Chapter 11: Managing Intergroup Relations
Throughout our discussion of how to design, run, adapt, and improve our system, an inescapable theme is the importance of intergroup collaboration. Collaboration across silos is notoriously difficult to achieve, and efforts to spread better practices or change outmoded structures often screech to a halt at intergroup boundaries. While a full exploration of change management and implementation science is beyond the scope of this report, the problem of intergroup conflict is so glaring and so pivotal to ED–system relations, that it seemed essential to devote a section to this topic.
Conflict among the programs, sites, professions, and specialties that provide care impairs how systems function, and prevents a shared vision for change from developing. Unfortunately, such conflict is pervasive in healthcare. [1] It certainly appears in the emergency department (ED), where a diffuse patient population and complex interconnections with other departments create prime conditions for strife about who “owns” which patient.
A classic study documented how ED patient charts—supposedly repositories of objective information—were battlegrounds of inter-specialty competition and sniping, with potentially devastating consequences for patients caught in the crossfire. [2] The picture is hardly prettier at the system level, with its ubiquitous silos among professions, programs, sites, and sectors, not to mention between clinicians and management. [3]
Why, then, are intergroup relations so problematic, and what can we do about it?
Getting to the Root Cause
To start with, this isn’t an interpersonal issue that can be solved by sending everyone for training in communication skills: the problem doesn’t reflect lack of skill, but rather the active expression of strongly-held social identities. [2] These are the parts of people’s identity that come from being a member of a group or category, such as one’s nationality, gender, profession, or department. While there are many formal and folk theories of how groups operate, social identity theory [4,5] outperforms with its comprehensiveness, theoretical coherence, and robust evidence base. [6] It provides a broad, multifaceted approach to understanding how people interact with others within and between groups.
Decades of research have illustrated the powerful force of social identity; even meaningless groups assigned in a lab can influence the way people treat in-group vs. out-group members. [4-6] In reality, of course, social identities are not empty labels, but include meaningful identity content (such as group-defining characteristics, norms, and values) which makes them all the more powerful. [7]
Why do we categorize ourselves and others? Doing so serves two deep needs: the cognitive need to simplify the social world, and the emotional need to identify with something greater than ourselves. [4,5] In other words, social identity isn’t going away. Nor should it. Although negative outcomes, such as prejudice, discrimination, and conflict come to mind, shared identity can also be the wellspring of collaboration, altruism, and solidarity. [8] The question is not how to get rid of social identities (we can’t) but how to manage them so that their effects are positive instead of negative.
The most obvious solution is to urge everyone to abandon narrow distinctions and transfer their identification to one all-encompassing group. After all, aren’t we all here for the patient? We see how when a crisis strikes, say, after a natural disaster, or at the height of the pandemic, everyone unites behind a common cause, putting aside intergroup rivalries—only to take them up again when the crisis abates. Why can’t we all simply identify as healthcare providers, or indeed, as members of humanity?
It’s not that simple. For one thing, we are wired to pay attention to intergroup contrast. [5] Under most circumstances, an abstract, all-inclusive category provides very little information about the social world. It also tends to have limited emotional resonance; it is hard to get excited about who we are if nothing distinguishes us from anyone else. All things being equal, groups with high distinctiveness (owing to their small size, unique identity content, and/or alignment with meaningful physical boundaries) are most likely to be significant to us, as observed both within and outside healthcare. [3,5] So although a crisis can temporarily override intergroup distinctions, we should not be surprised when they surface again.
Additionally, people react unfavourably to the prospect of a valued identity being removed or altered. [8] Unfortunately, identity threat, as it is called, can easily be triggered by well-meaning appeals to put aside intergroup differences in favour of the common good, [1.9] especially if they come from an outgroup. This is even more likely if the subtext is “we’d all get along if only you people would be more like us,” an appeal for unity that appears more often than you’d think. [10] But the problem cannot be remedied merely by crafting better messages: any perceived challenge to a valued group’s existence, status, distinctiveness, or norms—essentially any attempt to get people to work together differently—can trigger identity threat, and spark resistance.
So how can change ever succeed?
Strategies that Work
Change can take place by working through social identities, not against them. [1,6] A diverse body of literature has uncovered a sequence dubbed reinforce-redefine-replace. [10] Counterintuitive as it may seem, agents of change must start by reinforcing existing identities, reassuring members that the groups and group-defining values they cherish will not disappear. Once these identities are secure and not under threat, members may entertain ideas that somewhat redefine the group and/or its relationship to others, so long as a strong link to the past is retained. Eventually, a new conception of group identity, or of an intergroup relationship, may come to replace the old.
The literature offers diverse examples of reinforce-redefine-replace sequences, such as the following:
Building a Mosaic Identity
Several organizations struggling to improve staff engagement have found the ASPIRe (Actualizing Social and Personal Identity Resources) model [9] helpful. After a phase of discovering what sub-groups (e.g., profession, department) are locally meaningful, employees meet in identity-based subgroups (reinforce) before coming together to identify commonalities (redefine) and finally set shared goals (replace).
This process seeks to build a mosaic identity that recognizes each subgroup’s uniqueness as well as its contribution to a larger whole. Separate from tests of the ASPIRe model, the theme of mosaic identity has emerged strongly from case studies of organizations that have achieved a high degree of interprofessional collaboration, such as the Dana Farber Cancer Institute. [10]
Reinforcing Another Group’s Identity
Conflict between managers and physicians is common in healthcare, and many hospitals have tried to repair strained relationships. Leaders’ efforts often begin with overtures to reopen communication with physicians and build one-on-one relationships, but then what? The most effective next steps are typically those that reinforce physician identity, for instance by supporting their ability to act as a group. This might include encouraging the formation of a physician advisory board and compensating members for their time; upholding physician norms such as keeping meetings brisk and action-oriented; and using language that belongs in a clinical setting rather than a corporate boardroom. [12,13] Such actions can help advance the intergroup relationship to a point that allows cooperation around specific objectives (redefine), and eventually, the development of shared goals and structures (replace). However, this process cannot be forced or rushed. One hospital CEO, emboldened by the success of early efforts to de-escalate tension, decided to leapfrog over stages, and moved quickly to ask everyone to create a common agreement for working together. Conflict immediately flared again, and the CEO was back on the phone with the social identity consultant, who backed away slowly. [12] Even a smaller leap from interpersonal strategies to the redefine phase has shown evidence of backfiring. [11]
Honouring the Past
Back in the 1950s, nursing textbooks would praise Florence Nightingale as the physician’s loyal helper, a subservient role considered part of nursing identity. As the decades advanced, gender roles changed and nursing roles along with them, but the textbooks could not very well abandon their pioneer. So, they did not. They just let the idea of subservience quietly slip away, while focusing on aspects of nursing identity that did not change, such as being nurturing. The authors also began to introduce new aspects that were more consistent with equal status, such as patient advocacy, a commitment to holism, and eventually, the possession of a distinct body of scientific knowledge. And who did they position as the scientific, holistic patient advocate? You guessed it: Florence Nightingale. [14]
At no point did the textbooks explicitly break with the past; rather, they emphasized a sense of continuity with history to legitimize new features of this identity. A similar process over a shorter time frame is seen in studies of physicians who participate in new models of primary care. In this case, their identity shifts from autonomous expert to head of team by gradually incorporating new elements that are perceived as congruent with the old. [15]
Putting it Together
The literature also suggests that identity mobilization works in alternation with practical, concrete changes to the working environment. [1] The purpose of reinforcing and redefining identities is to build enough support to implement practical changes; once implemented, such change can stimulate further identity reshaping, enabling a more extensive shift in the next cycle.
Education and training are particularly important settings for social identity management. Interprofessional education programs have demonstrated positive impacts on both learners and patients and should continue to be expanded and refined. [16] It’s also crucial that residency programs include opportunities for productive interaction among specialties, for instance, by ensuring that internal medicine residents rotate through the ED. Collaborative experiences during the process of forming a person’s identity can promote identification with a group beyond one’s own profession or specialty, and at the same time establish teamwork as part of one’s professional identity.
This chapter has focused on managing the internal dynamics of the healthcare system. Of course, social identity theory has much broader applications. Better understanding of identity processes could enhance our efforts to combat racism in healthcare, and to promote EDI more generally. Social identity thinking may also help the health community engage more effectively with the public on health policy and public health issues.
Conclusion
There is no magic bullet when it comes to implementing system change: no matter how carefully social-identity-management strategies are selected and calibrated, the process remains difficult, and the outcome uncertain. Nonetheless, it can be helpful to block off time to examine potential strategies through this lens. Understanding how social identities work—in particular, the problem of identity threat and the promise of reinforce-redefine-replace sequences—can help change agents increase the chance of success.
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