I am a single mother of seven running a household! Professionals mastering identity ambiguity to improve participation in a small-scale nursing home

Abstract

Introduction: Participation of service users and carers is advocated in many countries, because involvement of these lay partners inform high-quality, person-centered care. Despite increasing discussions on conceptualizations of participation and person-centered care, it is unclear how the envisioned approach can be translated in practice. Moreover, the strong, paternalistic professional identity is usually considered to impede transformation and challenges a participative role of lay partners. Indeed, questioning the way care is delivered, questions the identity of both professionals and lay partners. Aim: The purpose of this paper is to study how the professional identity changes in context of the paradigm shift in healthcare to generate insight how professionals can be successful in encouraging participation in their everyday work life. Methods: We have conducted ethnographic fieldwork in a Dutch nursing home for elderly with dementia. In a 3 month-period, 10 nurses, 24 residents and 15 family members were observed during work shifts. All nurses, 8 family members and 3 managers were informally interviewed. Based on a relational perspective on identity, we analyzed how identity constructions of these actors have manifested participation. Results: Our study shows contradictions between manners in which professional identity constructions manifest participation. We elaborate on the motivations for, types and consequences of participation. Moreover, we demonstrate how close relations between professionals and lay partners do not suffice and explain how endemic contradictions between identity constructions of professionals and lay partners complicate participation. Discussion: Our relational identity approach provides a way to compare experiences of professionals with their lay partners. In doing so, we have complemented literature on integration between professionals in answer to calls for elucidating integrated participation of 'non-professionals'. Additionally, taking nurses as exemplary group showcases complications beyond relationship investments with lay partners, and problems of resisting or underestimating these relationships because of expertise or time tradeoffs. We argue that mastering identity ambiguity in diverse situations is needed to realize different types of participation. This dynamic capability provides an opportunity to reinforce rather than threaten the professional status. Conclusion: We explain professionals' struggles, despite their strong relationship with lay partners. Awareness of contradictions within and between identity constructions by professionals and lay partners enables implementation of participation policies. Lessons learned: Besides openness, trust and dialogue, expectation management of rights and responsibilities is vital to improve participation of lay partners. Additionally, it is important to distinguish passive from active types of participation. Limitations and future research: Small-scale dementia care is typically supported by relationships between professionals and lay partners, which is particularly considered to be a task of nurses. However, the insights can be valuable for other professions and domains to the extent that these are user-oriented. Further research is necessary to develop training programs within nursing homes in specific on one hand and to confirm implications for participation in other settings (e.g. extramural care, cure sector) on the other. Furthermore, since the relational identity approach clarifies group dynamics in general, our findings are transferable to other changes in the healthcare sector and to other countries.