article title

Role Transition and the Interaction of

Relational and Social Identity: New
Nursing Roles in the English NHS
Graeme Currie, Rachael Finn and Graham Martin

Abstract

Graeme Currie Our study provides an analysis of role transition, examining how macro-level influences
Nottingham and micro-level practice interact in framing role transition, with a focus upon profes-
University Business sional identity. Empirically, we examine the case of nurses in the English NHS, for
School, UK whom government ‘modernization’ policy has opened up a new occupational position in
the delivery of genetics services within a professional bureaucracy. We track the experi-
Rachael Finn
University of York, ences of the nurses through their recruitment to, enactment of, and progress on from, the
UK new genetics role over two years. Our qualitative interview-based study encompasses
six comparative cases. Analysis draws upon two linked literatures – role and identity,
Graham Martin and sociology of professions – to examine the tension between the identity expected by
University of the profession and the role expected by government policy-makers. While policy
Leicester, UK encourages reconfiguration of roles and relationships to support the new, less-bounded
role, concerns aligned to professional identity mean that inter-professional competition
between doctors and nurses, and intra-professional competition within nursing itself,
constrain the enactment of the new role. Through our empirical study, we develop liter-
ature on role transition through its application to a professionalized context, and sociol-
ogy of professions literature, within which issues of identity are relatively neglected.
Our study demonstrates that the emphasis of identity within a professional bureaucracy
lies at the collective level.

Keywords: role transition, social identity, institutions, professions, NHS, nurse, England

Introduction

Theoretically, our study develops literature that focuses on the influence of the
interplay of interpersonal (role-related relationships) and collective levels of orga-
nization (focus on oneself as a prototypical member of a group) upon one’s identity
Organization
Studies and identification in the workplace (Ashforth and Mael 1989; Pratt et al. 2006;
31(07): 941–961 Sluss and Ashforth 2007). From a sociology of professions perspective, our study
ISSN 0170–8406 also provides a more contextualized analysis of professional dynamics and identi-
Copyright © The
Author(s), 2010. ties, considering the interaction of macro-level influences and micro-level practice
Reprints and that frame the implementation of new, policy-driven roles for healthcare profes-
permissions: sionals (Bourgeault and Mulvale 2006; Bourgeault et al. 2008; Coombs and Ersser
http://www.sagepub.
co.uk/journals 2004; Dent and Whitehead 2001; Harrison and McDonald 2008; Sanders and
permissions.nav Harrison 2008). Analysis of such policy-driven change in healthcare professional

www.egosnet.org/os DOI: 10.1177/0170840610373199

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942 Organization Studies 31(07)

roles has generated significant interest within articles published in Organization

Studies over recent years (Ackroyd 1996; Dent 1995; Doolin 2002; Kitchener
2002; Levay and Waks 2009; Reay and Hinings 2005, 2009; Waring and Currie
2009). Of these, the analysis by Reay and Hinings (2009) of healthcare reform
aimed at doctors in Canada – examining how group members’ collective beliefs
about who they are and how they are different from others informs patterns of col-
laborative healthcare delivery – is particularly relevant to our study. Similar to Reay
and Hinings, our study considers the interaction of macro-level and micro-level
influences, and we build upon their suggestion to focus research upon healthcare
professionals other than doctors, and that, ‘different intentions, different learning
approaches and different goals are all associated with different patterns of collabo-
rative activities, and ultimately different outcomes’ (Reay and Hinings 2009: 633).
In summary, our contribution lies at the crossroads of role transition, professional
identity and public policy aimed at workforce reform to develop literature on role
transition through its application to a professionalized context, and sociology of
professions literature, within which issues of identity are relatively neglected.
Empirically, our study is set in the context of ongoing policy reforms aimed at
modernizing the NHS workforce in England. The English NHS exemplifies
attempts globally to reconfigure professional roles and relationships through skills
mixing to engender more collaborative forms of healthcare delivery that are based
on professional accomplishment, rather than traditional jurisdiction, and so medi-
ate shortages of doctors, curb rising costs, and improve quality of care (Bourgeault
and Mulvale 2006; Bourgeault et al. 2008; Buchan and Calman 2005; Sibbald et al.
2004). Specifically, we examine the experience of nurses making a role transition
from a mainstream disease area (such as cardiology, renal care, endocrinology),
where they are embedded in long-established nursing hierarchy and specialization,
and subordinate to the power of doctors, into delivery of genetics healthcare, rep-
resenting a novel area of specialization for nurses where they are expected to act
more independently from doctors. Our study is a longitudinal one, which encom-
passes 68 interviews carried out across six in-depth case studies of the implemen-
tation of new genetics nurse roles over a two-year period.
Our paper is structured as follows. First, we review theory about roles and iden-
tities, and sociology of professions. Second, focusing upon nursing, we consider
the likelihood of less-bounded roles within the distinctive context of healthcare
settings. Having set out our research context and design, we present and discuss
our data: analysis of the implementation of new, less-bounded roles that arise
empirically from comparative cases. In our conclusion, we highlight our theoreti-
cal contribution and consider transferability of our findings to other contexts.

Roles and Identities

We draw heavily upon Sluss and Ashforth’s study of relational and social identity
and identification (Sluss and Ashforth 2007). They highlight that the influence of
an interplay of interpersonal and collective levels of organization upon identity
and identification is much neglected, arguing that the question of identity and
identification should be one of ‘who are “we”?’, rather than ‘who am “I”?’

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 943

At the interpersonal level, relational identity is how role holders enact their
respective roles vis-à-vis each other. Role-based and person-based identities of
two individuals in a role relationship interactively influence the relational iden-
tity. A role-based identity is the goals, values, beliefs, norms, interaction styles
and time horizons typically associated with the role. The person-based identity
is the personal qualities of the role occupant that bear on the enactment of the
role-based identity, meaning that no two role enactments are identical, except in
extremely strong situations (Ashforth 2001). A question that flows from this sec-
ond dimension of relational identity is what represents an ‘extremely strong sit-
uation’; specifically, does a heavily professionalized context fit this description?
Relational identity has both generalized or globalized (as manager of subordinates)
and particularized components (managing a particular subordinate), which reci-
procally influence each other. So, relational schemas may exist that encompass
general beliefs about the way in which roles interact, to detailed beliefs specific
to the case of two interacting individuals.
Relational identification is the ‘(partial) definition of oneself in terms of a
given role-relationship’ (Sluss and Ashforth 2007: 15). Like role identity, this
has a generalized and particularized component, so a person holds a generalized
perceived oneness with the role relationship (e.g. with the co-worker relation-
ship apart from any specific co-worker) and a role relationship with a particular
co-worker. As with relational identity, generalized and particularized compo-
nents are mutually reinforcing.
The influence of the collective level lies within the province of Social Identity
Theory (SIT) (Tajfel and Turner 1985), which focuses upon the role holder as a
prototypical member of a group, such as an organization, or as in our empirical
case, as a member of a profession (Sluss and Ashforth 2007). Consequently, ‘an
individual is viewed as an “interchangeable exemplar of the social category”
rather than as a unique person’ (Turner 1985: 99), i.e. group prototypes rather
than personal characteristics prevail, with the consequence that the relationship
between two individuals will not transcend their roles (Sluss and Ashforth
2007). So, the definition of others and the self are largely ‘relational and com-
parative’ (Tajfel and Turner 1985: 16), with social identity derived not only from
the organization but from the work group and department, amongst many other
possible affiliations. Indeed, subunit-specific identification within ‘complex’
organizations, such as healthcare, is intensified (Albert and Whetten 1985;
Ashforth and Mael 1989), particularly informed by professional occupation
(Pratt et al. 2006). SIT emphasizes the collective level, with individuals tending
to choose activities congruent with salient aspects of their identities, and then
supporting the institutions embodying those identities. Social identities are
maintained primarily by intergroup comparison, with groups seeking to posi-
tively differentiate themselves from other reference groups, more so when a
group’s identity is insecure because its domain or resource base is threatened
(Ashforth and Mael 1989).
Drawing upon interpersonal and collective notions of identity, Sluss and Ashforth
(2007) are particularly interested in how role and person-based identities interact over
time to reveal the unfolding relational identity. They present a typology of likely rela-
tional identification, which encompasses three outcomes – relational identification;

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944 Organization Studies 31(07)

relational dis-identification; ambivalent relational identification – resulting from

interaction of the other’s identity (role-based or person-based) and identity valence
associated with this (positive, negative). Relational identification occurs when the
other’s role- and person-based identities have positive valence, i.e. where there is per-
ceived oneness with the role-relationship, and it can be either generalized or particu-
larized. So within the nurse-doctor relationship, the doctor may accept the role holder
is expert to develop and deliver a clinical service and that a particular nurse is one
whom s/he works well with. Relational dis-identification occurs when the other’s
role- and person-based identities have negative valence, e.g. the doctor regards the
nurse not as expert and doesn’t like that particular nurse. Meanwhile, ambivalent rela-
tional identification is multi-faceted, with all aspects of role-based or person-based
identities unlikely to be perceived wholly positively or negatively. In short, mixed
feelings are likely to characterize the role-relationships.
Our study, drawing upon the above, considers the interplay of interpersonal or
relational levels of identity and identification, with that of the collective level.
We seek to understand what happens between two individual role holders once
interaction commences and the group prototypes (role-based identities) poten-
tially become softened by personalization (person-based identities). However,
prior to this, we consider aspects of role-based identities within professional
bureaucracies, specifically that common to healthcare systems.

Professional Identities and New Roles in the NHS

Our study considers the interaction of macro-level influences (i.e. the institu-
tionalized relationship between doctors and the state, and the dominance of the
bio-medical model that privileges doctors in healthcare delivery) and micro-level
practice (which gives rise to professional autonomy) to frame the implementation
of new healthcare professional roles (Bourgeault and Mulvale 2006; Bourgeault
et al. 2008; Harrison and McDonald 2008; Reay and Hinings 2009). Regarding
this, long-standing literature on the sociology of professions highlights the
importance of policing of occupational boundaries by professional associations
(Freidson 1988, 1994; Nancarrow and Borthwick 2005; Sanders and Harrison
2008), with the term ‘professional’ represented as a much sought after identity,
enhancing exclusivity and privilege of those who lay claim to it.
A distinctive, specialized, professional identity is developed and shared amongst
professional members through enhanced career prospects, associated with a pro-
fessional qualification and socialization, as a consequence of long and rigorous
training, and a lifetime spent doing the same tasks with a group of peers (Halford
and Leonard 1998). However, professional identity is relational, and legitimacy
has to be actively constructed and reproduced in relation to others. One way to
defend jurisdiction is for the ‘expert’ profession to delineate a particular domain
of competence, with other relevant actors accepting the legitimacy of the ‘expert’
profession to position them as ‘amateurs’, and if necessary, also accepting
subordination by the ‘expert’ profession (Fournier 2001).
Professional institutions however do not act in isolation to determine roles,
but are influenced by relationships with the state and other professions within an

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 945

interdependent system. The English NHS is not immune from such global trends;
indeed it is a fast mover regarding skills mixing for healthcare staff and collab-
orative ways of delivering healthcare (Bourgeault et al. 2008). Consistent with
global policy generally, workforce reconfiguration represents a response to work-
force shortages and the need to better utilize resources, serving as the means to
accomplish patient-centred care (Department of Health, 2000a, 2000b, 2000c, 2002).
Importantly, Nancarrow and Borthwick (2005) argue that this has resulted in
dynamic boundaries between the professions, whereby opportunities for changes
in jurisdictions of work are opened up, e.g. nurses taking on responsibilities pre-
viously the domain of doctors. This then represents state endorsement of chal-
lenges to medical dominance, with possibilities for some professions to extend
their remit by taking up new areas of work, while others engage in processes of
diversification, specialization and substitution.
However, three issues are important here. First, national policy may support
new roles less than is immediately apparent. For example, policy documents
give little attention to wider social and cultural factors that might inhibit the suc-
cess of reforms to professional designations, career pathways and competency-
based roles (Bourgeault et al. 2008; Hyde et al. 2005). Policy-makers fail to
understand the social structures that underpin the introduction of new roles for
healthcare professionals within the existing division of labour. On this basis
there arises a policy-implementation gap, with workforce development unlikely
to be aligned with policy intent (Currie et al. 2009).
Second, professions operate as part of an interdependent system (Abbott 1988),
where the activities and developments of one group necessarily impact upon,
and are constrained by, other groups within the system. Reflecting the emphasis
of SIT (Tajfel and Turner 1985), processes of change may be contested or
consensual between professions, tied up with issues of power, status and control.
Specifically, workforce modernization remains a contested area, nowhere more
so than in healthcare, where it works against pre-existing, but dynamic, profes-
sional systems (Currie et al. 2009; Hyde et al. 2005; Martin et al. 2009). Policy
initiatives introducing new roles interact with traditional professional identities,
with the potential for fragmentation and internecine strife within healthcare pro-
fessions (Freidson 1988). In particular, as discussed below, any expansion of the
nursing role relies on the acquiescence of the medical profession (Nancarrow
and Borthwick 2005).
Third, professional bodies can mediate state influence on professional work
jurisdictions and roles, through the extent to which they support and institution-
alize developments (Bourgeault and Mulvale 2006; Bourgeault et al. 2008; Dent
and Whitehead 2001; Harrison and McDonald 2008). Thus, while the drive for
flexibility may create possibilities for shifts in professional boundaries and
opportunities for less-bounded roles, professional institutions influence the extent
to which these become realized. Processes of institutionalization involve formal
recognition of new sets of knowledge and skills into definitions of work roles and
expertise, for example through training, accreditation, regulation and incentives.
Should new roles not enjoy the support of relevant professional bodies, then
recruitment into, enactment of, and progress onwards from these new roles may all
prove challenging (Nancarrow and Borthwick 2005). Hence, in contrast to popular

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946 Organization Studies 31(07)

use of the term ‘boundaryless’ to describe the way actors move into and out of roles
in enacting career paths, which has been applied to creative, biotechnology and IT
sectors of employment (Arthur et al. 1999; Peiperl et al. 2000), we draw attention
to our deliberate use of the term above – a ‘less-bounded’ role – to describe the way
in which professional hierarchy acts to limit career actors’ agency in large, profes-
sionalized bureaucracies (Dany et al. 2003; Currie et al. 2006).

Nurses Moving into Less-Bounded Roles

Literature specific to nurses’ roles suggests that the professional structures and
boundaries of nursing have seen some particular, and to some extent contradic-
tory, changes. In England, as in much of the rest of the economically-developed
world, there has been a significant push to raise the professional standing of
nursing, and in the process improve autonomy, power and respect for the occu-
pation (Iley 2004). Senior-level clinical roles for nurses have been introduced,
particularly in nurse-led services, including enhanced clinical responsibilities
and substituting for certain roles traditionally fulfilled by doctors (Robinson et al.
1997, 2006) with the introduction of posts such as nurse specialist, nurse pre-
scriber and nurse consultant.
The outcome has been a narrowing of the role of specialist nursing, with nursing
care increasingly fragmented in a way that may drive out a broad, flexible,
generic nurse role (While 2005). Evidence from other countries shows nursing
has been professionalized in a similar manner for some time (Rognstad et al.
2004). Over the last decade in particular, leading figures in the profession have
sought to establish nursing as a graduate profession: in England, for example,
nursing will become a degree-only profession from 2013. A key facet of this has
been an attempt to establish a distinctive knowledge base for nursing, with an
associated stress on the role of the qualified nurse in the management of patient
care (Coombs and Ersser 2004). Consequently, nursing is increasingly a profes-
sion whose work is highly technical and likely to be more so (Dingwall and
Allen 2001).
At the same time, vertical substitution in tasks traditionally performed by doc-
tors may take nurses away from the core of their professional duties in a way
which will not appeal to all. For some nurses extra clinical responsibilities repre-
sent a shift in, rather than extension of, the professional identity of nursing (Iley
2004). New roles for nurses may undermine the core attributes which attracted
them in the first place, such as patient contact and holistic care. In the face of
changes, nurses may exhibit uncertainty about their identity (Dingwall and Allen
2001; Hallam 2000; Thompson and Watson 2005). Thus, self-development in
pursuit of enacting any new role may take on a different hue for nurses.
Meanwhile, despite the rise of ‘new’ nursing and renewed strategy of profes-
sionalization detailed above, we highlight that nurses expend considerable energy
in organizing doctors through a co-ordination role that is linked to the profes-
sional hierarchy characterizing the relationship between them. Whilst nurses may
undertake work that blurs the boundary between medicine and nursing, they

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 947

remain controlled by doctors. Medical hegemony in decision-making represents

a barrier to interdisciplinary working, with nurses’ knowledge and their role
devalued, vis-à-vis doctors, in the more interdisciplinary and collaborative
arrangements for delivering healthcare (Allen 2007; Coombs and Ersser 2004).
Contemporary changes in role, where nurses are encouraged to take on some
of the technical tasks associated with medicine, might suggest nursing is break-
ing away from its reliance upon doctors. However, this is less an extension of
nurses’ licence and more a re-interpretation of its established terms, with nurses
remaining subordinate to doctors (Dingwall and Allen 2001). Therefore, we
should not be surprised if the genetics nurse finds it difficult to enact a role with
increased autonomy, since this requires that the legitimacy of current boundaries
be challenged, and actors’ access to knowledge and resources that enable them
to practise a more autonomous role be re-stratified (Goodwin et al. 2005).
We take account of the above within our study, combining insights gleaned from
literatures in sociology of professions and in role and identity. We focus on an assess-
ment of the process of professional identity construction, in particular how newly-
constructed identities are validated by others, including those with similar social
positions, i.e. inter-professional and intra-professional validation (Pratt et al. 2006).
In so doing, our study moves beyond traditional, narrower sociological treatments of
identity that focus on how professions as an ‘occupational’ group establish legiti-
macy, status and boundaries (cf. Abbott 1988; Freidson 1988, 1994; Larson 1979)
towards consideration of the individual actor, to assess how role-based and person-
based identities interact over time in a relational way (Pratt et al. 2006).
In summary, our study responds to a gap in the understanding of social struc-
tures underpinning the introduction of any new roles for healthcare professionals
within an existing division of labour. Specifically, we examine the following
questions within our research:

• How do individuals respond to the ‘opportunity’ to move into the new

less-bounded roles?
• How do professional institutions support (or not) movement of individuals
into the new roles?
• How do individuals ‘progress’ onwards from the new roles?

Research Design

Our empirical case was focused upon a specific government policy initiative –
‘mainstreaming genetics’ – which exemplifies the wider policy context aimed at
workforce modernization in the English NHS. Through funding pilot ‘main-
streaming’ projects, the Department of Health [DoH] aims to move genetics
knowledge from regional specialist organizations (tertiary care) to either local
generalist organizations (primary care) or established, more specialist, hospital-
based ‘mainstream’ services (secondary care), such as renal care or cardiology.
Associated with this, knowledge is expected to transfer between specialist doctors

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948 Organization Studies 31(07)

(geneticists) to holders of the new role of ‘genetics nurse’, who are expected to sup-
port the delivery of genetics services within networked arrangements that bring
together different organizations and professionals. The impact of modernization
processes is explored from an actor-centred perspective with a focus upon diffi-
culties faced by genetics nurses in moving into, enacting, and moving on from
their new role.
The majority of pilot funding is used to employ between one and three genetics
nurses in each of our projects. Policy intention is, first, to allow nurses more auton-
omy from doctors. Second, the new roles require nurses to work across organiza-
tional boundaries, e.g. different departments and hospitals. Third, nurses are
expected to integrate genetics and mainstream nursing knowledge in developing
and delivering services, e.g. offering family history clinics in a community health
centre or in a mainstream area of the hospital. In essence, the new role positions
nurses as a genetics ‘expert’, expected to provide advice to their nursing peers and
doctors within mainstream disease areas. This is in contrast to traditional nursing
roles, where they are subordinate to doctors and their role is firmly framed by a
hierarchical grading system within a single specialist disease area associated with
a specific client group and typically within a single healthcare organization.
Across the six pilot projects, interviews were carried out with 14 genetics
nurses, and all other stakeholders (a further 34) within the pilot network, such as
genetics and mainstream doctors, nurse managers, genetic counsellors. Genetics
nurses (14) and lead doctors (6) were interviewed twice (six months into the
pilot project and at the end of the pilot project). In total, over two years, we carried
out 68 interviews. In presenting our case, we rely mainly upon quotes from
genetics nurses. However, we highlight their perceptions of recruitment into,
enactment of, and progress from the new, less-bounded role was one shared by
other stakeholders. Aligned to the requirements of ethics approval in the NHS,
we assured anonymity to respondents in reporting interview quotes to policy-
makers and within academic papers. Consequently, within our empirical
sections, we stop short of providing information that might aid identification of
any pilot project or interviewee.
In analysing data, we were concerned to understand both issues in each pilot
project (within case analysis) and the differences and similarities between pilot
projects (across case analysis) (Yin 1994; Eisenhardt 1989, 1991). A number of
iterations were undertaken by the authors in the development of key themes from
interviews. Each author engaged in fieldwork, and subsequent independent analy-
sis. The three authors read interview transcripts and then created analytic notes
alongside the interview transcript, which were then copied and placed within the
accompanying interview text, i.e. embedded analysis. Related parts of the embed-
ded analysis in each interview were placed together. At least one co-author
checked and discussed the coding of transcripts of another, ensuring reliability of
interpretation and enhancing analysis. The analysis agreed across the authorial
team for each pilot project was considered against the over-arching research ques-
tions. At all stages, authors were alert to counter-evidence to the emergent ana-
lytical themes. Finally, to authenticate and elaborate upon our analysis, our
findings have been presented in written and verbal form to healthcare profession-
als and policy-makers, including the genetic nurse subjects of our study.

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 949

Findings

Findings are structured along three themes reflecting the longitudinal nature of
the research design: ‘Moving into the role’; ‘Enacting the role’; ‘Moving out of
the role’. Common across the three themes is the limiting effect of the profes-
sional institution upon attempts by genetics nurses to enact new, less-bounded
roles. We discuss this in detail in the following sections.

Moving into the Role

Nurses recruited to the projects tended to be unusual, with motivations and expe-
rience that were aligned to these less-bounded roles. Typically, applicants came
from a background that included a research component, experience of boundary-
crossing roles and motivation for self-development. The emphasis for these
nurses was very much on personal satisfaction and learning when moving into
the new roles:
It just seemed like a unique opportunity, something that’s never been done before and to
be a part of that was quite exciting but there again, quite daunting because we don’t usu-
ally have as much autonomy as the genetics nurse role allows. However, I didn’t want to
be a couple of years down the line and still be working on the wards and thinking ‘what
if or if only I had taken up the new role?’
However, despite such enthusiasm illustrated above, the willingness of many
nurses to move into new roles was constrained by the professional institution of
nursing. The nursing profession itself did not support the development of
‘hybrid’, boundary-crossing roles, which required a degree of autonomy unfa-
miliar to nurses. Applicants for the new post were thin on the ground because it
did not fit with institutionalized grading arrangements in nursing. Interviewees
suggested that nurses are socialized into roles where they are dependent upon
others’ clinical decisions, rather than exercising clinical judgement themselves:
Nursing has always followed a path of very much traditional subservience in terms of
relationships to medicine in general. However I know I’m an exception to the rule. The
consultants that I’ve worked with and they’ve been very appreciative of what work some
nurses have actually achieved and allowed them to be autonomous and accountable in
their own right. You’ve got to be a certain specific personality to be able to work like that
and to be confident to do it.
The nurse above appears confident that person-based characteristics can over-
come institutionalized role-based relationships, where combined with doctors’
willingness to cede jurisdiction to the genetics nurse. Our next section, focused
upon enactment of the role, suggests such optimism is misplaced.

Role Enactment

The enactment of a more autonomous role for genetics nurses was particularly
constrained by the expectations of mainstream doctors for a more traditional
working relationship across the medical-nursing divide. The role of genetics
nurses appeared of scant interest to mainstream doctors, who remained focused
upon their own services, and the everyday working relationship between main-
stream doctors and genetics nurses remained one of professional hierarchy:

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950 Organization Studies 31(07)

They don’t see me as a helping hand. Instead, they stress that they are the doctor, they’re
doing the treatment, they’ve made a diagnosis and this is their recommendations. I’m just
the nurse who communicates this to the patient … We’re not allowed to act
autonomously. I have been criticized for the fact that I took too many steps off my own
back, when I should have probably been more consultative about it.

This meant genetics nurses could only work to a certain level in their interac-
tions with mainstream doctors. For example, professional hierarchy dictated that
education of doctors was best left to an expert drawn from their own profes-
sional ranks:
Me [geneticist] going to talk to mainstream doctors is fine because they will listen to
those people who come to inform them of clinical developments if they perceive them as
experts. The problem is that they don’t perceive nurses to be experts.

There was also the issue of the degree to which geneticists, as well as main-
stream doctors, were happy for nurses to exercise a degree of autonomy. Specialist
genetics services wanted to retain a degree of control over the work of the nurses
through close supervisory arrangements and directing education and develop-
ment opportunities.
We also highlight an intra-professional challenge, i.e. lack of support within
nursing for the new role. The degree to which senior nurses understood hybrid
roles and were able to provide supervision and developmental support was
limited:
And because it’s [the genetics nurse role] a stand alone specialist post it is not as
well understood as might be other mainstream specialities. Genetics is so technical,
almost exotic for traditional nurses. So that there’s a tendency by senior nursing
management, steeped in traditional nursing, to either ignore me, and/or let me get
on with it.

In the absence of support and understanding from within their own ranks, genetics
nurses had to be self-driven in terms of their requirements for education and
development:
I’ve had to do quite a lot of reading and research into the different areas because otherwise
I wouldn’t have been able to provide them [patients] the help that they need in the clinic.

We note the absence of education and support for the new nursing roles repre-
sented an institutional problem and discuss this further in the next section.
However, we also note some limited evidence that genetics nurses countered
top-down forces and mediated the institution of professional hierarchy faced in
enacting their roles, in particular through developing a more trusting relation-
ship with doctors:
Initially the geneticist was the driving force behind the pilot. Then she let off the reins as
she felt more secure about me. I’ve led it a little bit more. Once she realised that I was
quite capable then she let me have more autonomy.

The nurse above drew on person-based influence to counter the effect of role-
based influence. However, in this case, the autonomy allowed to the nurse above
was ‘bounded’. The nurse was given increased freedom in terms of the service
development role, i.e. re-organizing the way service was delivered, as trust was
developed across the inter-professional hierarchy, but in terms of clinical matters,

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 951

close supervision by the doctor persisted. In short, role-based characteristics pre-

vailed over those person-based characteristics.
In sum, across our six pilot projects, there was little deviation from our rela-
tively bleak narrative about enacting the new role. However, in one of the cases,
two out of three genetics nurses connected to the pilot project had been recruited
internally from the mainstream area in which the pilot was located. This appeared
to allow them more autonomy than the nurse above (who was externally recruited),
on the basis they developed an effective relationship over time, prior to the pilot,
with the mainstream doctor with whom they worked. Yet, even here one of the
nurses reported: ‘the doctor only trusts me to carry out development of care
pathways because of an understanding that I take account of his [the doctor’s]
interests in so doing’.
Meanwhile, the third genetics nurse, who was recruited externally, had previ-
ously developed a research role focused on genetics, in which she described her-
self as enjoying a good deal of autonomy in the development and delivery of
service, in part due to the absence of doctors in the developing country context
in which she was employed. She wished to continue in a similar vein, but found
the genetics nurse role to be considerably constrained within the English NHS.
Even before the pilot finished, in the face of resistance by the doctor to a more
autonomous nursing role, she moved into an academic research post, far
removed from delivering service on the frontline.
In summary, comparative case analysis across pilots illustrates similar expe-
riences for the genetics nurses in enacting their new roles as a consequence of
strong institutionalized structures. We move on to discuss how other genetics
nurses moved out of their roles in the next section. As with our last genetics
nurse above, some enacted more research-orientated roles as they moved on. For
others, however, moving on from the genetics nurse role proved difficult.

Moving out of the Role: Where Next?

Some nurses hoped their new roles would be sustained following cessation of
pilot funding. However, many were left in ‘limbo’ and continued on a temporary
basis to provide genetics services in response to the increased demand generated
by the pilots. Commonly this was funded by under-spending during the pilot
with the Department of Health’s agreement that this could be used to continue
employment for 3–6 months, in the hope that local purchasers of genetics health-
care would sustain funding of the service.
As evident in our discussion of recruitment, applicants might be considered
‘unusual’ in their motivation for moving into genetics nursing. Thus, we should not
assume traditional expectations of progress are held by those in genetics nurse
roles. Some nurses might have embarked upon an opportunity for learning fuelled
by a desire to maintain stability. Consistent with evidence in our first empirical sec-
tion, applicants for the genetic nurse posts wanted to retain a high degree of patient
contact, consonant with a traditional nursing identity of holistic care focused upon
the patient. They sought to maintain their traditional nursing mandate through new
roles, rather than embrace the opportunity to move across organizational and pro-
fessional boundaries so their career development moved onwards:

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952 Organization Studies 31(07)

I think that’s one of the big issues in terms of nursing progression. You get to a certain
point and to go further you have to move away from nursing, away from looking after
patients. When I came to this project, I had no intention of ever staying in genetics. I only
came to see what else I can offer the families I see. I look after people from cancer diag-
nosis to death and I wanted to know, ‘what more can I offer the family on their mum’s
death?’ I can now pick these family members up early and get them into screening. I want
to stay in cancer and be patient-focused. That’s my first love.

For this nurse, the move into the genetics role appears mainly to buttress professional
identity, rather than progress career.
To progress, but maintain patient contact, might mean moving into another
role within genetics, such as genetics counsellor, where their experience gained
in the new genetics nurse role might give them a ‘head start’. However, there
existed a very limited number of training places in accredited courses for genet-
ics counsellors. That a number of genetic counsellors involved in the main-
streaming genetics pilots were drawn from abroad was revealing of the greater
progress genetic counsellors had made elsewhere beyond England in profes-
sionalizing their occupation. Within England, having obtained a ‘package’ of
new knowledge and experience in delivering genetics services, there appeared
little prospect of genetics nurses using this knowledge to move into new roles
within genetics.
In short, in England at least, genetic counselling is not institutionalized in
educational terms, i.e. role transition from nursing to genetics counselling is not
effectively supported by professional bodies. Consequently, for many of our
interviewees, they move back into roles that they previously occupied:
I’m actually employed by the hospital on a permanent basis, but I’m being funded for two
years by the Department of Health for the genetics nurse role. When that ends I’ve still
got a contract with the hospital. I might end up back in my old area if the worst came to
the worst. If so, I can’t see how I will use any genetics knowledge I have developed.

Counter to the emergent, pessimistic analysis, we note an example of a move

onwards from the genetics nurse role that might be described as a ‘successful’
transition. One genetics nurse was kept in post permanently following the end of
pilot funding. The cost of this was met by the mainstream department in which
she delivered genetics services. We should note, however, that the mainstream
department in question was one that was attached mainly to the university, rather
than the NHS hospital. Research funding allowed the continued employment of
the nurse on the basis that the genetics activity was linked to the research focus of
the department. Further, the nurse in question was research-orientated and keen to
add to her Master’s degree qualification through PhD study, i.e. for this nurse, the
role transition was less about mainstream to genetics nurse and more about main-
stream to research nurse, and this transition appeared to be more supported.

Discussion

We reveal limits to the enactment of new roles within the specific setting of our
study. Recruitment into the new less-bounded role of genetics nurse is difficult
because it appears unattractive to the existing nurse workforce. First, new roles

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 953

that cross organizational, professional and sector boundaries are not supported by
the professional institution. Instead, the professional institution determines that
roles are embedded within elaborate grading systems, linked to narrow, special-
ist disease areas that are long-established, professionally-controlled domains of
knowledge. The dynamics of interaction between the professional institution and
implementation of the new genetics nurse role are characterized by particular
contestation due to the ongoing professionalization of nursing, which attempts to
take nurses away from their longstanding holistic, patient-focused role (Dingwall
and Allen 2001). Second, a specialist role is regarded more highly than that of
generalist, with nurses reluctant to ‘dilute’ their expertise through a hybrid role
that encompasses two clinical areas, such as cardiology and genetics. This might
be expected to mean genetics specialization is attractive for potential applicants
to the new roles. However, nurses perceive that genetics is a novel clinical area,
regard it as esoteric and, consequently, new roles have low status. The nurse view
on this matter is influenced by lack of support from their professional institution
with respect to education and accreditation. Related, finally, the nursing group
appears to be culturally ‘conservative’ and unwilling to take the risk in moving
into novel roles. Those making the move might be characterized as ‘unusual’
individuals compared to the majority of their peers. In short, at the recruitment
stage, the problem of limited applications appeared one that was influenced and
hindered by the nursing profession itself.
When considering those nurses who make the move, we note some take advan-
tage of an opportunity for learning about genetics, although this is mainly self-
driven with little educational support at local or national levels. Furthermore, the
effect of the professional institution, specifically the effect of inter-professional
hierarchy, is one that engenders disappointment and frustration on the part of
those who made the move into genetics. Genetics nurses remain subordinate to
doctors in a way that limits their autonomy and learning, and are also closely
monitored and managed by geneticists within the regional specialist centres.
Finally, they are subject to intra-professional hierarchy as nurse managers try to
push them towards less genetics and more mainstream service in their new roles,
or fail to integrate them with structures and processes in the mainstream disease
area in which they work. It appears nurses cannot escape inter-professional and
intra-professional hierarchy and experience a more limited set of learning oppor-
tunities than they anticipated.
Consequently, in moving onwards, genetics nurses may retrospectively regret
their role move following lack of progression at end of the pilot projects. For
some, they move back to the mainstream disease area in which they were previ-
ously located, with their genetics knowledge and experience poorly utilized.
Some continue to run genetics clinics in mainstream disease areas on a tempo-
rary basis to ‘mop up’ waiting lists and wait to see if further funding will be
forthcoming. This appears unlikely. Alternatively, at the outset of the pilots,
some nurses hoped to move into genetic counselling positions within regional
genetics centres. However, in our study such moves were absent due to limited
training places. In short, the promise of a new, less-bounded role for nurses
appears mythical. On a more positive note, a limited number of nurses sought to
develop a more research-orientated role. While for some of their peers this

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954 Organization Studies 31(07)

role transition is unattractive because it takes them away from patient contact
(Dingwall and Allen 2001), for the limited number following a learning trajectory
(Kamoche and Mueller 1998) such role transition appeals and, further, appears
more supported by professional institutions.
In sum, for the majority of nurses, the new, less-bounded roles are unattrac-
tive. In part this is due to the inherent conservatism nurses exhibit towards novel
roles (Davies 2002; Walby et al. 1994). The few nurses that make a move may
find it difficult, if not impossible, to enact the less-bounded, autonomous role.
Finally, moving onwards from the new roles proves challenging, due in large
part to the absence of education and support from professional bodies, so that
state attempts to reconfigure the healthcare workforce are mediated (Dent and
Whitehead 2001). We might expect the change in structure towards networked
delivery of genetics services to support workforce reconfiguration and new
workforce roles. However, the networked pilot initiative was one overlaid by
inter- and intra-professional hierarchy that decoupled changes in structures from
the development of new roles.
We might conclude that the majority of nurses who do not apply for the new
roles in the first place are justified in their decision. However, it seems the
uncertainty nurses felt regarding ‘professionalization’ of their occupation may
mean they are entirely comfortable with the notion that their temporary role
move allows them to maintain and even bolster the status quo around nursing
practice focused on patient care. They have extended their role and engaged in
self-development, while at the same time remaining true to the traditional notion
of the nursing role that attracted them to the profession in the first place. Nurses
may seek to remain aligned to an occupational mandate based upon holistic care
and quality of the relationship with patients. So, nurses may seek to fit new roles
and knowledge around this more traditional occupational mandate (Allen 2007;
Dingwall and Allen 2007; Hallam 2000; Thompson and Watson 2005).
Overall, the explanation for new roles remaining ‘bounded’ is an institutional
one. Within our study the interdependent nature of role development across pro-
fessions (Abbott 1988; Nancarrow and Borthwick 2005) keeps nurses subordi-
nate to doctors, with a more autonomous role for nurses constrained by genetics
and mainstream doctors. This is also evident within nursing itself, where the
new role is subject to intra-professional pressures. Thus, reconfiguration of pro-
fessional roles and relationships may be slow to emerge in the NHS. Influenced
by professional institutions, roles in the NHS still emphasize stability, hierarchy
and professionally and organizationally bounded job positions (Currie et al.
2006; Dany et al. 2003).

Conclusion

A particular contribution of our study is the focus on the tensions between indi-
vidual and collective identity constructions. This is a broadly neglected area in
the debates of changing roles of health professions. Specifically, our study demon-
strates the relevance of collective identity constructions in relation to more indi-
vidual constructions grounded in everyday interactions and the specific work

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 955

contexts of inter-professional healthcare services. Our study moves beyond the

traditional treatment of the issue within sociology of professions literature
through, first, complementing concern with how professions as an occupational
group construct boundaries around their identity with a focus upon individual
actors and the interpersonal levels of professional identity construction
(Ashforth and Mael 1989; Pratt et al. 2006; Sluss and Ashforth 2007). Second,
we examine the interaction of government policy intended to reconfigure pro-
fessional roles and relationships with professional expectations about relational
identities within and across occupational groups (Currie et al. 2009).
Within our study, on the surface there appear examples of person-based iden-
tity transcending role-based identity. For example, where a nurse has a long-
established, more particularized and personalized, relationship with a doctor,
they seem able to enact the genetics nurse role, as conceived by policy, more
easily. However, the particularized component of the role appears overwhelmed
by the more generalized notion that the nurse is subordinate to the doctor. The
nurse may ‘work’ the doctor, but within the institutionalized professional hierar-
chy, where the nurse remains subordinate to the doctor. The outcome is one where
the role, if less bounded, is one where the hierarchy between doctor and nurse
has only been slightly mediated.
Exacerbating this effect, alongside inter-professional hierarchy is intra-
professional competition, so that within the horizontal division of labour, role-
based identity is influenced by the dynamics of professionalization of nursing that
constrains the enactment of a more autonomous role for the genetics nurse imag-
ined by policy. Again, role-based identity prevails over person-based identity.
Thus, contrary to our expectations set out at the start of the article, our analy-
sis emphasizes that collective level of identity, focused upon the individual as a
prototypical member of a social category and specifically their professional iden-
tity, remains central to prospects for any role transition promoted by government
policy. Healthcare represents a heavily professionalized context (Mintzberg
1979, 1995), and as such represents an ‘extreme situation’, which means that
role enactments across and within professions are relatively similar rather than
unique (Ashforth 2001). As such, the interplay of individual and interpersonal
identity with the collective level of identity, which Sluss and Ashforth (2007)
propose, is less evident when considering the dynamics of professional identity
construction. Instead, structural influences counter any agency of those placed
in the new, less-bounded roles.
We make a number of more specific contributions to existing literature that are
particularly relevant to policy-makers and healthcare managers concerned with
reconfiguring professional roles and relationships. Studies of reconfiguration of
professional roles and relationships tend to be located at the institutional level of
analysis (e.g. Mizrachi and Shuval 2005), with much less located at the micro-
level of analysis (Charles-Jones et al. (2003), McDonald et al. (2007) and Martin
et al. (2009) represent recent exceptions). Micro-level studies are important
because they ground assertions about renegotiation of boundaries between health-
care professionals in the face of policy change (Currie et al. 2009). In this vein,
first, we show that an opportunity may be opened up by government policy for
one profession to enact a less-bounded role. However, within an interdependent

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956 Organization Studies 31(07)

system of professions, this may be perceived as a threat by other professions. The

important point here is the effect of prevailing power relations, which may
impose a considerable constraint upon those less-powerful actors that attempt to
enact a less-bounded, more autonomous role (Sanders and Harrison 2008).
Our study supports the view that professional roles are more institutionally-
determined than other organizational roles. At least within a professional
bureaucracy set in the public services domain, there is little room for negotiation
with the social world by an individual actor when enacting a new, less-bounded
role. There were very few examples of deviation to counter our narrative that
roles are institutionally-determined for less powerful actors in a large, profes-
sional bureaucracy where there is considerable inter-professional and intra-pro-
fessional dependency (Currie et al. 2009). In light of the above, we suggest the
challenge for nurses enacting a less-bounded, more autonomous role might be
seen as an institutional one, where they failed to establish legitimacy both within
their own ranks and with doctors (Sanders and Harrison 2008).
Our more contextualized analysis suggests the policy attempt to skills mix in
pursuit of collaborative healthcare delivery is rather too generic in its concep-
tion. Policy fails to take account of the interplay of collective and interpersonal
identities within and across professions, as new roles are developed and imple-
mented. In short, policy changes aimed at skills mixing to deliver collaborative
healthcare do not automatically impact upon day to day professional work
(Harrison et al. 1990; Harrison and McDonald 2008). We suggest that policy
needs to address institutional arrangements in healthcare systems if the struc-
tural embeddedness of medical dominance, which constrains new healthcare
roles, is to be overcome (Bourgeault and Mulvale 2006; Bourgeault et al. 2008).
On the one hand, we suggest our findings are transferable to other similar
contexts. Within the context of new health policies attempting to create collab-
orative care teams and to shift tasks – especially between doctors and nurses, but
also between and within other professional groups – the findings are highly relevant
for the management of healthcare organizations and the governance of a profes-
sional workforce internationally (Bourgeault and Mulvale 2006; Bourgeault et al.
2008). Supporting transferability of findings beyond our specific case to other
professional groups in healthcare, we note the existence of potentially compet-
ing managerial and professional logics (Reay and Hinings 2009) which, when
applied to the development of new roles, constrain their enactment at the local
level (McBride et al. 2005). Healthcare professionals are likely to exhibit a
defensive response towards others encroaching upon their traditional jurisdic-
tion (Martin et al. 2009; Sanders and Harrison 2008).
Moving beyond healthcare, a study by Marchington et al. (2005) examines
workforce changes associated with new organizational forms and indicates sig-
nificant institutional challenges for the enactment of new boundary-crossing
professional roles more generally. At the individual level, Marchington et al.
(2005) highlight that employees may be ‘losers’ – for example, their labour mar-
ket power may lessen, as they become less specialized and their control over a
distinctive area of knowledge is loosened. Associated with this, employees posi-
tioned in boundary-spanning roles face uncertainty about where the locus of control
and authority lies.

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Currie et al.: Role Transition and the Interaction of Relational and Social Identity 957

On the other hand, having highlighted potential transferability of our analysis

to other large professional bureaucracies, we note limits of our study that might
be considered in future research. There appear to be some specific contextual
factors at play, which constrain the development of new roles. Reay and Hinings
(2009) suggest that the intentions of entering parties to collaborative healthcare
delivery influence outcomes. Relevant to our study are the intentions of genet-
ics nurses, and those with whom they are interdependent, mainstream nurses and
specialist doctors in genetics or mainstream disease areas. While the intent of
genetics nurses was to gain knowledge from specialist doctors in genetics, which
they would then transfer to mainstream nurses and specialist mainstream doc-
tors, all stakeholders, other than genetics nurses, sought to maintain strong and
separate identities, which constrained the role of genetics nurses in brokering
knowledge.
Adding to the difficulties faced by genetics nurses, first, the professional knowl-
edge domain in which our study of the implementation of a novel role is located –
genetics – might be considered unusual or distinctive because it is perceived to be
an esoteric clinical area, marginal to mainstream services. The institutions that
frame the new roles are decoupled from local practice; for example, there are
limited education and career opportunities for genetics nurses. Meanwhile, doctors
utilize a professional logic regarding who is expected to diagnose and intervene
with a patient to constrain any autonomy for nurses in delivering genetics care
(Reay and Hinings 2009). Reflecting this, even where good pre-existing interper-
sonal relationships between nurses and doctors exist, these act to buttress profes-
sional cultures and styles so that a nurse remains subordinate to a doctor, and at
best co-ordinates care (Coombs and Ersser 2004). In contrast, hybrid roles that
cross professional boundaries may be more successfully implemented in other less
marginal or esoteric domains of professional knowledge, where new roles enjoy
the support of professional bodies, e.g. in educational and accreditation terms,
nurses are supported to take on specialist roles (Bourgeault et al. 2008).
Second, the nursing profession exhibits greater division of labour, encompassing
specialization and fragmentation of interests similar to other professions within
healthcare (Sanders and Harrison 2008) and beyond to other professionalized
organizational settings (Scott 2008). Moreover, we suggest a distinctive feature
of context is that nurses are stymied in their aspirations to enact more autonomous
roles due to their subordinate position to doctors and may also be influenced by
uncertainty regarding the direction of the development of their profession (Allen
2007; Dingwall and Allen 2001; Hallam 2000; Thompson and Watson 2005).
Enacting less-bounded roles may prove easier for more powerful professions,
such as the high flying lawyers, but less available to those outside the elite, such
as junior legal staff (Dinovitzer and Hagan 2006), i.e. even within a professional
bureaucracy a limited group of privileged employees may be able to enact a less-
bounded role.
Third, in professional bureaucracies dominated by a single profession (e.g.
educational establishments) the interaction of the professional institution and
less-bounded roles may play out rather differently, since there may be less inter-
dependence between professions in such circumstances (although in our study,
resistance to less-bounded roles was evident within the nursing profession itself).

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958 Organization Studies 31(07)
References Abbott, Andrew
1988 The system of professions: A study in
the division of expert labour. London:
University of Chicago Press.
Ackroyd, Stephen
1996 ‘Organization, contra-organizations:
Professionals and organizational
change in the United Kingdom’.
Organization Studies 17/4: 599–621.
Albert, Stuart, and David A. Whetten
1985 ‘Organizational identity’ in Research
in Organizational Behaviour. L. L.
Cummings and B. M. Staw (eds),
263–295. Greenwich, CT: JAI Press.
Allen, Davina
2007 ‘What do you do at work? Profession
building and doing nursing’.
International Nursing Review 54/1:
41–48.
Arthur, Michael B., Kerr Inkson, and Judith
K. Pringle
1999 The new careers: Individual action
and economic change. London:
SAGE.
Ashforth, Blake E.
2001 Role transitions in organizational life:
An identity based perspective.
Mahwah, NJ: Lawrence Earlbaum.
Ashforth, Blake E., and Fred Mael
1989 ‘Social identity theory and the
organization’. Academy of
Management Review 14/1: 20–39.
Bourgeault, Ivy Lynn, and Gillian Mulvale
2006 ‘Collaborative health care teams in
Canada and the U.S.: Confronting the
structural embeddedness of medical
dominance’. Health Sociology Review
15/5: 481–495.
Bourgeault, Ivy Lynn, Ellen Kulhman, Elena
Neiterman, and Sirpa Wrede
2008 How can optimal skill mix be
effectively implemented and why?
Tallinn, Estonia: WHO European
Ministerial Conference on Health
Systems (www.euro.who.int/
document/hsm/8_ hsc08_ePB_
11.pdf. accessed 28 October 2009).
Buchan, James, and Lynn Calman
2005 Skill-mix and policy change in the
health workforce: nurses in advanced
roles. Paris: OECD (OECD Health
Working Paper No. 17 www.oecd.org/
dataoecd/30/28/33857785.pdf,
accessed 28 October 2009).
Downloaded from oss.sagepub.com at PENNSYLVANIA STATE UNIV on March 4, 2016
Charles-Jones, Huw, Joanna Latimer, and
Carl May
2003 ‘Transforming general practice: The
redistribution of medical work in
primary care’. Sociology of Health &
Illness 25/1: 71–92.
Coombs, Maureen, and Steven J. Ersser
2004 ‘Medical hegemony in decision-
making: a barrier to interdisciplinary
working in intensive care’.
Journal of Advanced Nursing
46/3: 245–252.
Currie, Graeme, Sue Tempest, and Ken Starkey
2006 ‘New careers for old? Organizational
and individual responses to changing
boundaries’. International Journal of
Human Resource Management 17/4:
755–774.
Currie, Graeme, Graham Martin, and
Rachael Finn
2009 ‘Professional competition and
modernizing the clinical workforce in
the NHS: Possibilities and limits to
the development of the specialist
generalist in primary care’. Work,
Employment & Society 23/2:
267–284.
Dany, Françoise, Mary Mallon, and
Michael B. Arthur
2003 ‘The odyssey of career and the
opportunity for international
comparison’. International Journal of
Human Resource Management 14/5:
705–712.
Davies, Celia
2002 ‘Registering a difference: Changes in
the regulation of nursing’ in
Regulating the health professions. J.
Allsop and M. Saks (eds), 108–119.
London: SAGE.
Dent, Mike
1995 ‘The new NHS: A case of
postmodernism?’. Organization
Studies 16/5: 875–899.
Dent, Mike, and Stephen Whitehead
2001 Managing professional identities:
knowledge, performativity and the
‘new’ professionalism. London:
Routledge.
Department of Health
2000a A health service of all the talents:
Developing the NHS workforce.
Consultation document on the review
of workforce planning. London: NHS
Executive.
Currie et al.: Role Transition and the Interaction of Relational and Social Identity
Department of Health
2000b The NHS plan. London: Department
of Health.
Department of Health
2000c Shifting the balance of power: The
next steps. London: Department of
Health.
Department of Health
2002 HR in the NHS plan: More staff
working differently. London:
Department of Health.
Dingwall, Robert, and Davina Allen
2001 ‘The implications of healthcare
reforms for the profession of nursing’.
Nursing Inquiry 8/2: 64–74.
Dinovitzer, Ronit, and John Hagan
2006 ‘Lawyers on the move: The
consequences of mobility for legal
careers’. International Journal of the
Legal Profession 13/2: 119–135.
Doolin, Bill
2002 ‘Enterprise discourse, professional
identity and the organizational control
of hospital clinicians’. Organization
Studies 23/2: 369–390.
Eisenhardt, Kathleen M.
1989 ‘Building theories from case study
research’. Academy of Management
Review 14/4: 532–550.
Eisenhardt, Kathleen M.
1991 ‘Better stories and better constructs:
The case for rigor and comparative
logic’. Academy of Management
Review 16/3: 620–627.
Fournier, Valerie
2001 ‘Amateurism, quackery and
professional conduct: The constitution
of “proper” aromatherapy practice’ in
Managing professional identities:
Knowledge, performativity and the
‘new’ professionalism. M. Dent and S.
Whitehead (eds), 116–137. London:
Routledge.
Freidson, Eliot
1988 Profession of medicine: A study of the
sociology of applied knowledge.
Chicago: University of Chicago Press.
Freidson, Eliot
1994 Professionalism reborn: Theory,
prophecy and policy. Chicago:
University of Chicago Press.
Goodwin, Dawn, Cathy Pope, Maggie Mort,
and Andrew Smith
2005 ‘Access, boundaries and their effects:
Downloaded from oss.sagepub.com at PENNSYLVANIA STATE UNIV on March 4, 2016
959
Legitimate participation in
anaesthesia’. Sociology of Health and
Illness 27/6: 855–871.
Halford, Susan, and Pauline Leonard
1998 ‘Professionalism, managerialism and
the construction of self’ in
Professionals and the new
managerialism in the public sector.
M. Exworthy and S. Halford (eds),
102–121. Buckingham: Open
University Press.
Hallam, Julia
2000 Images of nursing. London: Routledge.
Harrison, Stephen, and Ruth McDonald
2008 The politics of healthcare in Britain.
London: SAGE.
Harrison, Stephen, David J. Hunter, and
Christopher J. Pollitt
1990 The dynamics of British health policy.
London: Unwin Hyman.
Hyde, Paula, Anne McBride, Ruth Young,
and Kieran Walshe
2005 ‘Role design: New ways of working
in the NHS’. Personnel Review 34/6:
697–712.
Iley, Karen
2004 ‘Occupational changes in nursing:
The situation of enrolled nurses’.
Journal of Advanced Nursing 45/4:
360–370
Kamoche, Ken, and Frank Mueller
1998 ‘Human resource management and the
appropriation-learning perspective’.
Human Relations 51/8: 1033–1066.
Kitchener, Martin
2002 ‘Mobilizing the logic of
managerialism in professional fields:
The case of academic health centre
mergers’. Organization Studies 23/3:
391–420.
Larson, Magali Sarfatti
1979 The rise of professionalism: A
sociological analysis. London:
University of California Press.
Levay, Charlotta, and Caroline Waks
2009 ‘Professions and the pursuit of
transparency in healthcare: Two cases
of soft autonomy’. Organization
Studies 30/5: 509–527.
McBride, Anne, Paula Hyde, Ruth Young,
and Kieran Walshe
2005 ‘How the “customer” influences the
skills of the front-line worker’.
Human Resource Management
Journal 15/2: 35–49.
960 Organization Studies 31(07)
McDonald, Ruth, Nicola Mead, Sudeh
Cheraghi-Sohi, Peter Bower, Dianne
Whalley, and Martin Roland
2007 ‘Governing the ethical consumer:
Identity, choice and the primary care
medical encounter’. Sociology of
Health and Illness 29/3: 430–456.
Marchington, Mick, Damian Grimshaw,
Jill Rubery, and Hugh Willmott
2005 Fragmenting work: Blurring
organizational boundaries and
disordering hierarchies. Oxford:
Oxford University Press.
Martin, Graham P., Graeme Currie, and
Rachael Finn
2009 ‘Reconfiguring or reproducing intra-
professional boundaries? Specialist
expertise, generalist knowledge and
the “modernization” of the medical
workforce’. Social Science &
Medicine 68/7: 1191–1198.
Mintzberg, Henry
1979 The structuring of organizations.
Englewood Cliffs, NJ: Prentice Hall.
Mintzberg, Henry
1995 ‘The professional organization’ in The
strategy process. H. Mintzberg, J. B.
Quinn, and S. Ghosal (eds). London:
Prentice Hall.
Mizrachi, Nissim, and Judith T. Shuval
2005 ‘Between formal and enacted policy:
Changing the contours of boundaries’.
Social Science & Medicine 60/7:
1649–1660.
Nancarrow, Susan A, and Alan M. Borthwick
2005 ‘Dynamic professional boundaries in
the health care workforce’. Sociology
of Health and Illness 27/7: 897–919.
Peiperl, Maury, Michael Arthur, Rob Goffee,
and Tim Morris
2000 Career frontiers: New conceptions of
working lives. Oxford: Oxford
University Press.
Pratt, Michael G., Kevin W. Rockmann, and
Jeffrey B. Kaufmann
2006 ‘Constructing professional identity:
The role of work and identity learning
cycles in the customization of identity
among medical residents’. Academy
of Management Journal 49/2:
235–262.
Reay, Trish, and C. R. (Bob) Hinings
2005 ‘The recomposition of an organizational
field: Health care in Alberta’.
Organization Studies 26/3: 349–382.
Downloaded from oss.sagepub.com at PENNSYLVANIA STATE UNIV on March 4, 2016
Reay, Trish and C. R. (Bob) Hinings
2009 ‘Managing the rivalry of competing
institutional logics’. Organization
Studies 30/6: 629–652.
Robinson, Sarah, Trevor Murrells, and
Louise Marsland
1997 ‘Constructing career pathways in
nursing: Some issues for research and
policy’. Journal of Advanced Nursing
25/3: 602–614.
Robinson, Sarah, Trevor Murrells, and
Michael Clinton
2006 ‘Highly qualified and highly
ambitious: Implications for workforce
retention of realising the career
expectations of graduate nurses in
England’. Human Resource
Management Journal 16/3: 287–312.
Rognstad, May-Karin, Olaf Aasland, and
Vigdis Granum
2004 ‘How do nursing students regard their
future career? Career preferences in
the post-modern society’. Nurse
Education Today 24/7: 493–500.
Sanders, Tom, and Stephen Harrison
2008 ‘Professional legitimacy claims in
the multidisciplinary workplace:
The case of heart failure care’.
Sociology of Health and Illness
30/2: 289–308.
Scott, W. Richard
2008 ‘Lords of the dance: Professionals as
institutional agents’. Organization
Studies 29/2: 219–238.
Sibbald, Bonnie, Jie Shen, and Anne
McBride
2004 ‘Changing the skill mix of the health
care workforce’. Journal of Health
Services Research and Policy, 9/S1:
28–38.
Sluss, David M., and Blake E. Ashforth
2007 ‘Relational identity and identification:
Defining ourselves through work
relationships’. Academy of
Management Review 32/1: 9–32.
Tajfel, Henri, and John C. Turner
1985 ‘The social identity theory of
intergroup behaviour’ in Psychology
of intergroup relations. S. Worchel
and W. G. Austin (eds), 7–24.
Chicago: Nelson Hall.
Thompson, David R., and Roger Watson
2005 ‘Editorial: The state of nursing in the
United Kingdom’. Journal of Clinical
Nursing 14/9: 1039–1040.
 Currie et al.: Role Transition and the Interaction of Relational and Social Identity 961

Turner, John C. Organizational challenges and

1985 ‘Social categorization and the self managerial futures for the UK
concept: A social cognitive theory of medical profession’. Organization
group behavior’. Advances in Group Studies 30/7: 755–778.
Processes 2: 77–121. Greenwich, CT:
JAI Press. While, Alison
2005 ‘In defence of nursing and the
Walby, Sylvia, June Greenwell, Lesley generic nurse’. International
MacKay, and Keith Soothill Journal of Nursing Studies
1994 Medicine and nursing professionals in 42/7: 715–716.
a changing health service. London:
SAGE. Yin, Robert K.
1994 Case study research: design
Waring, Justin, and Graeme Currie and methods. Newbury Park,
2009 ‘Managing expert knowledge: CA: SAGE.

Graeme Currie Graeme Currie is Professor of Public Services Management at Nottingham University
Business School and Director, Collaboration for Leadership in Applied Health Research
and Care, Nottinghamshire, Derbyshire, Lincolnshire (CLAHRC NDL). His research
interests focus upon leadership, knowledge management, reconfiguration of professional
roles and relationships, and translation of innovation in healthcare and other public ser-
vices. Published articles from these research streams appear in Leadership Quarterly,
Journal of Public Administration Research and Theory, Journal of Management Studies,
Human Relations.
Address: Nottingham University Business School, Jubilee Campus, Nottingham NG8
1BB, UK.
Email: Graeme.Currie@nottingham.ac.uk
Rachael Finn Rachael Finn is a Lecturer in Organizational Theory at The York Management School,
University of York. Her research encompasses the sociology of organization and
management applied to healthcare, with a particular focus on professions and teamwork.
She has published in Human Relations, Public Administration and Social Science &
Medicine.
Address: The York Management School, University of York, Heslington, York, YO10
5DD, UK.
Email: rf537@york.ac.uk

Graham Martin Graham Martin is Senior Lecturer in Social Science applied to Health in the Department
of Health Sciences, University of Leicester. He has wide-ranging research interests
around the implementation of health and social care policy, organizational change, man-
agement and the professions, and patient and public participation in health care. He has
published in journals including Social Science & Medicine, Sociology of Health & Illness
and the Journal of Public Administration Research & Theory.
Address: Department of Health Sciences, Adrian Building, University Road, Leicester
LE1 7RH, UK.
Email: gpm7@le.ac.uk

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