GPs, nurses and pharmacists as prescribers in primary care: an exploration using the social identity approach / Hausärzte/-innen, Diplomierte Pflegefachpersonen und Apotheker/-innen als Arzneimittelverschreiber/-innen: eine Exploration mit dem Ansatz der Sozialen Identität
Published Online: Sep 05, 2016
Page range: 153 - 164
Received: Dec 03, 2015
Accepted: Jun 23, 2016
DOI: https://doi.org/10.1515/ijhp-2016-0023
Keywords
© 2016 Marjorie C Weiss, Jo Platt, Ruth Riley, Susan Horrocks, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.
Over the past two decades, there has been a widespread growth in non-medical prescribing, broadly defined as the extension of the legal authority to professional groups, other than doctors, to write prescriptions. Most commonly, this includes nurses, but can also include pharmacists and allied health care professionals such as optometrists, physiotherapists, podiatrists, radiographers and chiropodists. Non-medical prescribing has been seen as one answer to rising health care challenges in Western countries, that of increasing health care costs and workload associated with a rising elderly population with increasing chronic disease and co-morbidity (Bhanbro et al., 2011; Weeks et al., 2014). The assumption is that nurse and pharmacist prescribers can engage in the on-going prescribing and monitoring of patients with chronic diseases, thereby enabling doctors to see more complex patients.
Globally, non-medical prescribing has developed unevenly across different countries, resulting in different non-medical prescribing models. There are more dependent prescribing models which allow non-medical prescribers to only prescribe those medicines in a protocol within a specific clinical area. More autonomous models also occur, such as within the United Kingdom (UK) where nurse and pharmacist prescribers can be trained to become independent prescribers and prescribe within any clinical area in which they are competent (Emmerton et al., 2005). Prior to the development of independent prescribing, there was supplementary prescribing, which is a form of delegated or dependent prescribing using a specific clinical management plan (CMP) for each patient. These CMPs were patient-specific, needed the patient’s agreement and detailed the specific clinical conditions under which the nurse or pharmacist could prescribe. Later, UK legislation in 2006 allowed for nurses and pharmacists to become independent prescribers where they were able to undertake training to become the practitioner ‘responsible for the assessment of patients with diagnosed or undiagnosed conditions and for the decisions about the clinical management required, including prescribing’ (Department of Health, 2005). In the UK, the perceived benefits of independent prescribing by nurses and pharmacists were to improve patient care without compromising safety, improve patient access to medicines, increase patient choice in accessing medicines, make better use of the clinical skills of professionals such as pharmacists and nurses and contribute towards more flexible team working in the NHS (Department of Health, 2006). Ultimately it was hoped that non-medical prescribing would decrease the workload of general practitioners.
The advent of independent prescribing by nurses and pharmacists (with the ability to make diagnostic decisions) has the potential to threaten the traditional dominance of medicine within health care (Weiss, 2011). Prescribing is a clear demonstration of clinical autonomy, core to professional identity and dominance of medicine (Freidson, 1970; Freidson, 1985; Willis, 2006). Indeed prior to the extension of prescribing rights to other professional groups, prescribing was the activity that demarcated the medical profession from other professional groups (Britten, 2001). With the extension of prescribing, the prized medical activity shifted from prescribing to diagnosis, such that, as noted by the editor of the
Yet research into the practical operationalization of nurse and pharmacist prescribing has not supported any substantive threat to the medical profession’s power. Weiss and Sutton (2009), drawing upon 23 qualitative interviews with supplementary pharmacist prescribers, argued that the factors that helped legitimate their role as prescribers were also those that kept them in a position subordinate to doctors. These factors included blurred definitions of prescribing, pharmacist prescribers self-limiting their prescribing practice to areas of competence and the development of prescribing into a team activity. Cooper et al. (2011) looked at the loss of prescribing as part of the GP’s arsenal of skills, and how diagnosis may be used to protect the threat from non-medical prescribing. He also identified a range of ‘micro-social strategies’ that GPs used to accommodate prescribing by other health care professionals that also acted to maintain medical hegemony. These micro-social strategies included patients’ and supplementary prescribers’ perception of doctors as being hierarchically superior and doctors’ denigration of most routine prescribing.
However, while medical hegemony may still pervade, this does not mean that change has not occurred, particularly in primary care. Abbott (1988) argued that occupations compete by making jurisdictional claims for areas of work. These jurisdictional claims are mediated through interactions and negotiations at a legal, public and workplace level, where contests for jurisdictional claims at the workplace level, in particular, can be extremely fluid, ingrained with potential for challenges to traditional hierarchies (Abbott, 1988). Professionals are increasingly delegating tasks to other disciplinary groups, with previously unskilled workers taking on tasks that, not long ago, were only undertaken by professionals (Charles-Jones et. al 2003). The development of independent prescribing by nurses and pharmacists is part of this process involving vertical substitution, with nurse and pharmacist prescribers adopting tasks normally discharged by the medical profession (Nancarrow & Borthwick, 2005), but also forming new hierarchies within professions. This dynamic landscape suggests that the threat to medical hegemony may be one way of understanding this process. Other theoretical perspectives might also offer valuable insights. One perspective that has been increasingly used in health care is the social identity approach (Haslam, 2014). Kreindler et al. (2012) argue that professionalization research has provided rich description of the strategies used by professional groups to increase their professional status. However, they suggest this literature focuses on groups’ instrumental motivations to gain professional status (e.g. increased power and autonomy), but with less exploration of their psychological motivation to maintain a positive social identity. It is from this emphasis on the psychology of inter-group processes that the social identity approach (SIA) emerged in the 1970s. It seeks to explain how people’s behaviour is structured not only by their personal sense of self, but also by their membership in social groups (Haslam, 2014). SIA comprises two theories: The social identity theory (SIT) (Tajfel & Turner, 1979) and the self-categorisation theory (SCT) (Turner et al., 1987).
SIA can be a practical tool for synthesising health workplace dynamics and identifying mechanisms for positive change. SIA explores how we see ourselves, and others, in terms of social categories, and how this affects our perceptions, attitudes and behaviour. SIA has five key dimensions (Kreindler et al., 2012):
Haslam (2014) recently reviewed the social identity approach, discussing how previous research using SIT in social psychology can be used to inform practical applications of SIT in health. Using this approach, the role of team members is not only largely structurally determined, but the changing nature of the roles themselves shape the very structures within which they work. SIA literature suggests that successful mobilisation within the health care team will involve crafting a new identity amongst and with the team, rather than placing a ready-made model in the workplace and expecting all members to understand and accommodate these changes. Leaders of these groups become identity champions (Haslam, 2014). In health, SIA has been used to explore inter-group conflict and how doctors use medical records to express their speciality identity (Hewett et al., 2009).
While the use of the SIA in health is not new, it has yet to be applied to GP, nurse and pharmacist prescribing in primary care. This research aimed to explore the group identities of GPs, nurses and pharmacists as prescribers. In particular, we sought to describe the social identities of GPs as prescribers, nurses as prescribers and pharmacists as prescribers, as well as the extent to which these identities are expressed and accepted. In addition, we sought to use the social identity approach as a way of understanding how nurse and pharmacist prescribing could be developed in the future.
This was a qualitative study, which was part of the Communication in Consultations (CIC) study that took place between October 2009 and September 2011. The study received NHS ethical approval and research and development permission from 36 primary care trusts (PCTs) across southern and central England and Wales. In the main CIC consultation study, over 500 consultations between patients and GPs, nurse prescribers (NPs) or pharmacist prescribers (PPs) were audio-recorded. The independent prescribers recruited to the CIC study needed to be working in primary care with NPs and PPs having obtained their qualifications post 2003. GPs, NPs and PPs were recruited with the support of local primary care research networks through newsletters, websites and e-mails. The main CIC study findings have been published elsewhere (Riley et al., 2012; Weiss et al., 2013, 2015). The qualitative study involved interviews with a sub-group of prescribers that took part in the main CIC study. There were 51 prescribers in the CIC study: 20 GPs, 19 nurse prescribers (NPs) and 12 pharmacist prescribers (PPs). From these, 21 prescribers were recruited for the interview study, seven from each of the prescriber groups.
Interviews with prescribers were conducted after the recordings for the main CIC study were completed. At the end of the main CIC study, prescribers were asked if they were interested in being interviewed and, if so, further details of the research were supplied. Written consent was obtained before setting a mutually agreed date for interview. Prescribers were purposively sampled to yield a diverse sample with respect to surgery size, geographical location, level of deprivation of the practice area, prescriber gender and prescriber age.
A topic guide was developed to explore the participant’s experience of non-medical prescribing, their awareness and impact of these new roles, how these new roles have impacted upon professional status and clinical responsibility, any benefits or concerns about the extension of prescribing and any concerns about patient safety. All prescriber interviews were conducted face-to-face and were digitally audio-recorded. Audio files were transcribed and anonymised.
Data were analysed thematically using the principles of the constant comparative technique (Green, 1998). Transcripts were first imported to NViVo and codes (‘nodes’ in NVivo) were created and relationships between codes were explored in the transcript narratives. Codes and sub-codes were identified by the researchers (JP, RR) within the GP and NP transcripts and explored within and across prescriber groups. These codes were grouped into clusters, which were then re-examined and refined further. Due to recruitment difficulties, the PP interviews were conducted later in the project timeframe. These interviews were analysed by MCW using the original coding frame, after completion of the project. Once this preliminary inductive analysis had been conducted, MCW explored the emerging clusters of codes and related these to the key dimensions of the SIA. These dimensions included social identity, social structure, identity content, strength of identity and context (Kreindler et al., 2012). These were then further refined with the twin aim of maintaining the integrity of issues and themes emerging directly from the data while drawing out insights, which resonated with the SIA.
Interviews were conducted with 21 prescribers: seven GPs, seven nurse prescribers and seven pharmacist prescribers. Three sets of GP and nurse prescribers were from the same practice (GP1 and NP3, GP25 and NP26 and GP36 and NP37). Two GPs (GP16 and GP21) had neither a nurse or pharmacist prescriber in their practice, all other GPs had experience of working with nurse or pharmacist prescribers. Interviews lasted on average 39 (GPs), 42 (NPs) and 51 (PPs) minutes. Pharmacist prescribers tended to be slightly younger (mean age = 42 years) compared with nurse (mean age = 47 years) or GP (mean age = 51 years) prescribers. The characteristics of the participating prescribers are presented in Table 1.
| Code GP = General Practitioner, NP = Nurse Prescriber, PP = Pharmacist Prescriber | Gender | Age | Prescribing Area | Location |
|---|---|---|---|---|
| GP01 | M | 62 | General Practice | Semi-rural |
| GP05 | M | 44 | General Practice | Semi-rural |
| GP16 | F | 58 | General Practice | Urban |
| GP21 | F | 50 | General Practice | Urban |
| GP25 | M | 50 | General Practice | Town & Fringe |
| GP35 | M | 53 | General Practice | Semi-rural |
| GP36 | M | 42 | General Practice | Rural |
| NP03 | F | 37 | Minor ailments | Semi-rural |
| NP10 | F | 48 | Minor ailments | Town & Fringe |
| NP12 | F | 55 | Warfarin/Minor Ailments | Urban |
| NP24 | F | 43 | Minor ailments | Semi-rural |
| NP26 | F | 55 | Diabetes | Town & Fringe |
| NP30 | F | 38 | Minor ailments + triage | Urban |
| NP37 | F | 50 | Minor ailments | Rural |
| PP19 | M | 52 | Hypertension | Urban |
| PP32 | F | 36 | Medicines Review | Urban |
| PP45 | M | 43 | Medicines Review | Urban |
| PP46 | F | 38 | Blood Pressure Clinic | Sub-Urban |
| PP49 | M | 38 | Hypertension | Sub-Urban |
| PP51 | F | 47 | COPD | Urban |
| PP57 | F | 41 | Blood Pressure Clinic | Urban |
Data are presented under themes aligned with the SIA and include ‘A no man’s land’ (social identity), ‘the doctor is king’ (social structure), ‘subtle prescribing’ (identity content), ‘more than just competent’ (identity content) and ‘engaging with each other’s identities’ (context).
In primary care, nurse and pharmacist prescribing was introduced into an existing hierarchy of inter-professional relations. Although nurses have been able to prescribe since the 1990s, even in 2009, nurses and pharmacists working as prescribers were still considered to be quite ‘new’ roles. It was evident from the interviews that nurse and pharmacist prescribers saw themselves as different, both from their wider professional group and from other prescribers such as doctors or other nurse or pharmacist prescribers. This ambiguity of space, somewhere between a doctor and a non-prescribing nurse, meant that significant numbers of new prescribers currently found themselves in a ‘no man’s land’. Prescribing nurses in particular found themselves no longer part of the nursing social and working space, yet neither afforded an invitation into the social or clinical meeting space of the GPs. Many talked of their isolation from regular practice clinical meetings.
The reception team too were unsure of their place, whether they should be offered the administrative support extended to GPs in the surgery, or whether nurse prescribers should organise their own administration. As noted by one nurse, even those within her own profession did not consider her part of their social group:
The ambiguity of the social identity of the nurse prescriber was exemplified in the wearing of a uniform. As noted by Tellis-Nayak and Tellis-Nayak (1984), most non-prescribing nurses wear a uniform whereas doctors wear what they like. As such, clothing is a visual reminder of the power imbalance between doctors and nurses. In some surgeries, nurse prescribers are expected to continue to wear uniforms, while others asked them not to and to align themselves more with the GP prescribing team. This caused complications in team dynamics for nurses and also, to an extent, some confusion for patients.
The uncertainty created by nurses’ emerging innovative roles, between GPs and nurses as well as between different groups of nurses, has been described previously (Williams & Sibbald, 1999). The social identity of nurse prescribers was clearly distinct from their wider professional group, situated in between a non-prescribing nurse and a doctor. For pharmacist prescribers, there was a similar ambiguity, albeit for different reasons. All of the pharmacists had been (or were currently) employed by the PCT and went into individual practices with tasks associated with the PCT’s agenda of, for example, rationalising drug choices (e.g. switching patients from one drug within a category to a cheaper version) or conducting PCT audits. As such, the practice was not paying for the pharmacist’s time but if the pharmacist had time, they could run clinics or engage in other tasks that the practice identified. As described by one pharmacist:
Pharmacists felt that not only weren’t they a part of the surgery but that their prescribing was a secondary role and less secure financially:
For these nurse and pharmacist prescribers, neither group saw themselves as fitting in with existing practice structures. For nurses, this was about not fitting in with their wider professional group who were already employed by the practice. For pharmacists, the lack of fit within the practice was about their PCT role being external, potentially viewed as a policing role by the practice and financially insecure. In practice the prescribing role of the pharmacist was subordinate to this PCT role and a ‘free’ service to the practice. This was compounded by the fact that there were usually only a few (one, or possibly two) nurse or pharmacist prescribers at each surgery site so there were few other existing practice exemplars to align themselves with. As described in the next section, the extent to which this role fitted in with existing practice structures was influenced by the social structures and power relationships within each of the surgery settings.
The social structures within and external to the practice in which the nurses and pharmacists worked could impose restrictions or boundaries on their role and what they could prescribe. Prescribing constraints, imposed by the practice’s GP partners, conveyed a clear message of who controlled and limited their prescribing and reinforced the medically dominant professional and social hierarchy. This could create some tension around prescribing:
This nurse prescriber contrasted her current experience with her previous role in a practice, which was forward-thinking and happy for her to take on ‘new things’. Yet this lack of recognition or understanding of the nurse prescriber’s role could also come from other nurses and pharmacists:
The doctors’ and patients’ views of the nurse prescribers, frequently drew upon traditional nursing stereotypes of being more caring, task focused and less formal:
These nursing stereotypes could then be used to increase patient throughput to nurse prescribers:
While a reliance on approachability may help facilitate access and through this, patients’ recognition of the nurse prescriber role, it could also reinforce traditional nursing stereotypes associated with caring and low status (McDonald, Campbell & Lester, 2009, Dingwall & Allen, 2001). This could lead to patients’ perceptions of different ‘kinds’ of prescribers, with nurses at a lower level than prescribing GPs.
According to Tajfel and Turner (1979), one of the ways in which unequal status groups operate when wishing to either increase or decrease the magnitude of status difference is through social creativity, by creating new group ideologies. Weiss (2011) suggested that doctors have tried to emphasise the uniqueness of their own role as diagnostician (as opposed to prescriber). However, this unique role in diagnosis has become more tenuous (Weiss, 2011) as the new independent prescribers are also able to diagnose the patient’s condition. For this reason, a more nuanced role for GPs as diagnosticians and prescribers needed to be developed. GPs, as a prescribing group, are then left to try to carve out a particular prescribing identity, distinct from the other prescribers. This identity sees GP prescribers as risk takers and as having a particularly intuitive ability to put their finger on what is wrong with a patient:
This GP later goes on to give an example of the particular expertise a doctor has:
Through this emphasis on the subtleties and indeterminacy of prescribing that could not be reduced to a protocol or other more formulaic forms of learning, GPs as prescribers were seeking to define their group in a way which was positive, distinctive and enduring (Haslam, 2014). This identity, with its focus on abstraction and more challenging intellectual skills, was also clearly viewed as being superior to nurses’ and pharmacists’ prescribing role. Combined with the social structures within the GP surgery setting that reinforced the hegemony of medicine, this sense of a superior group prescribing ideology could be used as a rationale to restrict and oppress other prescribing groups:
Equally, if GP prescribers felt this identity was being undermined, they would lament the introduction of nurse and pharmacist prescribing as encroaching on their prescribing territory:
Competence is the cornerstone of nurse and pharmacist prescribing in the UK. Although core competencies for nurse and pharmacist prescribers were originally devised by the National Prescribing Centre (now part of the National Institute for Health & Care Excellence), prescribing competence is now part of medical training as well (Maxwell & Whalley, 2003; Mucklow, Bollington & Maxwell, 2011). However, while these initiatives describe the generic core competencies to become safe and effective prescribers, the term ‘competence’ was used by our nurse and pharmacist prescribers to describe the clinical areas in which they felt they had the clinical knowledge and confidence to prescribe. As articulated below, identifying the clinical areas in which a new prescriber is competent and limiting your practice to these areas has become a core professional ideal for new prescribers (Weiss & Sutton, 2009):
These prescribers described what they do as having a high level of knowledge and skills but within circumscribed areas of practice. However, this is not the only accepted meaning of the word competence. On the one hand, it can mean doing something to the level of the bare minimum, although it can also be defined as embracing all that is required in terms of knowledge and understanding, because anything less is not competent (Lum, 1999). Pharmacists’ and nurses’ definitions appear to encompass the latter meaning although by defining themselves in terms of competence, because of its multiple meanings, they risked making it sound as if their prescribing was at a lower level to doctors’. This is in conjunction with their competence being limited to one or two specific areas of practice. Yet there were other new prescribers, having started with one particular clinical area, expanded beyond this to multiple areas of competence:
Nurse and pharmacist prescribers have defined their social identity in terms of competence but have sought to cast this in terms of having a high level of knowledge and skills in one or more circumscribed areas of practice. While this attribute may constrain what they are able to do and have some negative connotations of doing something at a minimal level, these representations went far beyond this to a highly skilled and valued aspect of nurse and pharmacist prescribers’ group identity. Indeed, the transformation of competence into a professional virtue is part of an ideology, which reaffirms their own positive distinctiveness and the group’s social worth (Kreindler et al., 2012). It can also be seen as an example of social creativity where nurse and pharmacist prescribers, as the lower status group, seek to enhance their standing without challenging the higher status group of GP prescribers (Haslam, Reicher & Reynolds, 2012).
GP prescribers’ identity was focused on their role as subtle prescribers, with an intuitive ability to put their finger on causes of more opaque patient presentations. Nurse and pharmacist prescribers saw their identity as one of a knowledgeable, skilled professional whose expertise was in particular clinical areas of practice. There were situations where an appreciation of each other’s identities did appear to be acknowledged by the other professional group:
It was not only that the skills of each other’s professional groups were acknowledged but they supported each other and functioned better as a team:
The data reinforced a key insight from Turner’s self-categorisation theory: “
As noted by Haslam et al. (2012), the power of groups is unlocked by working with social identities, not across or against them. This was evident in the way some practices were able to describe how the team worked together within the practice:
Hinted at in the third quote above is the potential for different social identities to work together to benefit patient outcomes. In his review, Haslam (2014) suggested that if we wish to reap the benefits of social identity theory, it is not just respectful engagement with social identities that makes a difference but that these groups can become a vehicle for improvement in patients’ lives. Productive interaction within groups who each have a distinct social identity can be mobilised at an organisational level to develop a shared working understanding of the organisation, which is itself reconstructed by the social identities within it (Haslam, Eggins & Reynolds, 2003). A sense of this dynamic process, the willingness to engage with different social identities and reframe these within the organisational context of a GP surgery, is conveyed by this pharmacist prescriber:
Respect and recognition for each other’s social identities and supporting each other through teamwork appeared to be the route towards forming a shared practice identity oriented towards multi-disciplinary patient care. While this study did not explore the relationship between patient outcomes and organisation of care within the different practice settings, other intervention research using a social identity approach has demonstrated a link between group membership and well-being (Haslam et al., 2008, 2010; Cruwys et al., 2013). This suggests that SIA could be a powerful tool for understanding the link between practice identity, organisation of care and patient outcomes.
This research applied the social identity approach to the novel area of non-medical prescribing in primary care. It was a useful tool to inform findings from GP, nurse and pharmacist prescriber interviews regarding their perceptions of professional identity and group working in the primary care setting. In addition to describing the social structures that impacted on these roles, how particular individuals described themselves and their professional group enabled different professional group identities to be hypothesised. Further, the social identity approach offered an explanation for why there were cases where these professional groups were able to come together to form a positive organisational group identity at the practice level. This was through recognition and respect for each other’s social identities, where support and teamwork enabled the development of a shared practice identity focused on multi-disciplinary patient care.
Our findings similarly emphasise the dynamic nature of SIA where a change in the context (nurse and pharmacist prescribing) provokes a change in the different prescribers’ identities, which in turn enables further context change (greater multi-disciplinary working). This cyclical phenomenon has been observed by Kreindler et al. (2012) who states that “
Indeed, both the ‘subtle prescribing’ and ‘more than just competent’ themes also underscore the interactive, cyclical and dynamic nature of SIA. While both are described here as part of the identity content dimension, they could also be seen as part of the social structure. The social creativity of GPs, nurse and pharmacist prescribers to create new identity content for themselves can be seen to fit with the existing literature on the professionalising strategies that GPs, nurses and pharmacist undertake to enhance their professional status (Nancarrow & Borthwick, 2005), and part of SIA’s social structure dimension. However, these findings also suggest that social creativity is being used to form new inter-group relationships. Identity content influences social structure, which then influences and reinforces further changes in identity content through greater inter-group working.
Previous research has found that, in those settings where different health care professionals worked well together and had reciprocally respected social identities, there was greater teamwork and role satisfaction. De Moura et al. (2009) used the social identity theory to explore the relationship between organisational identification and job turnover, finding that organisational identification offered a strong motivator towards decreasing turnover intention. Further work has suggested a link between teamwork and better patient care, even in situations of high workload. These researchers found that the relationship between increased workload and better quality patient care was moderated by teamwork, as measured by relational climate (Mohr et al., 2013). Higher workload was associated with lower quality of care when there was lower relational climate, but with better quality of care when there was higher relational climate. Further evidence comes from a study involving 991 Medicare beneficiaries. These authors found that patients of those organisations with higher levels of team commitment, as measured by perceived task delegation, role collaboration, patient orientation and team ownership, had better physical and emotional health at two years following baseline assessment than patients in lower functioning organisations (Roblin et al., 2011). These studies draw attention to the importance of organisational features noted in our research such as role collaboration and teamwork. This suggests that in the organisations that we observed where differing social identities were respected and supported, a positive organisational identity in terms of multi-disciplinary working may also be more likely to provide better patient care than those practices where traditional hierarchies and rigid professional boundaries predominated.
However, Finn et al. (2010) discuss how the very ambiguity of the word ‘teamwork’ enables sufficient space for different groups to co-opt it in the service of their own professional interests. Relating back to Haslam (2014), if the political superordinate identity of teamwork is imposed instead of exposing and engaging identity fault lines, then the potential for a positive organisational identity to emerge will fail. A strategy of social identity suppression ‘
Indeed, Haslam et al. have used the social identity approach to develop a model to enable employees to identify and mobilise both personal and shared group identity resources to improve organisational outcomes (Haslam, Eggins & Reynolds, 2003). Haslam’s model, Aspire (
The data considered in this paper comprises 21 prescribers in the south of England and so may not be generalizable within or across these prescribing groups. The sample was also taken from prescribers who had volunteered to participate in a communication study and therefore may be biased by being more aware of communication issues within their practice or more innovative in their approach to patient care.
The social identity approach provides a useful vehicle for understanding the social identities of GPs as prescribers, nurse prescribers and pharmacist prescribers. It has also examined how social structures, such as uniforms, meeting attendance and use of working space may affect social identity expression. Further, where social identities were respected and supported, the social identity approach offered insight into how the resulting teamwork could lead to a shared practice identity oriented towards multi-disciplinary working to facilitate patient care. Future work should focus on developing and evaluating social identity approach interventions, which enable identity based differences between professional groups to be the basis for productive higher-order integration and creativity. This may also further elaborate the dynamic and cyclical nature of the different dimensions of the social identity approach where context, social structure and identity iteratively influence, inform and reinforce each other. These, in turn, can be used to construct positive, shared practice based identities, which, ultimately, may be associated with improved patient care.