsen en de patiënt hebben allemaal hetzelfde beeld over de verwachting van een patiënt over de behandeling en zorg
.414 .402
Verpleegkundigen en artsen discussiëren regelmatig met elkaar om medische en verpleegkundige problemen op te lossen
.442
Als verpleegkundigen en artsen van mening verschillen over het beleid voor de zorg aan een patiënt, bespreken ze dat om hun verschil in inzicht op te lossen
.489
Verpleegkundigen en artsen overleggen regelmatig of moet worden doorgegaan met een behandeling, wanneer deze niet het verwachte effect heeft
.554
Wanneer artsen en verpleegkundigen worden geconfronteerd met een moeilijke patiënt, overleggen ze met elkaar over hoe de situatie moet worden aangepakt
.422
bijwerkingen of complicaties optreden, overleggen artsen en verpleegkundigen samen over het te volgen beleid
Het verdere behandelplan van een patiënt is gebaseerd op een wederzijdse uitwisseling van meningen tussen artsen en
verpleegkundigen
.663
Wanneer er een verandering optreedt in het behandelplan, hebben artsen en
verpleegkundigen dezelfde informatie over de redenen voor deze verandering
.512
Table 2.
Descriptive statistics and correlations
M SD 1 2 3 4 5 6 1. Prof identity 4.13 .55 (.84) 2. Out-group threat 2.53 .62 -.10 (.88) 3. Collaboration 3.30 .49 .04 -.57** (.88) 4. Status differences 3.13 .95 -.08 -.04 -.08 (.73) 5. Dominance 3.80 .69 -.11 -.16* -.06 .13 (.71) 6. Task complexity 2.27 1.06 -.30** .05 .09 .14 .14 (.78) 7. Education 1.46 .50 .13 .19* -.20* -.30** .04 -.29** Note. * p < 0.05; ** p < 0.01; N = 154; (..) = Cronbachs’s alpha
Table 3.
Descriptive statistics for medical (below diagonal) and nursing students (above diagonal)
M Medical SD Medical M Nursing SD Nursing 1 2 3 4 5 6
1. Prof identity 4.07 .53 4.21 .57 1 -.04 .11 -.08 -.20 -.27* 2. Out-group threat 2.42 .57 2.66 .66 -.22* 1 -.66** -.21 .07 .13 3. Collaboration 3.39 .43 3.19 .53 .02 -.42** 1 .27* .07 .14 4. Status differences 3.39 .82 2.81 1.00 .01 .30** -.27* 1 .13 .11 5. Dominance 3.78 .61 3.83 .78 -.03 .26* -.21 -.18 1 .21 6. Task complexity 2.53 1.07 1.92 .94 -.26* .11 -.04 -.01 .11 1
Table 4.
Multiple Regression Analysis medical and nursing students
Willingness to collaborate
Model 1 Model 2 Model 3
Predictor B SE B SE B SE Controls Dominance -.08 .08 -.09 .08 -.09 .09 Task Complexity .10 .08 .11 .09 .11 .09 Main effects Professional identity .06 .09 .04 .29
Perceived status differences .08 .08 .05 .65
Interaction
Professional identity x Perceived status differences
.04 .69
Table 5. Mediation analysis Variable b SE t p Out-group threat -.57 .07 -8.28 .00 Professional identity -.00 .07 -.03 .98 Dominance .01 .07 .18 .86 Task complexity .12 .07 1.67 .10 Note: R2 = .43; F = 21.17; p = .00 Mediation effect
Variable B SE LLCI ULCI
Out-group threat .05 .04 -.03 .14
