Professional Insecurities: Examining the Relationship between Identity Safety, Moral Agency and Patient Safety

There is a growing consensus that “the last mile” in improving coordination of care and patient safety is understanding why it is that professionals say they “know” how to work collaboratively in teams and have the competences to provide “safe” care but continue to report that they find it difficult to actually implement these skills in day-to-day practice. Evidence suggests that in order to make further progress we need a greater appreciation of how interprofessional practice actually occurs in clinical settings and how sociocultural factors facilitate or impede high quality communication and coordination amongst professionals. Theoretical perspectives from organizational scholars have shown that effective interprofessional practice is predicated on professionals’ sense of “psychological safety”; however, they also argue that “a well-entrenched status hierarchy exists in medicine making it difficult to speak across professional boundaries” (Nembhard and Edmondson, 2006). “Status” and a sense of psychological safety derive not only from one’s professional identity and position in the medical hierarchy, but also one’s personal identity and circumstances. As Nembhard and Edmondson argue: “status refers to the level of prominence, respect and influence associated with an individual as a result of some characteristic such as age, education, ethnicity, gender, organizational position, profession, wealth etc. (2006:944).We include the expansion of precarious work as another critical factor for appreciating a worker's status. Studies by Edmondson and her colleagues have highlighted how status differences may undermine a worker’s sense of psychological safety, making those in lower status positions less willing to engage in quality improvement activities in health care settings as they feared that their suggestions could expose them to reprimand or ridicule and were likely to be ignored. Drawing on Nelson's work on "damaged identities", we theorize how identity safety may infiltrate the consciousness of some workers, impeding their agency in intra and interprofessional interactions.