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

ORIGINAL RESEARCH

Maintaining equilibrium in professional role identity: a grounded

theory study of health visitors’ perceptions of their changing

professional practice context

Alison I. Machin, Tony Machin & Pauline Pearson

Accepted for publication 12 November 2011

Correspondence to A.I. Machin:

e-mail: [email protected]

Alison I. Machin MSc PhD RN

Principal Lecturer

School of Health Community and Education

Studies, Northumbria University, Newcastle

upon Tyne, UK

Tony Machin MSc PGCE RN

Principal Lecturer



upon Tyne, UK

Pauline Pearson BA PhD RN

Professor of Nursing



upon Tyne, UK

MACHIN A.I . , MACHIN T. & PEARSON P. (2012)MACHIN A.I . , MACHIN T. & PEARSON P. (2012) Maintaining equilibrium in

professional role identity: a grounded theory study of health visitors’ perceptions of

their changing professional practice context. Journal of Advanced Nursing 68(7),

1526–1537. doi: 10.1111/j.1365-2648.2011.05910.x

AbstractAims. This article reports the study of a group of United Kingdom health visitors’

interactions with their changing practice context, focusing on role identity and

influences on its stability.

Background. United Kingdom policies have urged health visitors to refocus their

role as key public health nurses. Reduced role identity clarity precipitated the

emergence of different models of health visiting public health work. An inconsistent

role standard can lead to role identity fragmentation and conflict across a group. It

may precipitate individual role crisis, affecting optimum role performance.

Methods. Seventeen health visitors in two United Kingdom community healthcare

organizations participated in a grounded theory study, incorporating constant

comparative analysis. Direct observations and individual interviews were under-

taken between 2002 and 2008.

Results/findings. Four interlinked categories emerged: professional role identity

(core category); professional role in action; interprofessional working; and local

micro-systems for practice; each influencing participants’ sense of identity and self-

worth. The Role Identity Equilibrium Process explains interactive processes occur-

ring at different levels of participants’ practice.

Conclusion. Re-establishing equilibrium and consistency in health visiting identity

is a priority. This study’s findings have significance for other nurses and health

professionals working in complex systems, affected by role change and challenges to

role identity.

Keywords: family nurse, grounded theory, health visiting, preventative family

health care, public health nursing, role identity

1526 � 2011 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

Introduction

Global healthcare systems are characterized by: persistent

health inequalities; an international health economy under

pressure; and complex inter-relationships between countries,

organizations and professionals. In response, existing health-

care roles are evolving and new roles emerging which can

lead to blurred practice boundaries and unclear responsibil-

ities. To remain fit for purpose, professionals must adapt,

however, working differently can challenge established role

identity.

Conflicting views exist on the core nature of a public

health-related, health visiting role identity (Smith 2004).

Imbalance between role legitimacy, adequacy and support

may impact negatively upon role performance (Machin &

Stevenson 1997) leading to possible identity confusion. Left

unresolved this may result in individual psychological crisis

(Caplan 1961).

This article details a grounded theory study (Glaser &

Strauss 1967) of health visitors’ interaction within their

changing professional context. The study was conceptualized

when health visitors were being urged by policy change to

undertake more family orientated public health work (Home

Office 1998). In local contexts some health visitors perceived

existing roles to be entirely public health, perceiving no need

for change and felt devalued. Others suggested public health

would represent additional time burdens, negatively affecting

existing service provision. It was envisaged that this research

study would clarify factors influencing the health visitors’

perceptions, informing strategies to address apparent differ-

ences.

Background

United Kingdom (UK) health visitors are Registered Nurses

with additional specialist education (Nurses Midwives and

Health Visitors Act 1997) to work in preventative contexts

with individuals, families and communities. The role shares

similarities with the public health nurse or family nurse role

common in other European countries and America. The

nursing role in preventative family health care, working

alongside community and other health professionals, is

integral to World Health Organisation (WHO) strategy for

improving child and family health towards achievement of

health-related millennium development goals (WHO 2011).

In the UK, shared health visiting identity is, theoretically,

facilitated by four practice principles (CETHV 1977). How-

ever, there has been little policy consensus in applying public

health concepts within health visiting roles (SNMAC 1996,

Home Office 1998). Research suggests confusion continues

with the emergence of different models of public health work

in health visiting (Pearson et al. 2000, Carr et al. 2003, Carr

2005). A title change from Health Visitor to Specialist

Community Public Health Nurse (SCPHN) [Nursing and

Midwifery Council (NMC) 2004a], caused further disagree-

ment within the profession (Cowley 2007) exacerbating this

confused identity picture.

Being prerequisite for health visiting, nursing will influence

practitioners’ identity. Fagermoen (1997, p. 436) determined

two groupings of nursing identity values, ‘self orientated’ and

‘other orientated’. Autonomy, a key professional attribute

(Macdonald 1995), was not identified as a self orientated

value, despite their interviewees being senior nurses. Ohlen

and Segesten (1998) studied the effect of role change on

nursing identity. One nurse suggested her identity was stable

and meant ‘feeling’ like a nurse, not just working as a nurse

(p. 723). They concluded self-image and self-esteem are core

to personal identity, the latter being the foundation for

professional identity and role function.

Identity is self verifying through social interaction and

dialogue (Burke 1980, Rapport & Wainright 2006).

Shared role understandings facilitate role recognition.

However, individuals may debate the relative value of

each role aspect. Where roles are practiced inconsistently,

role identity may fragment within a group (Collier 2001).

Castells (1997, p. 8) suggested three types of political

identity construction: ‘legitimizing’, engendering to order,

predictability and perpetuation of the social structures

from which it is generated; ‘resistance’, actively resisting

dominant oppressive forces in society; and ‘project’, the

deliberate, transformational building of identity (Godin

1996).

A common stable identity can be a vehicle for advancing

practice (McDonald 2004). However, instability in health-

care systems may create ‘identity uncertainty’ (Williams &

Sibbald 1999). Left unmanaged, identity confusion may leave

individuals feeling disempowered (McDonald 2004), nega-

tively affecting service provision. Health visiting has been

described as a profession in crisis (Craig & Adams 2007), and

processes influencing health visitors’ experiences in profes-

sional contexts are not well understood.

The study

Aim

The aim was to generate theory explaining processes by

which health visitors interpreted and interacted with policy

driven changes to professional practice contexts. Two

research questions guided the study:

JAN: ORIGINAL RESEARCH Professional role identity: HV perceptions

� 2011 Blackwell Publishing Ltd 1527

• How are health visitors interacting with their changing

professional practice context?

• How have the changes influenced them and their practice?

Design

Grounded theory methodology (Glaser & Strauss 1967) is

rooted in interpretivism (Hughes 1990) and a symbolic

interactionist (Blumer 1969) perspective which suggests

reality exists in meanings individual social actors derive from

interpreted interactions. Study design was also influenced by

negotiated order theory, acknowledging influences of orga-

nizational systems (Strauss 1978). A process of constant

comparative analysis was undertaken, with theoretical sam-

pling, data collection and analysis occurring concurrently

during the research process (Strauss & Corbin 1990),

generating theory from the data.

Sample/participants

Theoretical sampling, using a sampling matrix (Reed et al.

1997) guided selection of participants based upon relevance

to the study and emerging theory. The matrix was

constructed from responses to postal questionnaires sent to

potential participants (N = 160) from two UK community

healthcare organizations. Both were promoting the public

health role of health visitors and changes to service delivery.

It was anticipated participants would therefore have experi-

ence of changing professional practice contexts. Inclusion

criteria for follow-up required registration as a health visitor

and anticipated relevance to theoretical issues emerging from

data analysis. For example, on the matrix, participant 1

suggested their work was 100% public health therefore

potentially able to give rich data. Subsequent participants

were selected from the matrix, seeking maximum data

variation. As analysis progressed, sampling became increas-

ingly theoretical with ‘far out’ examples chosen to challenge

the emerging theory (Strauss & Corbin 1990). Following

procedures for informed consent, 17 participants were

selected from the matrix over the course of the study, 15

women and 2 men. The number of years since initial

preparation for health visiting role varied from 2 months to

20 years. Thirteen participants held caseloads, two held

specialist health visiting roles and two specialist nursing roles.

Data collection

Data were collected between 2002 and 2008, the constant

comparative analysis (Glaser & Strauss 1967) extending the

time spent in collecting data. Ten direct observations of

participants in their usual work context were undertaken.

Condensed field notes taken during observations noted

factors relevant to the research question and aims. These

notes were expanded afterwards (Spradley 1980, p. 69),

depicting a more detailed picture of participants’ practice

context. Observation data mainly informed development of a

data category labelled ‘professional role in action’. After ten

observations no new data emerged to augment the category

concepts, therefore observations ceased. Data collection

subsequently focused on interviews where the meanings

participants attached to their practice could be established.

Twenty individual, tape recorded interviews were under-

taken, 17 initial interviews and 3 follow-up interviews, the

latter used to further explore and check emerging theory.

Semi-structured interviews allowed new areas of discussion

to emerge whilst ensuring the interview remained relevant to

the research question (Bowling 2002). A guide of six broad

topics, developed from preceding and ongoing analysis, was

used to frame theoretical relevance of discussion. Topics

included: meanings participants afforded the term public

health and how that was incorporated into practice; percep-

tions of preparation for the public health role and its efficacy;

what they understood health visiting role to entail and its

relation to previous nursing role; opinions about policy and

professional changes; what their current role was; and key

factors influencing feelings about their work.

Literature searching continued throughout the research,

providing additional contextual data (Clarke 2005) and

facilitating ongoing theoretical sensitivity, a key feature of

grounded theory methodology, referring to the reflexive,

interpretative relationship the researcher has with existing

knowledge and theory (Glaser 1978, Strauss & Corbin 1990).

Whilst this enhanced the constant comparative process, the

insiderpositionof the researcher andreflexive relationship with

the research was also acknowledged (Reed & Procter 1995).

Ethical considerations

The Research Ethics Committee with ethical governance

responsibility for healthcare research in the region gave

permission for study, as did research and development

departments in both participating organizations. Information

was provided, and consent secured from participants. Con-

fidentiality in reporting was assured, together with rights to

refuse or withdraw at any time. Given the nature of public

health work, other professionals and service users who were

not participants were present in observation settings. They

were afforded the same reassurance as participants. The

NMC professional code of conduct (Nursing and Midwifery

Council 2008) augmented governance.

A.I. Machin et al.


Data analysis

Data with shared characteristics were categorized and

examined for ‘fit’ with the emerging grounded theory using

a range of analytical processes (Strauss & Corbin 1990).

Observation field notes and interviews were transcribed

verbatim and analysed line by line using ‘open’ or ‘substan-

tive’ coding techniques. This informed selection of subse-

quent study participants and reflexive evolution of the

interview guide. As categories consolidated, axial and vari-

ational analysis sought data which broadened properties and

dimensional ranges of categories. In the final stages of

constant comparative analysis, selective, theoretical, coding

tested ideas and explored ‘far out’ examples, challenging or

confirming proposed theory.

Rigour

Within an interpretative methodology, the canons by which

quantitative studies are judged are irrelevant without adap-

tation (Strauss & Corbin 1990). The quantitative research

term ‘validity’ is rarely used in grounded theory research,

although the concept is integral to the rigour of any study.

Criteria for judging grounded theory studies (Strauss &

Corbin 1990) were used throughout the constant, compar-

ative process, checking emergent theory against data and

literature, for ‘accuracy’ or ‘fit’ with participants’ perceived

reality (Smith & Biley 1997). Supported by processes of

supervision and peer review including co-authors, the final

categories and theory were affirmed as accurate reflections of

data collected. Some re-interviews were undertaken, provid-

ing opportunities to recheck accuracy of interpreted data in

reflecting participants’ meanings. A reflective diary enabled

the researcher to note issues which may have affected

research processes and data interpretation (Machin 2009).

Results

Theory developed from this study proposes that health visitor

participants’ professional role identity is influenced, through

a self-referent feedback process, by: other health visitors;

interprofessional colleagues; and local and national policies.

Through processes of ‘maintaining identity equilibrium’

(Figure 1), participants interact and interpret this feedback

to establish stability and value in professional role identity.

Four data categories were identified within the developed

theory. The category Professional Role in Action is presented

first. This captures the work of individual health visitors,

forming a basis for understanding their role perceptions. The

core category of Professional Role Identity is then presented,

depicting meanings participants attached to their Professional

Role in Action, providing foundation for the theory gener-

ated. It also reflects effects of other people and systems upon

identity. This is elaborated in subsequent presentation of the

remaining two categories, Interprofessional Working and

Local Micro-Systems for Practice. Categories comprised a

number of properties and sub properties (Table 1), each with

a dimensional range (Strauss & Corbin 1990). It is not

possible within the present scope to undertake detailed

discussion of interrelationships between all concepts, discus-

sion reflects only the essence of each main category,

supported by data. How categories relate to the Role Identity

Equilibrium Process (RIEP) (Figure 1) developed from the

findings, is also identified. Participants have been coded with

P and a number depicting order of selection.

Professional role in action

Three principles of health visiting (CETHV 1977) were

evident throughout participants’ professional role in action

through: assessing health needs of individuals, families and

populations; raising awareness of needs in home and clinic

settings, through campaigns and multi agency working; and

facilitating health enhancing activities. Several participants

belonged to cross agency groups tackling, for example, child

accident prevention, acting as liaison between services,

providing a health visiting perspective. However, partici-

pants’ work influencing policy was difficult to identify except

when employed in strategic leadership positions, supporting

earlier research findings (Carr et al. 2003).

Participants mainly worked with individuals in home or

clinical settings, assessing need and establishing relationships.

However, one participant employed group approaches to

smoking cessation, viewing this as an effective context for the

work. Other group activities identified, such as postnatal

support, aimed to facilitate social support networks. Work

focused mainly, although not exclusively, on families with

preschool children, reflecting policy emphasis [Department of

Health (DoH) 2011]. Other work included: adults’ exercise

class; healthy lifestyle work in schools; visiting older people

and cardiac rehabilitation. Work with older people was less

prioritized, supporting earlier research (Davidson & Machin

2003) suggesting work with older people was perceived as a

‘luxury’. Work with groups other than preschool children

sometimes overlapped with other nurses:

In terms of doing health assessments ….we share that equally.. the

practice nurses, see the elderly who are able to walk to the surgery,

district nurses would see the ones at home that they are nursing.. I see

the others (P8).



However, ‘role interchangeability’ between nurses and health

visitors may precipitate blurred role boundaries, and confu-

sion in interprofessional working (Cowley 2007, Harmer

2010) potentially affecting identity equilibrium of those

involved as they seek to establish value within teams.

Knowledge underpinning practice also overlapped: within

nursing and medical knowledge domains, around prescribing,

smoking, obesity and hypertension; and in social domains with

nursery nurses and social workers around family support and

safeguarding children. This perceived variation in role may

reflect role autonomy, the increasing range of healthcare

contexts where health visitors practice, and influences of others

in the interprofessional team. Within the individual identity

dimension of the Role Identity Equilibrium Process (RIEP)

(Figure 1), practitioners interpret interactions in practice

seeking affirmation and stabilization of role identity through

self-referent, verifying feedback (Collier 2001, Foley 2005).

This process echoes processes of ‘double loop’ reflection in and

on practice (Argyris & Schon 1996). Interactions over time in

their professional practice setting influences identity (Blumer

1969) and the degree of perceived identity equilibrium expe-

rienced (Figure 1).

Professional role identity (core category)

Interactions with other health visitors influenced the equilib-

rium of the professional role identity of individuals within it

(Figure 1). Several areas of consensus in data suggested a

unifying, stabilizing, collective professional role identity. For

example, home visiting for relationship building, an estab-

lished core feature of health visiting (De La Cuesta 1994,

Cowley & Frost 2006), was highly valued, with recent

attempts to reduce it provoking a collective defensive

response:

Interactive, reflexivefeedback from referent group

Collective identity Professional referent group Professional role in action

Individual identity

Individual professional role in action

Self - referent feedback

Individual professionalrole identity

MAINTAINING IDENTITY EQUILIBRIUMM

AIN

TA

ININ

G ID

EN

TIT

Y E

QU

ILIB

RIU

M

Public identity (interactive) Interprofessional referentgroup Interprofessional working

Interactive, reflexivefeedback from other referent groups

Public identity (structural)Organisational referent point Micro systems for practice (local)

Public identity (structural & cultural)

National policy referent point

Identityverified viareflexiveinteractionwith roleparameters

Identityverified viareflexiveinteractionwith policyparameters

Figure 1 Role identity equilibrium

process.

A.I. Machin et al.


…… the home visiting part of health visiting was rubbished ….it

wasn’t valued…the health visitors challenged it (P4).

There was also evidence of a collective resistant identity

(Castells 1997), exercised through much valued autonomy,

although this might be perceived as change resistance.

Reports come out like Hall 4 but some health visitors are ignoring it

and doing what they’ve always done anyway (P3).

Autonomy, a core aspect of health visitors’ identity and a self

orientated value, suggests differences from nursing identity as

described by Fagermoen (1997).

Participants agreed on the importance of universal service

provision. UK policy (DoH 2009, 2010) suggests moving

towards ‘proportionate’, ‘progressive’ universalism to effi-

ciently address health inequalities, minimum service to all,

with resource reallocation on the basis of need.

However, one participant working in an area categorized

as ‘affluent’, felt devalued by this and by interactions with

health visitor peers suggesting that not all health visitors had

the same perspective:

…I think that people [other health visitors] think that round here

people don’t need health visitors! (P9).

Table 1 Table of categories.

Categories

Professional role

identity (Core category)

Professional role

in action

Interprofessional

working

Local micro-systems

for practice

Properties and sub properties

The essence of health visiting Context of health visiting

practice

Working with other nurses Practice maintenance systems

Home visiting Clinic Role differentiation Specialist health visiting

Challenging traditional practice Home Influence of manager’s

background

GP attachment

Professional autonomy Drop in Working collaboratively Corporate caseload

Influence of policy driven role

change

Community Role interchangeability

Group

The meaning and significance of

public health work

Collaboration Working with medical

professionals

Resource management

approach

Policy awareness Role overlap Influence of public health targets Available staff resource

Comfort with public

health role

Working with others Relative autonomy Organizational priorities

Health inequalities Knowledge for health visiting

practice

Professional hierarchy Workload equity

Public health role in practice Nursing Lack of role awareness Management support

Commitment to public health Social Protocols for practice

Role adequacy Medical Post natal depression

Smoking cessation

Child development surveillance

Nursing as a foundation for

health visiting identity

Health visiting clients The interagency dimension System overlap

Adequacy of education for role Age Collaborative confidence Influence of infrastructure

Significance of nursing

knowledge

Sex Managing complexity Influence of policy change

Professional credibility Individuals Role awareness Effectiveness of information

sharing systems

Groups Conflicting values

Populations Power and control

Significance of pre-defined role Framework for practice: health

visiting principles

Working with nursery nurses Practice development approach

Influence of stereotypes Assessing health needs Nursery nurse skills Project driven change

Identity portability Influencing policy affecting health Professional responsibility Resource driven change

Facilitating health enhancing

activities

Raising awareness of health needs



Disagreement was evident on the meaning of a public health

role and the impact of attempts to alter existing practice.

Suggestions that public health was new to health visiting

invoked an emotive example:

Health visitors are ‘up to here!’ at the moment, they’re sick of being told

they should be doing public health when they always have been (P2).

Implicit here is an assumption that all health visitors felt the

same. However for others, public health work was addi-

tional, less prioritized than child/family caseload work:

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

The child health screening function of role also engendered

different responses:

[Universal developmental screening is] totally pointless… a total

waste of time (P3).

Conversely:

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

Ambiguity around legitimacy of different role aspects

(Machin & Stevenson 1997) was challenging the role identity

of one participant who was considering leaving service

because of the lack of support from peers:

There’s a lot of.. friction between different colleagues em, with the

ones that are doing public health work and the ones that say they

haven’t time to….(P4).

There was disagreement about the relationship of nursing to

health visiting. Several participants felt their nursing qualifica-

tion enhanced professional credibility and public identity. One

participant appeared to wrestle with notions of having moved

on from nursing, yet wanting to maintain role credibility:

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

Another participant valued nursing identity as pre requisite

for health visiting, reflected in disapproval of direct entry to

education for health visiting role:

I don’t even think a newly qualified nurse could come into health

visiting, you need so much experience and expertise.. to deal with the

families in those situations (P16).

Foranotherparticipant,theprofessionalregisterchangeofhealth

visitortitle infavourof‘specialistcommunitypublichealthnurse’

(NMC 2004a) undermined the distinctiveness of the role:

NMC, UKCC and the government who is the lead on this, have sent

out a profound message to health visiting about how they’re valued

….. I think we were sold down the river (P15).

Tension in debate relating nursing to health visiting identity is

captured by the following quote:

I think there’s a kind of a tension with this because [health visitors

are] kind of proud to be nurses but don’t necessarily want to be

grouped as nurses, they want to be grouped as health visitors (P17).

In the collective identity dimension of the RIEP (Figure 1)

individuals interact with the peer group assumed to share

collective role identity, which should ideally give an identity

referent point for individuals. However, this study suggests

collective identity cannot be assumed. Disagreement between

peers evidently causes discomfort and disequilibrium, leading

to identity displacement for some.

Interprofessional working

In practice environments, other professionals also influenced

participants’ role identity, for example doctors. Historically,

medicine entails more power than nursing in health systems

(Freidson 1970), often perpetuated from within nursing

(Roberts 2000) through social interaction (Riley & Burke

1995), a sign perhaps of legitimizing identity (Castells 1997):

I decide what’s the priority ….unless the GP asks me to see

somebody... (P7).

There was indication this power balance might be changing:

At one time people would say ‘yes doctor no doctor’ but I think now

people will say...why have I got to do that? What difference will it

make? (P3)

The interprofessional nature of public health work was

identified by one participant, although she questioned the

adequacy of preparation for the role:

How can we [health visitors] expect to be working with other people

in a public health…. if we haven’t got the skills ourselves.. other

agencies aren’t going to respect our input (P3).

This reflects other findings (Pearson et al. 2000) questioning

whether cross agency public health is viewed as core to health

visiting role identity for which new entrants are prepared.

One participant suggested health visitors increasingly

needed to defend their practice in interprofessional contexts,

linking to earlier discussion on role interchangeability:

I think the spirit of health visiting has been lost ………… they’re

[other professionals] trying to take over our roles well (P16).

Interprofessional team influence on participants’ professional

role identity is reflected within the interprofessional, public

identity dimension of the RIEP (Figure 1). One participant

identified the role of health visitors in interprofessional

A.I. Machin et al.


working as providing a health visiting perspective. However,

identified ‘role interchangeability’, knowledge overlaps and

deficient role standards (Burke 1980), can make it difficult to

articulate the unique nature and value of health visiting/This

may have caused identity disequilibrium for practitioners

(Hall 2003) through conflict arising from misunderstanding

of expectations within interprofessional contexts.

Local micro-systems for practice

Most participants worked in practice maintenance systems

within doctor-led teams, perceiving this as effective. Some

participants were negative about work in increasingly com-

mon, corporate caseload systems, which fits with other

research findings (Craig & Adams 2007):

I feel that I’m struggling to maintain continuity of a kind and I’m

struggling to maintain effective communication…..the organisation

takes a massive amount of time ….. I’m really, really stressed about

it (P11).

In discussing resource management and workload allocation

systems, health visitors were clearly feeling effects of national

shortage of health visitors (Craig & Adams 2007),

Where there are staffing problems …you are on your knees before

you get help (P8).

They also felt devalued by the financial remuneration

category in which they were placed during human resource

reclassification (DoH 2004). Significantly, public health work

was perceived as being de-prioritized by local redeployment

of community development health visitors into caseloads.

Participants who had changed organizational roles still

indicated a strong sense of ‘feeling’ like health visitors, linked

to public health. For example:

I do feel as a health visitor ……..though my job title is officially

specialist nurse, I always put/health visitor at the end of any

communication because em, my role is public health (P16).

This suggests a degree of ‘identity portability’ within systems.

However, data indicated variation in what ‘being a health

visitor’ actually meant to individuals, influenced by interac-

tion within individual changing professional practice

contexts.

The public identity (structural) level of the RIEP (Figure 1)

depicts processes by which variations in local practice

systems such as human resource priorities, practice mainte-

nance and local policies affect identity of individuals and

others in the system. Unpredictable organizational health

visiting role standards in local settings and different levels of

management support influenced the professional identity of

individuals through interaction and feedback. This could

occur directly or indirectly. Similarly the public identity

(structural and cultural) (Figure 1) illustrates how macro

level policies can directly affect the identity equilibrium of

individuals, for example the health visiting role title change,

or indirectly through policy driven organizational change and

interaction with others in change management positions in

the healthcare system.

Discussion

Limitations of the study

Barbour (2000) suggests ‘theoretical generalizability’ in

qualitative research derives from production of new models

or ‘typologies’, such as the proposed explanatory model

presented herein (Barbour 2000, p. 158) which is likely to

resonate with UK health visitors sharing some history and

policy context (Williams 2000). The theory generated is also

relevant to other professions in the UK and internationally,

experiencing similar contextual role changes and challenges.

The theory developed here involves several general concepts,

such as identity, role and profession, providing propositions

about relationships between them. The model generated

therefore represents ‘practical wisdom’ (Macnaughton 1998),

providing others with insights to ‘control’ their situation

(Glaser & Strauss 1967) through improved understanding.

Discussion of the findings

The grounded theory generated here is reflected in the Role

Identity Equilibrium Process (Figure 1) introduced and

developed alongside the findings in the previous section. It

proposes health visitor participants’ professional role identity

is influenced by the interpretation of feedback from social

interaction in professional practice contexts. Processes of

‘maintaining identity equilibrium’ enable individuals to

interpret different contextual influences relating to existing

professional role identity and respond to identity threats,

reaffirming value and self worth. This section develops the

discussion, considering the wider relevance of findings to

individual, collective and public identity.

Individual and collective identity

Findings illustrate the lack of consensus around public health

role identity of UK health visitors (Pearson et al. 2000, Carr

et al. 2003, Smith 2004, Cowley & Frost 2006). They also

reflect diversity and apparent lack of clarity in public health

nursing work in other international contexts (Philibin et al.

2010, Valaitis et al. 2011). For some participants public



health work meant smoking cessation, immunizations and

hypertension screening, underpinned by medical and nursing

knowledge, overlapping with other nurses. For others it

involved collaboration with social and voluntary sectors

around homelessness and domestic abuse, preventing social

isolation and working with communities, work more located

in social domains, less overlapped with other nurses. The

broad set of health visiting principles (CETHV 1977) sup-

ports variation in the way individuals autonomously opera-

tionalize roles. Identity is self verifying through social

interaction and dialogue (Burke 1980, Rapport & Wainright

2006), reflected here in the RIEP. Shared role understandings

facilitate role recognition. Inconsistency in role in action

potentially contributed to apparent identity fragmentation

within this study group, especially relating to public health

work (Collier 2001).

Some participants experienced identity disequilibrium as

public health role expectations and priorities changed. The

psychological impact of these changes on individuals related

to the fit with existing identity (Caplan 1961).Those consid-

ering health visiting to be intrinsically a public health role

(SNMAC 1996) appeared more comfortable with reframed

public health role expectations than others, whilst resenting

the implication that is was a new area of practice. Those who

felt ill prepared for what they perceived to be public health

work or questioned the legitimacy of it, experienced greater

challenges to identity equilibrium, potentially affecting opti-

mum role performance (Machin & Stevenson 1997).

There were perceived differences in the importance of a

nursing identity (Fagermoen 1997) as foundational. To

maintain role identity equilibrium, it might be that those

identifying more with nursing identity may be more likely to

legitimize public health work linked to disease prevention.

Others feeling less like a nurse might be more likely to

legitimize work directed at tackling social determinants of ill

health. However, with fifty per cent of role preparation

carried out by health visitor community practice teachers

(NMC 2004b), there is a risk that pervading role identity

confusion may affect entrants to the profession, perpetuating

fragmentation of a collective health visiting identity.

The suggestion from one participant that the ‘spirit’ of

health visiting is lost perhaps reflects perceived demise of

collective identity, leaving individuals feeling vulnerable.

Efforts to collectively move health visiting forwards may be

thwarted without stable role standards and sensitive

approaches to change facilitation, valuing identity of indi-

vidual practitioners (McDonald 2004, Higgs & Rowland

2005). Through the encouragement of personal reflection and

interaction with peer identity referent groups (Burke 1980,

Rapport & Wainright 2006), there are opportunities to

restore equilibrium in individuals’ role identity, provided

there is general agreement on the core nature of the role and a

sense of collective identity.

Public identity

Having a well developed sense of professional role identity is

a prerequisite for successful interprofessional working (Hind

et al. 2003). This is reflected in the interprofessional, public

identity level of the RIEP (Figure 1). Identity research sug-

gests that the execution of roles differently in a professional

group can engender confusion in conveying consistent public

identity (Burke 1980, Collier 2001, Foley 2005), which is

important for service users accessing health services. Role

title is an important feature of public identity (Strauss 1959,

1997). The change of health visiting title (NMC 2004a) to

specialist community public health nurse may have caused

public identity confusion which may also arise where differ-

ent practitioners with the same title demonstrate inconsistent

roles (Collier 2001) in the local setting. Resulting interpro-

fessional conflict may negatively affect the individual’s iden-

tity equilibrium and future interactions in local settings. The

emergence of inter-professional learning in pre registration

professional education represents a means of minimizing

development of negative attitudes and inaccurate role

perceptions (DoH 2001). This is likely to be less effective

where there are conflicts around collective professional

identities within a professional peer group. Uncovering

collective uniqueness in health visiting is challenging. Perhaps

its distinguishing feature is not specificity of knowledge, but a

broad cluster of capabilities (Hurley et al. (2008), utilized

contemporaneously in home visiting contexts meeting

complex family needs.

The RIEP (Figure 1) places individual interaction of

practitioners in the context of national policy and profes-

sional discourse. Participants evidently interacted via nego-

tiations within structural systems impacting on self worth and

identity, affirming the core premise of Negotiated Order

Theory (Strauss 1978). Despite most participants having very

similar job descriptions and role titles, they enacted roles in

different ways influenced not only by other people, but also

protocol, management arrangements and caseload organiza-

tion. Intended localized commissioning processes (DoH

2010) may exacerbate this by engendering differences in role

expectation across the UK, potentially reducing transferabil-

ity of health visiting across the healthcare system, perpetu-

ating role fragmentation and the formation of ‘tribes’ within

the profession (Collier 2001). Synergy between national

health visiting role standards and the educational preparation

for the role is essential. Role clarity is also required to

underpin global healthcare systems in which international

A.I. Machin et al.


and interprofessional working will be integral to the achieve-

ment of the Millennium Health Development Goals (WHO

1999, 2009).

Conclusion

Healthcare practice roles necessarily evolve, influenced by

demographics, economics, research and technological

advances. However, left unresolved, identity confusion with-

in health visiting in relation to nursing and public health,

threatens to compound already low morale, risking greater

attrition from the role at a time when strategies to increase

numbers are being implemented (DoH 2011). Health visitors

should seek to stabilize collective professional role identity to

enable consistent interprofessional working. In local settings

this may be through face to face meetings. More widely,

greater use of opportunities provided by social networking,

other online resources and communication media would

complement connections made at conferences and profes-

sional events, promoting and maintaining a sense of collective

identity (Valaitis et al. 2011).

Further research could help to refine the RIEP model

presented in this article, testing its utility in understanding

situations of other groups of workers within healthcare

systems, informing development of processes for managing

effective role identity changes in other nursing and health

professional roles across international healthcare communi-

ties.

Those charged with implementing health visiting strategies

need to consider identity influences, especially those from

within the profession. They also need to consider the

interprofessional context of implementing strategies and the

importance of clear public identity for health visitors.

Actively seeking ways to foster stable collective identity

through effective change facilitation (McDonald 2004, Higgs

& Rowland 2005) will contribute to improved role perfor-

mance of individual health visitors, minimizing identity

uncertainty caused by unstable healthcare systems (Williams

& Sibbald 1999).

Acknowledgements

The authors would like to thank Professor Carl May for his

valuable contribution to early thinking in this study.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

AM and PP were responsible for the study conception and

design, and performed the data analysis. AM performed the

What is already known about this topic

• There is lack of agreement on the core nature of health

visiting and its unique public health contribution within

global healthcare systems.

• Little is known about the nature of health visiting

identity as distinct from nursing identity.

• Lack of collective identity within a professional group

can lead to role fragmentation and confusion in

conveying consistent public identity.

What this paper adds

• The impact of role change on individual health visitors’

identity is influenced by perceived level of involvement

in the change and its fit with existing identity.

• Feedback from peer and interprofessional interactions

in their professional practice context influences the

professional role identity equilibrium of individual

health visitors.

• Individual health visitors have differing perceptions of

congruence of public health work and nursing with role

identity.

Implications for practice and/or policy

• The relationship of health visiting to nursing and public

health should be reviewed and clarified to reaffirm the

identity of individual practitioners in interprofessional

working contexts.

• Peers within professions should engage in regular group

interactions to foster the maintenance of equilibrium in

collective professional role identity. These interactions

can be facilitated face-to face, or utilizing the range of

contemporary on line and remote communication media

available.

• The Role Identity Equilibrium Model should be further

tested and refined through research with other

professional roles in different national and international

contexts.



data collection. AM, TM and PP were responsible for the

drafting of the manuscript and made critical revisions to the

paper for important intellectual content. TM provided

administrative, technical or material support. PP supervised

the study.

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