During the medical ward round in ICU which is led by a Consultant, opinions of all the practitioners having input in the care of the patients are always sought, and I took the opportunity to advise a repeat surgical review of Mr. X. Initially I was told that the surgical team has no interest as Mr. X would not survive surgical intervention. But a surgical review was arranged and I participated in the discussion. In the review, based on the Possum score, Mr. X had a 97% mortality of not surviving the surgical intervention. However, one of the major factors considered to arrive at 97% was the non-purposeful responses to command. Here I was able to clarify that based on my assessment of Mr X, there was in fact a response, and purposely obeyed simple commands. My advocacy here led the Surgical Consultant to make his own assessments and recommend surgical intervention. Mr. X had a successful emergency laparotomy with a revisable colostomy bag.
Where my clinical judgment and position within the established roles are in conflict, this can create confusion. I was clear that my duty was to my patient, but where best to address these concerns was not always clear. Mr X was being managed by a multidisciplinary team including intensive care, surgical, and nursing teams.
I needed to negotiate relationships with a number of different co-workers, such as reception and administration team colleagues, managers, nurse colleagues, consultants, and outside agencies. Despite the clarity of the hierarchy, these relationships were highly complex. I found myself implementing strategies, deliberately or not, within which to negotiate and maintain a professional space for my role. This was grounded in prior experience and via practical lessons learned from the socialization process within professional healthcare hierarchies at inter and intra-professional levels.
Levels of Trust
Trust is central within healthcare teams and was most relevant between me, nurses, and consultants. By examining the concept of trust within a framework of different levels of professional identity, it is clear that trust is built in complex layers, supported and influenced by prior experiences and preconceptions of professional healthcare hierarchies and identities. Oliver and Montgomery (2001) suggest trust is partly gained through the generalization of previous experiences to a particular current event.
I noticed that it was not simply a matter of demonstrating competence in order to gain trust, but my individual characteristics and the relationships I developed and maintained appeared of even greater importance to colleagues and consultants. In this way, I noticed that person-based characteristics were valued ahead of role-based characteristics, supporting the research of Sluss and Ashforth (2007).
Hierarchy
Power differentials and a well-recognized hierarchy are broadly acknowledged within healthcare organizations. Gaining an insight at a micro level has helped me to understand the processes which lead to enduring healthcare hierarchies and elevate such processes to a conscious level (Wackerhausen, 2009). Members of the healthcare team contribute to the development and endurance of hierarchical working, the mechanisms which influence clinical practice and which are underpinned by ideas of professional identity.
A Sense of Belonging
Throughout my experience, I have had a strong sense of being part of a community. This has come from learning from and through the role and through my own sense of being part of a group of professional practitioners with a shared goal. This is a key aspect of socialization and formation (Merton et al., 1957, Bucher and Stelling, 1977, Cavenagh et al., 2000). My own professional trajectory, my personal view on where I am aiming, and what I am aiming to learn and achieve impacted my feelings of belonging to the group of practitioners with whom I was working and learning.
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Reflections
The work, the workplace, and the people within it are central to the process of forming a professional identity and developing professional expertise for me and there is no doubt that the wider world and role of the 21st-century critical care practitioner had a profound effect on how I am developing my professional identity. Care delivery in the intensive care unit is an almost uniquely challenging environment. Nurses, Doctors, and other staff working in an intensive care unit environment would have been required to have received specialist training and have been deemed competent to engage in autonomous and safe practice. This would form a critical stage of professional identity development.
It is critical not to diminish the emotional and psychological effects of healthcare delivery in an Intensive Care Unit and the challenges it presents through constant competing anxieties and recurrent interferences (Aitken, 2003). The environment is highly complex and entails inherent uncertainty of outcomes and continuous physiological changes in critically ill patients leading to frequent changes in clinical decisions. While health interventions are guided by the phrase “at least do no harm”, the reality is that the majority of these decisions could have beneficial or damaging consequences for patients, healthcare workers, and the organization. This recognition leads to the central role of reflection in this environment, acknowledging the emotional content of the experience as well as learning outcomes. Dewey (1933,1938) describes reflection as ‘experimental’, and as a ‘non-therapeutic learning process’. Schon (1983, 1987) further discussed the need for professional practitioners to reflect on their interventions and justify every action and inaction. This process encourages self-awareness, which is an aspect of professional identity, and also improves prospects for the outcome of future decisions in clinical settings. It increases proactivity in subsequent decisions and draws meaning from past experience, which can influence future clinical practice, and learning, clearly with the goal of increasing the benefits that patients in comparable situations receive in the future.
I have become increasingly aware of the role of reflection and reflexivity in professional identity development, as well as in the delivery of clinical policies and procedures. Reflecting on my own decisions, role, and communications in relation to other professional practitioners and patients has provided me with a clear sense of my role and how I might participate in its ongoing improvement. Drawing on Boud et al (1994), knowledge is drawn from every clinical experience. In nursing and clinical practices, for a practitioner to be competent, knowledge would have been gained through either self-experience or from a senior colleague in the learning environment which allows opportunity for growth and development. Positioning learning environments in clinical settings ensures constant reflection; clinical interventions must have a purpose, well-established procedures for their completion, and be justified within available resources. They must be timely, safe, beneficial to the patients, and avoid unnecessary risk of complications. As described, reflections in healthcare are typically linked to interventions or care delivered to patients. If there was an avoidable cluster of events, that could have ended the life of a patient, the model of reflection used by Boud, Keogh, and Walker (1985), will be used to look at how, why, and when those events occurred. This reflection facilitates proactivity in subsequent decision makings and increases the level of responsibility and accountability of care for the patient.
The major types of reflective models are, iterative (Schon, 1983) and vertical (such as Dewey, 1933). An iterative model of reflection relates to previous experiences, paving the way for new knowledge and skills that if in clinical settings can reshape practices. Vertical reflective models refer to analysis and synthesis that generate a profound degree of shifting in the quality of service or actions.
In a healthcare environment, and this is particularly important in critical care settings, visible features, signs and symptoms, and physiological shifts and changes, may guide an informed clinical decision. This emerges from the knowledge of the practitioner, established guidelines, policies, and working methods; but as I have experienced through my own clinical practice, this does not supersede the judgment of the individual practitioner at the time of making the clinical decision.
In reflection, we undertake an analysis of events where changes or observations are preceded by intent, followed by a greater in-depth analysis of the observation or event. This links other unrelated past experiences, and observations, which can inform the learner or the observer of a wider context, thus creating a bigger picture, this event contributing just one part. A critical influencer of intent and other stimulators within the environment are referred to as the ‘learning milieu’ (Boud and Walker, 1990). Every organization has its own culture, developed through a web of policies and procures clearly defined roles and expected behaviors, and various standards of practice. In a healthcare environment, ethical considerations, clinical presentations, clinical skill, and the cap on the level of treatment to be delivered can have major influences on practitioners’ learning milieu and sensitivity and tolerance to what has been observed will further influence action to be taken. Applying this to the emotionally charged setting of working in medicine, is the personal, psychodynamic dimension of professional formation and the role of reflection in and on action (Schon, 1983).
Whilst some of these notions of reflection and professional identity development can be helpful in identifying important factors in creating one profession as distinct from another, in my view they provide an overly deterministic view and, based upon my experience, this neglects, or at least downplays, two critical issues: reflection on practice and also resistance to the established ways of operating. Firstly, matters of reflection, in the Schonian sense of the term (Schon, 1983) is the human quality that supports our own lines of inquiry and allows us to bring our prior experience to bear on current problems and to examine and make sense of what goes on around us. Secondly, I would suggest that critical care practitioners today are highly mindful of, and indeed sometimes challenge, a number of the assumptions, norms, and practices within their established area of work. Furthermore, this mindfulness of the field and the power relations and hierarchies being negotiated allows them to actively choose which elements of the established identity they chose to take on and which they choose to reject, and these choices are maybe about pragmatism and resolving tensions, and indeed securing the best outcomes for patients in their care.
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