although our review was protocol - driven , it allowed for evolution as we became more familiar with the literature . we undertook a systematic literature search for relevant empirical and theoretical sources , using electronic databases ( pubmed , cinahl , scopus , psycinfo , sociological abstracts , dissertation abstracts ) and google scholar , and also hand - searching relevant journals . we identified additional reports through our own collections and reference lists , using the context in which a reference was cited to assess its probable relevance . any item we thought might discuss social identity in health care was retrieved ; those discussing concepts other than social identity were sampled up to the point of theoretical saturation . two reviewers independently screened each abstract and subsequently assessed each report for inclusion ; disagreements were resolved by a tie - breaking vote for abstracts and by consensus for full reports . ( further methodological details and a full list of included and excluded reports are available from the authors upon request . ) to determine how the five sia dimensions were addressed , we undertook an inductive , iterative analysis of the literature , whereby we derived what we have termed conceptual currents . we did not rely on the authors espoused theories as a basis for categorization , as we discovered commonalities across theoretical labels and diversity within them ; moreover , many articles were atheoretical . instead , drawing on the approach of metanarrative synthesis ( greenhalgh et al . we began with simple content analysis , coding sources for the presence of each of the five sia dimensions ; however , since merely documenting a concept 's presence provided no information about how it was addressed , we used this as a springboard for thematic analysis . this process involved constant comparison of the data against one another and an emerging list of thematic categories . one reviewer ( sk ) used the preliminary codes , along with qualitative notes recorded for each report , to sort articles according to the combination and interpretation of sia dimensions that they reflected ; the analysis was then opened to the other team members . we reviewed 348 reports representing 335 unique sources ( 166 qualitative , 77 quantitative , and 17 mixed - methods studies ; 71 essays , commentaries , or theoretical papers ; and 4 reviews ) . the literature revealed a strong focus on interprofessional and , secondarily , intraprofessional issues ( n = 151 and 84 , respectively ) , with some examination of management - staff relations ( 30 ) , organizational change ( 29 ) , and other organizational issues ( 34 ) . as we confined our search to english - language reports , it is not surprising that most of the sources came from english - speaking countries such as the united states ( 90 ) , united kingdom ( 88 ) , australia ( 29 ) , and canada ( 24 ) . sit was referred to in 114 reports , representing 105 unique studies / essays ( about a fifth of which addressed it only briefly or used it implicitly by discussing organizational identification ) . these did not constitute a unified literature ; pockets of articles cited one another , while many articles cited no others within the group . not all presented social identity as a group - related issue , instead treating it as an individual - difference variable or an input to interpersonal relationships ( e.g. , fuller et al . some authors defined key sit terms incorrectly ( hallier and forbes 2005 ) or evinced awareness of only the earliest or simplest formulations of the theory , not its breadth and depth . for example , the efforts by mitchell and colleagues ( 2010 ) to  integrate  sit with an individualistic information - processing approach suggested a lack of familiarity with the extensive social identity literature on social cognition and social influence ( e.g. , abrams et al . furthermore , some of the papers that applied sit appropriately did not focus on health care , using it merely as a setting in which to test general hypotheses about intergroup or organizational behavior ( bartels et al . 2010 ; oaker and brown 1986 ) . thus , despite the apparently high number of sit citations , there was no evidence of a social identity literature on health care groups . content analysis suggested that sources featured an average of 2.5 of the 5 sia dimensions . whether or not a source cited sit was not a robust indicator of whether it addressed these dimensions in a manner consistent with the sia ; notably , we found several highly sia - congruent analyses among non - citers . for this reason , the theory - based synthesis does not privilege sit - citing sources , but discusses all sources together . in the next section , we group the conceptual currents ( in italics ) under the sia dimension that they most strongly reflect . to conserve space , we use citations for illustrative purposes , not exhaustively . the most basic insight of a group - based approach is that analyses of conflict or cooperation in health care must consider group , not merely interpersonal , dynamics . this insight was powerfully demonstrated in an expos of virulent intergroup conflict among hospital departments ( hewett et al . drawing on sit , the study revealed that patient charts  supposedly repositories of objective information  were rife with examples of intergroup competition and in - group enhancement . the study also showed how interspecialty competition to  own  ( or disown ) patients could threaten safe care and may have led to a patient 's death . the authors argued that interpersonal - skills training would be an inadequate remedy for physicians dysfunctional communication , since the problem resulted not from a lack of skill but from the active expression of group identities . such recognition of the importance of groups is echoed in papers that variously invoke sit ( shute 1997 ) , role theory ( booth and hewison 2002 ) , evolutionary psychology ( braithwaite , iedema , and jorm 2007 ) , and other concepts ( ferlie et al . 2005 ) . however , this body of literature is primarily descriptive . to identify potential solutions , therefore , the health care landscape comprises groups of unequal power and status . without an understanding of this issue , naive calls for  teamwork  may actually reinforce professional divisions and hierarchies . for example , finn ( 2008 ) documented how various providers appealed to the concept of teamwork to advance their profession - specific norms and interests : to nurses , teamwork meant more equal and respectful relations ; to surgeons , that others efficiently followed their orders . many authors stress the gendered nature of the doctor - nurse dynamic , tracing its origins to the subordination of women within the sexual division of labor ( campbell - heider and pollock 1987 ) . others put power first and gender second , emphasizing how the specific unequal relationship between doctors and nurses produces certain patterns of interaction . for example , tellis - nayak and tellis - nayak ( 1984 ) elucidated how structural inequalities are reinforced by social rituals ( concerning the differential use of space , time , language , and body language ) , arguing that any attempt to reduce the power imbalance must address both structural and symbolic factors . both gender- and power - related role expectations may constrain health care professionals to play the  doctor - nurse game ,  in which the nurse must offer any suggestion indirectly so that it seems to be the doctor 's idea ( stein 1967 ) . many structural analyses also touched on identity content by noting how the values , discourses , sources of knowledge , and types of labor associated with high - status groups ( men / physicians ) are privileged over those of low - status groups ( women / nurses ) ( wicks 1998 ) . roberts ( 1983 ) contended that intergroup inequality also taints nurses intragroup relations , giving rise to  oppressed group behavior  in which nurses accept the physician - dominated structure as legitimate and inevitable . she explained  horizontal violence  within nursing in terms of nurses efforts to repudiate a devalued group identity and align themselves instead with the oppressing group . while offering a provocative examination of health care hierarchies , this literature has attracted three major criticisms : ( 1 ) its perspective tends to be static and deterministic , missing the context - dependent , strategic , and , above all , variable nature of doctor - nurse interactions , and sometimes denying nurses agency ; ( 2 ) its accounts are frequently partisan , reflecting the unquestioned assumption that increased power for a certain group is an absolute good ; and ( 3 ) its overwhelming focus on doctor - nurse relations obscures other power relations in health care . for example , a uk study ( johns 1992 ) explored how the division of nurses into primary and associate roles created new power dynamics , including what might be described as a  nurse - nurse game ( i.e. , associate nurses confining themselves to indirect suggestions to maintain a facade of harmony ) . from an sia perspective , all three limitations spring from the fact that  unequal partners  analyses reify observed phenomena as immutable social facts , not recognizing them as examples of generalized group processes . according to sit ( tajfel and turner 1979 ) , the behavior of unequal - status groups can be understood in terms of two basic responses : individual mobility ( attempts to leave one group and enter the other ) and social change ( attempts to reduce , reverse , or increase the status difference between the groups ) . social change strategies include social creativity ( creation of ideologies that affirm the in - group 's worth ) and social competition ( competition with the out - group for power or resources ) . sit does not treat these strategies as unique to oppressed groups or as dependent on a particular group psychology , but rather as a function of the in - group 's structural position relative to the out - group , the features of the structural relationship , and the strength of the member 's group identification . the sia 's generality and objectivity allow it to encompass both entrenched intergroup inequalities and scenarios in which power relations are more complex , unexpected , and context - dependent . ( for a sit - informed account of doctor - nurse relations , see chattopadhyay , finn , and ashkanasy 2010 . ) the professional strategies tradition , grounded in the sociology of professions ( freidson 1970 ) , explores occupational groups struggles for territory and control . although medical dominance is a frequent focus , abbott ( 1988 ) underscored that the important phenomenon is not the empirical fact of a certain group 's dominance ( which can change ) but the ubiquity of intergroup competition  which occurs both interprofessionally and among intraprofessional subgroups ( currie , finn , and martin 2009 ) . unlike the  unequal partners  literature , this stream tends to regard all groups as self - interested and their ideologies as self - serving . it also offers a less static view , illustrating how the intergroup landscape may change when a strategy succeeds or backfires . in a study of health care reorganization , daykin and clarke ( 2000 ) illuminated how nurses  project  of professionalization was impeded by contradictions between the strategies used to gain territory from medicine and to protect their own . to affirm their status vis -  - vis medicine , nurses claimed a distinct body of knowledge grounded in caring , yet undermined this claim by devaluing the caring labor of health care assistants . the authors argued that , far from enhancing nurses professional status , such exclusionary tactics reduced their ability to resist the most pertinent threat : management 's fordist practices of routinization and de - skilling . the  professional strategies  literature often highlights the role of context ; for example , oncologists who worked in different settings used different means to promote their dominance over practitioners of complementary and alternative medicine ( cam ) ( broom and tovey 2007 ) . hospital physicians used the discourse of science to discredit cam , proclaiming the superiority of medicine 's  scientific mind - set  even in areas where no medical evidence existed . hospice physicians could not discredit cam , given its fit with their institution 's holistic philosophy ; instead , they found subtle ways to subsume cam within a biomedical paradigm , tightly controlling cam practice to avoid any challenge to ( bio)medical dominance . with its rich description of both the material and rhetorical strategies that groups use to secure and enhance their professional status , the professional strategies  literature depicts social competition and social creativity in action . echoing sit , it shows how members strategically compare their own group with others , choosing dimensions ( may and fleming 1997 ) , definitions ( norris 2001 ) , and comparison groups ( fournier 2002 ) that maximize the in - group 's positive distinctiveness . it differs from sit , however , in focusing on groups instrumental motivation to gain power and autonomy , seldom recognizing the psychological motivation to maintain a positive social identity . the assumption that groups care only about tangible , not symbolic , benefits can lead to inaccurate predictions ( e.g. , that health care groups would soon abandon professional ideologies , competing instead over who could meet market needs most cost - effectively ) ( light 1988 ) . skepticism about groups self - representations can be taken too far , to the point of dismissing all affirmations of group identity as strategic performances . the sia recognizes that such performances are not just strategic ; they often reflect highly valued identity content . group identities are not arbitrary but are defined by certain content : norms , values , and worldviews that are meaningful and important to members . a large literature frames this topic in terms of culture and cultural differences , delineating how professional groups differ in everything from values and attitudes ( degeling , kennedy , and hill 2001 ) to myths and rituals ( dombeck 1997 ) . but bald descriptions of identity content do not elucidate group processes , and inspire few solutions apart from vague calls for cultural sensitivity . accounts of professional culture may also miss intraprofessional diversity ; even explorations of professional subcultures ( leininger 1994 ) often stop short of asking what the different variants of identity mean . more sia - consistent studies may explain variability in terms of subgroups with different experiences or structural positions contesting ( advancing their own versions of ) identity content ( e.g. , pratt and rafaeli 1997 ) . in contrast to the  cultural differences  discourse , which portrays identity content as static , the sia takes a dynamic view , examining how different representations of group identity are constructed and mobilized in order to achieve group goals . research on professional socialization considers , among other things , how educational and practice environments encourage or suppress the enactment of a patient - centered identity . patient - centeredness can be an integral part of physician identity , yet its expression may be actively discouraged through both the formal and informal curricula of medical school ( apker and eggly 2004 ) . in contrast , nurses are strongly socialized into patient - centeredness  until they enter the working world , where demands for efficiency may imperil this core value , resulting in demoralization and disengagement ( limoges 2007 ) . odonohue and nelson ( 2007 ) stressed that professionals psychological contract with an organization depends not merely on individual rewards but on the organization 's respect for the values central to their collective identity . health care professionals are known to resist threats to their identity content ( fiol and oconnor 2006 ) ; however , interventions perceived as identity threatening in one context may be perceived as benign , even identity affirming , in another . physicians may reject management - imposed system redesign as a threat to the doctor - patient relationship , yet actively support the same redesign when it is seen as contributing to the achievement of a patient - centered medical home ( kreindler 2008 ) . when the threat involves alternative practitioners encroachment on medical territory , medicine is a science ( broom and tovey 2007)yet , when it involves managerial pressure to comply with clinical practice guidelines , medicine is an art ( mcdonald , waring , and harrison 2006 ) . at first glance , the finding that such varied , even contradictory , discourses are used to resist change seems to imply that change is impossible . the flexible ( re)construction of identity , however , may itself be a key to change . in one study , gps who became change leaders constructed a hybrid identity that affirmed the primacy of their physician identity while incorporating management skills ( redefined as a trivial subset of skills that most physicians possess ) ( hotho 2008 ) . they found this new identity more attractive than that of management ( still seen as a low - status out - group with objectionable values)or of rank - and - file gps ( seen as routine oriented and averse to change ) . organizational change efforts have been observed to founder when administrators either ignore social identity ( seeking to shape employees behavior through individual rewards and sanctions alone ) or assume that staff can be rallied behind an imposed organizational identity ( charles - jones , latimer , and may 2003 ; mcdonald 2004 ) . success is more likely when leaders guide change as it grows from the real values of existing groups ( brooks 1996 ; obrien et al . the fullest elaboration of this strategy occurs within the sia literature , with the aspire (  actualizing social and personal identity resources  ) model of organizational development ; the aspire process engages employees in building a  mosaic  identity that recognizes both common goals and the distinct contributions of valued subgroups ( haslam , eggins , and reynolds 2003 ) . ( bevan 2008 ) , organic development of a  network community  ( bate 2000 ) , and other concepts . one hospital used the norms of physician culture ( concrete , expert - led , decision - oriented discussions ) to encourage physician engagement in restructuring ( ohare and kudrle 2007 ) . other studies of positive physician - manager relationships have emphasized the development of a shared identity , facilitated by shared decision making grounded in common values ( in particular , service and excellence ; see graham and steele 2001 ; kirkpatrick et al . , they also can be mobilized to cope with change , or to achieve it . as the social identity literature has revealed , mobilization is not simply a matter of invoking a ready - made image of group identity , but involves  crafting a sense of us  ( haslam , reicher , and platow , 2011 ) that supports a desired change . goodrick and reay ( 2010 ) showed how nursing textbooks , using the idea of continuity with the past to foster the reconstruction of nursing identity , highlighted only those aspects of the past consistent with the new vision . attempts to promote identification with a certain group , to restructure groups , or to mobilize identities must reckon with members existing patterns of group identification . one stream of literature is concerned primarily with health care employees qua employees , examining organizational identification , its predictors ( e.g. , good communication up and down the hierarchy , value congruence between organization and employee , the organization 's prestige , and the employee 's sense of being respected ) , and its consequences ( e.g. , cooperation , organizational citizenship ) ( dukerich , golden , and shortell 2002 ) . nearly all these studies cite sit ; problematically , though , many are characterized by a management - centric assumption that organizations should , or even can , manipulate employees social identities ( e.g. , han and harms 2010 ) . yet even within this literature , it becomes clear that employee commitment is not so easily manipulable . for example , while participative decision making is among the strongest predictors of organizational identification , opportunities to  participate  are unlikely to foster organizational identification unless employees see them as genuine and relevant ( joensson 2008 ; tangirala and ramanujam 2008 ) . a second stream of literature recognizes that most health care providers are strongly identified with their profession . strong professional and organizational identification are not incompatible ; indeed , the two are often positively correlated ( bartels et al . however , most professionals identify more strongly with their profession than with their organization , which typically offers a less distinctive identity and a shorter period of socialization ( callan et al . 2007 ) . moreover , the combination of high professional and low organizational identification is linked to behavior that , from the organization 's perspective , is undesirable . physicians exhibiting this combination of attitudes have been found to resist influence from management , repay perceived organizational support with reduced compliance , and retaliate against perceived violation of their  psychological contract  with the organization ( hekman et al . tradition is that most of the studies , concentrating as they do on drawing general conclusions about organizational psychology , are not firmly grounded in the health care context . for instance , some studies have drawn inferences about  high - status  staff from analyses that excluded physicians or combined them with senior nurses ( callan et al . 2007 ; obrien et al . several qualitative studies have amplified the point that group membership does not equate with group identification . multidisciplinary team . however , direct care nurses and health care assistants , who continued to be excluded from decision making , did not share in this team identity ; rather , they felt alienated and unwilling to cooperate with the team 's directives . physicians are unlikely to identify with an organization whose management they perceive as a devalued out - group  in particular , one that threatens their autonomy in the service of values abhorrent to their profession ( fiol , pratt , and oconnor 2009 ; hekman et al . moreover , hoff ( 1999 ) found that creating physician - managers failed to bridge the divide between these two groups ; on the contrary , the physician - manager population itself became divided . those who saw themselves primarily as managers embraced their new identity , complete with management jargon , and even defended organizational policies that negatively affected physicians . those who continued to see themselves primarily as physicians asserted this identity by resisting and sabotaging the activities of the first group , whom they viewed as traitors . these findings invite the application of such sia concepts as categorization threat ( the threat of one 's being viewed as a member of a devalued group ; see ellemers , spears , and doosje 2002 ) and the black sheep effect ( in which an in - group member who flouts group norms attracts more censure than does an out - group member ; see marques , yzerbyt , and leyens 1988 ) . as we have seen , physician - managers can develop hybrid identities ( hotho 2008 ) , but this is not inevitable . doolin ( 2002 ) found that physicians revised their identities to incorporate a new management role only when they perceived the latter as congruent with their physician identity . context refers to the external conditions  such as organizational structures , working practices , and physical features of the work environment  that support a particular system of group relations . the sia holds that changing the context can change the way people view and relate to one another , ultimately altering existing patterns of group interaction . a handful of articles described successful organizational - development initiatives that put intergroup issues front and center ( van de vliert 1995 ) . staff have been invited to participate in collective reflection on group dynamics , and the insights derived from this process used to develop or implement new structures and working practices ( context changes ) that support more positive group relations ( bate 2000 ; bleakley et al . although the literature abounds with warnings that the mere establishment of a team does not guarantee true teamwork , some studies with a longer follow - up have reached more optimistic conclusions . a british study ( hudson 2002 ) found that effective teamwork between health and social care providers had begun to develop in practices where providers were co - located and informal working patterns were shifting . a longitudinal study of an interdisciplinary health team traced members gradual progression from defensiveness and stereotyping to a shared team culture in which roles were less differentiated ( farrell , schmitt , and heinemann 2001 ) . such findings suggest that what are seen as intractable problems with multidisciplinary teams may actually just be growing pains . there is some evidence , however , that role revision and teamwork are more likely to become realities when social identity is taken into account . a study of an unsuccessful attempt to introduce an enhanced nursing role suggested that the change process failed to engage with the entrenched social identity dynamics associated with a rigid professional hierarchy ( currie , finn , and martin 2010 ) . despite its superficial adoption , the new role was assimilated into the existing social structure and produced little real change . furthermore , a single organizational intervention may not suffice ; context change may entail addressing broader environmental factors that impede collaboration . for example , such contextual factors as organizational integration , resource availability , and various facilitators of long - term working relationships strongly influenced whether the introduction of teams reproduced or transformed professional hierarchies ( finn , currie , and martin 2010 ) . interprofessional education ( ipe ) is the only area in which sia - influenced interventions have been tested through controlled experiments . however , the interventions studied have not mined the depth of the social identity approach . this may be because their foundation is not actually the sia but the more interpersonally oriented contact hypothesis , which prescribes intergroup contact as a remedy for prejudice ( allport 1954 ) . many ipe articles noted that health care professionals propensity to categorize themselves in terms of a uniprofessional identity can impede interprofessional collaboration ( lidskog , lofmark , and ahlstrom 2008 ) . the literature also reflects an awareness of the various options for reshaping social categorizations ( hean and dickinson 2005 ) . two possible approaches are decategorization ( encouraging people to see themselves and each other as individuals , not group members ) and recategorization ( emphasizing a common in - group identity , not subgroup identities ) . however , both these approaches can provoke identity threat and  backlash  from highly identified health care professionals . most of the contemporary sia - influenced literature advocates a third option : acknowledging and valuing both a common superordinate identity and distinct subgroup identities . in contrast to the bottom - up approach of the aspire model ( haslam , eggins , and reynolds 2003 ) , the strategies reflected in the ipe literature are top - down : they involve controlling participants experiences in order to influence their attitudes in specific , planned ways . whereas the bottom - up approach makes identity content the driver of change , the top - down approach tends to treat it as incidental . proponents of contact - based interventions have maintained that structural issues are beyond their sphere of influence ( carpenter and hewstone 1996 ) . unfortunately , the enterprise of creating favorable interprofessional contexts within an inegalitarian social structure is fraught with challenges and contradictions . first , it is not always possible to create equal - status contact between unequal - status groups  as illustrated by a shared education program in which the location and curriculum had been arranged to meet the needs of medical students , thereby marginalizing dental students ( ajjawi et al . second , even if an equal - status  bubble  can be created , attitudes developed under such artificial conditions may evaporate when participants return to the real world . this difficulty has led contact theorists to develop increasingly elaborate techniques to encourage the generalization of newly acquired attitudes . this individualistic approach , which locates the problem in personal attitudes and stereotypes , is incompatible with a group - based perspective . the latter , because it views stereotypes as a symptom of a system of group relations that entrenches intergroup conflict , sees context as the necessary target of intervention . contact theorists preoccupation with decontextualized stereotypes has created ironic situations ; for example , researchers downplayed an ipe program 's successes with team function or client outcomes , lamenting instead that pencil - and - paper tests detected no change in stereotypes ( barnes , carpenter , and dickinson 2000 ; carpenter et al . the  contexts for contact  approach 's attentiveness to social categorization represents an advance over approaches that ignore groups or treat them as a nuisance . but without a substantial focus on identity content or social structure , this approach misses a lot of what is social about social identity , and falls short of harnessing the power of social identities to stimulate change . fiol , pratt , and oconnor ( 2009 ) have advanced a sequential , sia - based model for resolving intractable identity(-based ) conflict ( iic ) ( e.g. , between physicians and hospital administrators ) . in such cases , each in - group draws part of its identity from negating the out - group , making collaboration impossible . the iic model holds that de - escalation of such conflict must progress through the following stages : ( 1 ) readiness ( to come to the table ) , ( 2 ) mindfulness ( openness to other ways of conceptualizing the situation ) , ( 3 ) positive in - group distinctiveness ( ensuring a secure in - group identity without the need to negate the out - group ) , ( 4 ) simultaneous intergroup differentiation and unity ( cooperation around specific objectives while maintaining separate , distinct groups ) , and ( 5 ) integrative goals and structures . organizations may take steps to help a fractious relationship progress from one stage to the next . however , attempts to achieve a higher stage before lower ones have been completed ( e.g. , making appeals to unity while each group still views the other as a threat ) are likely to backfire . the sequence of stages 1 through 4 was borne out in a canadian study of the relationship between physicians and regional health authorities ; the parties might have ultimately progressed to stage 5 , but the government dissolved the regional system ( reay and hinings 2009 ) . in an australian study , allied health professionals appeared to traverse stages 3 through 5 , progressing from unidisciplinary identities to targeted collaboration and finally dual ( disciplinary and allied health ) identity ( boyce 2006 ) . in its bottom - up approach to the development of a superordinate identity , the most basic insight of a group - based approach is that analyses of conflict or cooperation in health care must consider group , not merely interpersonal , dynamics . this insight was powerfully demonstrated in an expos of virulent intergroup conflict among hospital departments ( hewett et al . drawing on sit , the study revealed that patient charts  supposedly repositories of objective information  were rife with examples of intergroup competition and in - group enhancement . the study also showed how interspecialty competition to  own  ( or disown ) patients could threaten safe care and may have led to a patient 's death . the authors argued that interpersonal - skills training would be an inadequate remedy for physicians dysfunctional communication , since the problem resulted not from a lack of skill but from the active expression of group identities . such recognition of the importance of groups is echoed in papers that variously invoke sit ( shute 1997 ) , role theory ( booth and hewison 2002 ) , evolutionary psychology ( braithwaite , iedema , and jorm 2007 ) , and other concepts ( ferlie et al . 2005 ) . however , this body of literature is primarily descriptive . to identify potential solutions , therefore the health care landscape comprises groups of unequal power and status . without an understanding of this issue , naive calls for  teamwork  may actually reinforce professional divisions and hierarchies . for example , finn ( 2008 ) documented how various providers appealed to the concept of teamwork to advance their profession - specific norms and interests : to nurses , teamwork meant more equal and respectful relations ; to surgeons , that others efficiently followed their orders . many authors stress the gendered nature of the doctor - nurse dynamic , tracing its origins to the subordination of women within the sexual division of labor ( campbell - heider and pollock 1987 ) . others put power first and gender second , emphasizing how the specific unequal relationship between doctors and nurses produces certain patterns of interaction . for example , tellis - nayak and tellis - nayak ( 1984 ) elucidated how structural inequalities are reinforced by social rituals ( concerning the differential use of space , time , language , and body language ) , arguing that any attempt to reduce the power imbalance must address both structural and symbolic factors . both gender- and power - related role expectations may constrain health care professionals to play the  doctor - nurse game ,  in which the nurse must offer any suggestion indirectly so that it seems to be the doctor 's idea ( stein 1967 ) . many structural analyses also touched on identity content by noting how the values , discourses , sources of knowledge , and types of labor associated with high - status groups ( men / physicians ) are privileged over those of low - status groups ( women / nurses ) ( wicks 1998 ) . roberts ( 1983 ) contended that intergroup inequality also taints nurses intragroup relations , giving rise to  oppressed group behavior  in which nurses accept the physician - dominated structure as legitimate and inevitable . within nursing in terms of nurses efforts to repudiate a devalued group identity and align themselves instead with the oppressing group . while offering a provocative examination of health care hierarchies , this literature has attracted three major criticisms : ( 1 ) its perspective tends to be static and deterministic , missing the context - dependent , strategic , and , above all , variable nature of doctor - nurse interactions , and sometimes denying nurses agency ; ( 2 ) its accounts are frequently partisan , reflecting the unquestioned assumption that increased power for a certain group is an absolute good ; and ( 3 ) its overwhelming focus on doctor - nurse relations obscures other power relations in health care . for example , a uk study ( johns 1992 ) explored how the division of nurses into primary and associate roles created new power dynamics , including what might be described as a  nurse - nurse game ( i.e. , associate nurses confining themselves to indirect suggestions to maintain a facade of harmony ) . from an sia perspective , all three limitations spring from the fact that unequal partners  analyses reify observed phenomena as immutable social facts , not recognizing them as examples of generalized group processes . according to sit ( tajfel and turner 1979 ) , the behavior of unequal - status groups can be understood in terms of two basic responses : individual mobility ( attempts to leave one group and enter the other ) and social change ( attempts to reduce , reverse , or increase the status difference between the groups ) . social change strategies include social creativity ( creation of ideologies that affirm the in - group 's worth ) and social competition ( competition with the out - group for power or resources ) . sit does not treat these strategies as unique to oppressed groups or as dependent on a particular group psychology , but rather as a function of the in - group 's structural position relative to the out - group , the features of the structural relationship , and the strength of the member 's group identification . the sia 's generality and objectivity allow it to encompass both entrenched intergroup inequalities and scenarios in which power relations are more complex , unexpected , and context - dependent . ( for a sit - informed account of doctor - nurse relations , see chattopadhyay , finn , and ashkanasy 2010 . ) the professional strategies tradition , grounded in the sociology of professions ( freidson 1970 ) , explores occupational groups struggles for territory and control . although medical dominance is a frequent focus , abbott ( 1988 ) underscored that the important phenomenon is not the empirical fact of a certain group 's dominance ( which can change ) but the ubiquity of intergroup competition  which occurs both interprofessionally and among intraprofessional subgroups ( currie , finn , and martin 2009 ) . unlike the  unequal partners  literature , this stream tends to regard all groups as self - interested and their ideologies as self - serving . it also offers a less static view , illustrating how the intergroup landscape may change when a strategy succeeds or backfires . in a study of health care reorganization , daykin and clarke ( 2000 ) illuminated how nurses  project  of professionalization was impeded by contradictions between the strategies used to gain territory from medicine and to protect their own . to affirm their status vis -  - vis medicine , nurses claimed a distinct body of knowledge grounded in caring , yet undermined this claim by devaluing the caring labor of health care assistants . the authors argued that , far from enhancing nurses professional status , such exclusionary tactics reduced their ability to resist the most pertinent threat : management 's fordist practices of routinization and de - skilling . the  professional strategies  literature often highlights the role of context ; for example , oncologists who worked in different settings used different means to promote their dominance over practitioners of complementary and alternative medicine ( cam ) ( broom and tovey 2007 ) . hospital physicians used the discourse of science to discredit cam , proclaiming the superiority of medicine 's  scientific mind - set  even in areas where no medical evidence existed . hospice physicians could not discredit cam , given its fit with their institution 's holistic philosophy ; instead , they found subtle ways to subsume cam within a biomedical paradigm , tightly controlling cam practice to avoid any challenge to ( bio)medical dominance . with its rich description of both the material and rhetorical strategies that groups use to secure and enhance their professional status , the professional strategies  literature depicts social competition and social creativity in action . echoing sit , it shows how members strategically compare their own group with others , choosing dimensions ( may and fleming 1997 ) , definitions ( norris 2001 ) , and comparison groups ( fournier 2002 ) that maximize the in - group 's positive distinctiveness . it differs from sit , however , in focusing on groups instrumental motivation to gain power and autonomy , seldom recognizing the psychological motivation to maintain a positive social identity . the assumption that groups care only about tangible , not symbolic , benefits can lead to inaccurate predictions ( e.g. , that health care groups would soon abandon professional ideologies , competing instead over who could meet market needs most cost - effectively ) ( light 1988 ) . skepticism about groups self - representations can be taken too far , to the point of dismissing all affirmations of group identity as strategic performances . the sia recognizes that such performances are not just strategic ; they often reflect highly valued identity content . many authors stress the gendered nature of the doctor - nurse dynamic , tracing its origins to the subordination of women within the sexual division of labor ( campbell - heider and pollock 1987 ) . others put power first and gender second , emphasizing how the specific unequal relationship between doctors and nurses produces certain patterns of interaction . for example , tellis - nayak and tellis - nayak ( 1984 ) elucidated how structural inequalities are reinforced by social rituals ( concerning the differential use of space , time , language , and body language ) , arguing that any attempt to reduce the power imbalance must address both structural and symbolic factors . both gender- and power - related role expectations may constrain health care professionals to play the  doctor - nurse game ,  in which the nurse must offer any suggestion indirectly so that it seems to be the doctor 's idea ( stein 1967 ) . many structural analyses also touched on identity content by noting how the values , discourses , sources of knowledge , and types of labor associated with high - status groups ( men / physicians ) are privileged over those of low - status groups ( women / nurses ) ( wicks 1998 ) . roberts ( 1983 ) contended that intergroup inequality also taints nurses intragroup relations , giving rise to  oppressed group behavior  in which nurses accept the physician - dominated structure as legitimate and inevitable . she explained  horizontal violence  within nursing in terms of nurses efforts to repudiate a devalued group identity and align themselves instead with the oppressing group . while offering a provocative examination of health care hierarchies , this literature has attracted three major criticisms : ( 1 ) its perspective tends to be static and deterministic , missing the context - dependent , strategic , and , above all , variable nature of doctor - nurse interactions , and sometimes denying nurses agency ; ( 2 ) its accounts are frequently partisan , reflecting the unquestioned assumption that increased power for a certain group is an absolute good ; and ( 3 ) its overwhelming focus on doctor - nurse relations obscures other power relations in health care . for example , a uk study ( johns 1992 ) explored how the division of nurses into primary and associate roles created new power dynamics , including what might be described as a  nurse - nurse game  ( i.e. , associate nurses confining themselves to indirect suggestions to maintain a facade of harmony ) . from an sia perspective , all three limitations spring from the fact that unequal partners  analyses reify observed phenomena as immutable social facts , not recognizing them as examples of generalized group processes . according to sit ( tajfel and turner 1979 ) , the behavior of unequal - status groups can be understood in terms of two basic responses : individual mobility ( attempts to leave one group and enter the other ) and social change ( attempts to reduce , reverse , or increase the status difference between the groups ) . social change strategies include social creativity ( creation of ideologies that affirm the in - group 's worth ) and social competition ( competition with the out - group for power or resources ) . sit does not treat these strategies as unique to oppressed groups or as dependent on a particular group psychology , but rather as a function of the in - group 's structural position relative to the out - group , the features of the structural relationship , and the strength of the member 's group identification . the sia 's generality and objectivity allow it to encompass both entrenched intergroup inequalities and scenarios in which power relations are more complex , unexpected , and context - dependent . ( for a sit - informed account of doctor - nurse relations , see chattopadhyay , finn , and ashkanasy 2010 . ) the professional strategies tradition , grounded in the sociology of professions ( freidson 1970 ) , explores occupational groups struggles for territory and control . although medical dominance is a frequent focus , abbott ( 1988 ) underscored that the important phenomenon is not the empirical fact of a certain group 's dominance ( which can change ) but the ubiquity of intergroup competition  which occurs both interprofessionally and among intraprofessional subgroups ( currie , finn , and martin 2009 ) . unlike the  unequal partners  literature , this stream tends to regard all groups as self - interested and their ideologies as self - serving . it also offers a less static view , illustrating how the intergroup landscape may change when a strategy succeeds or backfires . in a study of health care reorganization , daykin and clarke ( 2000 ) illuminated how nurses  project  of professionalization was impeded by contradictions between the strategies used to gain territory from medicine and to protect their own . to affirm their status vis -  - vis medicine , nurses claimed a distinct body of knowledge grounded in caring , yet undermined this claim by devaluing the caring labor of health care assistants . the authors argued that , far from enhancing nurses professional status , such exclusionary tactics reduced their ability to resist the most pertinent threat : management 's fordist practices of routinization and de - skilling . the  professional strategies  literature often highlights the role of context ; for example , oncologists who worked in different settings used different means to promote their dominance over practitioners of complementary and alternative medicine ( cam ) ( broom and tovey 2007 ) . hospital physicians used the discourse of science to discredit cam , proclaiming the superiority of medicine 's  scientific mind - set  even in areas where no medical evidence existed . hospice physicians could not discredit cam , given its fit with their institution 's holistic philosophy ; instead , they found subtle ways to subsume cam within a biomedical paradigm , tightly controlling cam practice to avoid any challenge to ( bio)medical dominance . with its rich description of both the material and rhetorical strategies that groups use to secure and enhance their professional status , the professional strategies  literature depicts social competition and social creativity in action . echoing sit , it shows how members strategically compare their own group with others , choosing dimensions ( may and fleming 1997 ) , definitions ( norris 2001 ) , and comparison groups ( fournier 2002 ) that maximize the in - group 's positive distinctiveness . it differs from sit , however , in focusing on groups instrumental motivation to gain power and autonomy , seldom recognizing the psychological motivation to maintain a positive social identity . the assumption that groups care only about tangible , not symbolic , benefits can lead to inaccurate predictions ( e.g. , that health care groups would soon abandon professional ideologies , competing instead over who could meet market needs most cost - effectively ) ( light 1988 ) . skepticism about groups self - representations can be taken too far , to the point of dismissing all affirmations of group identity as strategic performances . the sia recognizes that such performances are not just strategic ; they often reflect highly valued identity content . group identities are not arbitrary but are defined by certain content : norms , values , and worldviews that are meaningful and important to members . a large literature frames this topic in terms of culture and cultural differences , delineating how professional groups differ in everything from values and attitudes ( degeling , kennedy , and hill 2001 ) to myths and rituals ( dombeck 1997 ) . but bald descriptions of identity content do not elucidate group processes , and inspire few solutions apart from vague calls for cultural sensitivity . accounts of professional culture may also miss intraprofessional diversity ; even explorations of professional subcultures ( leininger 1994 ) often stop short of asking what the different variants of identity mean . more sia - consistent studies may explain variability in terms of subgroups with different experiences or structural positions contesting ( advancing their own versions of ) identity content ( e.g. , pratt and rafaeli 1997 ) . in contrast to the  cultural differences  discourse , which portrays identity content as static , the sia takes a dynamic view , examining how different representations of group identity are constructed and mobilized in order to achieve group goals . research on professional socialization considers , among other things , how educational and practice environments encourage or suppress the enactment of a patient - centered identity . patient - centeredness can be an integral part of physician identity , yet its expression may be actively discouraged through both the formal and informal curricula of medical school ( apker and eggly 2004 ) . in contrast , nurses are strongly socialized into patient - centeredness  until they enter the working world , where demands for efficiency may imperil this core value , resulting in demoralization and disengagement ( limoges 2007 ) . odonohue and nelson ( 2007 ) stressed that professionals psychological contract with an organization depends not merely on individual rewards but on the organization 's respect for the values central to their collective identity . health care professionals are known to resist threats to their identity content ( fiol and oconnor 2006 ) ; however , interventions perceived as identity threatening in one context may be perceived as benign , even identity affirming , in another . physicians may reject management - imposed system redesign as a threat to the doctor - patient relationship , yet actively support the same redesign when it is seen as contributing to the achievement of a patient - centered medical home ( kreindler 2008 ) . when the threat involves alternative practitioners encroachment on medical territory , medicine is a science ( broom and tovey 2007)yet , when it involves managerial pressure to comply with clinical practice guidelines , medicine is an art ( mcdonald , waring , and harrison 2006 ) . at first glance , the finding that such varied , even contradictory , discourses are used to resist change seems to imply that change is impossible . the flexible ( re)construction of identity , however , may itself be a key to change . in one study , gps who became change leaders constructed a hybrid identity that affirmed the primacy of their physician identity while incorporating management skills ( redefined as a trivial subset of skills that most physicians possess ) ( hotho 2008 ) . they found this new identity more attractive than that of management ( still seen as a low - status out - group with objectionable values)or of rank - and - file gps ( seen as routine oriented and averse to change ) . organizational change efforts have been observed to founder when administrators either ignore social identity ( seeking to shape employees behavior through individual rewards and sanctions alone ) or assume that staff can be rallied behind an imposed organizational identity ( charles - jones , latimer , and may 2003 ; mcdonald 2004 ) . success is more likely when leaders guide change as it grows from the real values of existing groups ( brooks 1996 ; obrien et al . 2004 ) . the fullest elaboration of this strategy occurs within the sia literature , with the aspire (  actualizing social and personal identity resources  ) model of organizational development ; the aspire process engages employees in building a  mosaic  identity that recognizes both common goals and the distinct contributions of valued subgroups ( haslam , eggins , and reynolds 2003 ) . ( bevan 2008 ) , organic development of a  network community  ( bate 2000 ) , and other concepts . one hospital used the norms of physician culture ( concrete , expert - led , decision - oriented discussions ) to encourage physician engagement in restructuring ( ohare and kudrle 2007 ) . other studies of positive physician - manager relationships have emphasized the development of a shared identity , facilitated by shared decision making grounded in common values ( in particular , service and excellence ; see graham and steele 2001 ; kirkpatrick et al . just as social identities can be mobilized to resist change , they also can be mobilized to cope with change , or to achieve it . as the social identity literature has revealed , mobilization is not simply a matter of invoking a ready - made image of group identity , but involves  crafting a sense of us  ( haslam , reicher , and platow , 2011 ) that supports a desired change . goodrick and reay ( 2010 ) showed how nursing textbooks , using the idea of continuity with the past to foster the reconstruction of nursing identity , highlighted only those aspects of the past consistent with the new vision . attempts to promote identification with a certain group , to restructure groups , or to mobilize identities must reckon with members existing patterns of group identification . one stream of literature is concerned primarily with health care employees qua employees , examining organizational identification , its predictors ( e.g. , good communication up and down the hierarchy , value congruence between organization and employee , the organization 's prestige , and the employee 's sense of being respected ) , and its consequences ( e.g. , cooperation , organizational citizenship ) ( dukerich , golden , and shortell 2002 ) . nearly all these studies cite sit ; problematically , though , many are characterized by a management - centric assumption that organizations should , or even can , manipulate employees social identities ( e.g. , han and harms 2010 ) . yet even within this literature , it becomes clear that employee commitment is not so easily manipulable . for example , while participative decision making is among the strongest predictors of organizational identification , opportunities to  participate  are unlikely to foster organizational identification unless employees see them as genuine and relevant ( joensson 2008 ; tangirala and ramanujam 2008 ) . a second stream of literature recognizes that most health care providers are strongly identified with their profession . strong professional and organizational identification are not incompatible ; indeed , the two are often positively correlated ( bartels et al . . however , most professionals identify more strongly with their profession than with their organization , which typically offers a less distinctive identity and a shorter period of socialization ( callan et al . 2007 ) . moreover , the combination of high professional and low organizational identification is linked to behavior that , from the organization 's perspective , is undesirable . physicians exhibiting this combination of attitudes have been found to resist influence from management , repay perceived organizational support with reduced compliance , and retaliate against perceived violation of their  psychological contract  with the organization ( hekman et al . tradition is that most of the studies , concentrating as they do on drawing general conclusions about organizational psychology , are not firmly grounded in the health care context . for instance , some studies have drawn inferences about  high - status  staff from analyses that excluded physicians or combined them with senior nurses ( callan et al . 2007 ; obrien et al . several qualitative studies have amplified the point that group membership does not equate with group identification . multidisciplinary team . however , direct care nurses and health care assistants , who continued to be excluded from decision making , did not share in this team identity ; rather , they felt alienated and unwilling to cooperate with the team 's directives . physicians are unlikely to identify with an organization whose management they perceive as a devalued out - group  in particular , one that threatens their autonomy in the service of values abhorrent to their profession ( fiol , pratt , and oconnor 2009 ; hekman et al . moreover , hoff ( 1999 ) found that creating physician - managers failed to bridge the divide between these two groups ; on the contrary , the physician - manager population itself became divided . those who saw themselves primarily as managers embraced their new identity , complete with management jargon , and even defended organizational policies that negatively affected physicians . those who continued to see themselves primarily as physicians asserted this identity by resisting and sabotaging the activities of the first group , whom they viewed as traitors . these findings invite the application of such sia concepts as categorization threat ( the threat of one 's being viewed as a member of a devalued group ; see ellemers , spears , and doosje 2002 ) and the black sheep effect ( in which an in - group member who flouts group norms attracts more censure than does an out - group member ; see marques , yzerbyt , and leyens 1988 ) . as we have seen , physician - managers can develop hybrid identities ( hotho 2008 ) , but this is not inevitable . doolin ( 2002 ) found that physicians revised their identities to incorporate a new management role only when they perceived the latter as congruent with their physician identity . one stream of literature is concerned primarily with health care employees qua employees , examining organizational identification , its predictors ( e.g. , good communication up and down the hierarchy , value congruence between organization and employee , the organization 's prestige , and the employee 's sense of being respected ) , and its consequences ( e.g. , cooperation , organizational citizenship ) ( dukerich , golden , and shortell 2002 ) . nearly all these studies cite sit ; problematically , though , many are characterized by a management - centric assumption that organizations should , or even can , manipulate employees social identities ( e.g. , han and harms 2010 ) . yet even within this literature , it becomes clear that employee commitment is not so easily manipulable . for example , while participative decision making is among the strongest predictors of organizational identification , opportunities to  participate  are unlikely to foster organizational identification unless employees see them as genuine and relevant ( joensson 2008 ; tangirala and ramanujam 2008 ) . a second stream of literature recognizes that most health care providers are strongly identified with their profession . strong professional and organizational identification are not incompatible ; indeed , the two are often positively correlated ( bartels et al . however , most professionals identify more strongly with their profession than with their organization , which typically offers a less distinctive identity and a shorter period of socialization ( callan et al . 2007 ) . moreover , the combination of high professional and low organizational identification is linked to behavior that , from the organization 's perspective , is undesirable . physicians exhibiting this combination of attitudes have been found to resist influence from management , repay perceived organizational support with reduced compliance , and retaliate against perceived violation of their  psychological contract  with the organization ( hekman et al . tradition is that most of the studies , concentrating as they do on drawing general conclusions about organizational psychology , are not firmly grounded in the health care context . staff from analyses that excluded physicians or combined them with senior nurses ( callan et al . several qualitative studies have amplified the point that group membership does not equate with group identification . . however , direct care nurses and health care assistants , who continued to be excluded from decision making , did not share in this team identity ; rather , they felt alienated and unwilling to cooperate with the team 's directives . physicians are unlikely to identify with an organization whose management they perceive as a devalued out - group  in particular , one that threatens their autonomy in the service of values abhorrent to their profession ( fiol , pratt , and oconnor 2009 ; hekman et al . moreover , hoff ( 1999 ) found that creating physician - managers failed to bridge the divide between these two groups ; on the contrary , the physician - manager population itself became divided . those who saw themselves primarily as managers embraced their new identity , complete with management jargon , and even defended organizational policies that negatively affected physicians . those who continued to see themselves primarily as physicians asserted this identity by resisting and sabotaging the activities of the first group , whom they viewed as traitors . these findings invite the application of such sia concepts as categorization threat ( the threat of one 's being viewed as a member of a devalued group ; see ellemers , spears , and doosje 2002 ) and the black sheep effect ( in which an in - group member who flouts group norms attracts more censure than does an out - group member ; see marques , yzerbyt , and leyens 1988 ) . as we have seen , physician - managers can develop hybrid identities ( hotho 2008 ) , but this is not inevitable . doolin ( 2002 ) found that physicians revised their identities to incorporate a new management role only when they perceived the latter as congruent with their physician identity . context refers to the external conditions  such as organizational structures , working practices , and physical features of the work environment  that support a particular system of group relations . the sia holds that changing the context can change the way people view and relate to one another , ultimately altering existing patterns of group interaction . a handful of articles described successful organizational - development initiatives that put intergroup issues front and center ( van de vliert 1995 ) . staff have been invited to participate in collective reflection on group dynamics , and the insights derived from this process used to develop or implement new structures and working practices ( context changes ) that support more positive group relations ( bate 2000 ; bleakley et al . although the literature abounds with warnings that the mere establishment of a team does not guarantee true teamwork , some studies with a longer follow - up have reached more optimistic conclusions . a british study ( hudson 2002 ) found that effective teamwork between health and social care providers had begun to develop in practices where providers were co - located and informal working patterns were shifting . a longitudinal study of an interdisciplinary health team traced members gradual progression from defensiveness and stereotyping to a shared team culture in which roles were less differentiated ( farrell , schmitt , and heinemann 2001 ) . such findings suggest that what are seen as intractable problems with multidisciplinary teams may actually just be growing pains . there is some evidence , however , that role revision and teamwork are more likely to become realities when social identity is taken into account . a study of an unsuccessful attempt to introduce an enhanced nursing role suggested that the change process failed to engage with the entrenched social identity dynamics associated with a rigid professional hierarchy ( currie , finn , and martin 2010 ) . despite its superficial adoption , the new role was assimilated into the existing social structure and produced little real change . furthermore , a single organizational intervention may not suffice ; context change may entail addressing broader environmental factors that impede collaboration . for example , such contextual factors as organizational integration , resource availability , and various facilitators of long - term working relationships strongly influenced whether the introduction of teams reproduced or transformed professional hierarchies ( finn , currie , and martin 2010 ) . interprofessional education ( ipe ) is the only area in which sia - influenced interventions have been tested through controlled experiments . however , the interventions studied have not mined the depth of the social identity approach . this may be because their foundation is not actually the sia but the more interpersonally oriented contact hypothesis , which prescribes intergroup contact as a remedy for prejudice ( allport 1954 ) . many ipe articles noted that health care professionals propensity to categorize themselves in terms of a uniprofessional identity can impede interprofessional collaboration ( lidskog , lofmark , and ahlstrom 2008 ) . the literature also reflects an awareness of the various options for reshaping social categorizations ( hean and dickinson 2005 ) . two possible approaches are decategorization ( encouraging people to see themselves and each other as individuals , not group members ) and recategorization ( emphasizing a common in - group identity , not subgroup identities ) . however , both these approaches can provoke identity threat and  backlash  from highly identified health care professionals . most of the contemporary sia - influenced literature advocates a third option : acknowledging and valuing both a common superordinate identity and distinct subgroup identities . in contrast to the bottom - up approach of the aspire model ( haslam , eggins , and reynolds 2003 ) , the strategies reflected in the ipe literature are top - down : they involve controlling participants experiences in order to influence their attitudes in specific , planned ways . whereas the bottom - up approach makes identity content the driver of change , the top - down approach tends to treat it as incidental . proponents of contact - based interventions have maintained that structural issues are beyond their sphere of influence ( carpenter and hewstone 1996 ) . unfortunately , the enterprise of creating favorable interprofessional contexts within an inegalitarian social structure is fraught with challenges and contradictions . first , it is not always possible to create equal - status contact between unequal - status groups  as illustrated by a shared education program in which the location and curriculum had been arranged to meet the needs of medical students , thereby marginalizing dental students ( ajjawi et al . bubble  can be created , attitudes developed under such artificial conditions may evaporate when participants return to the real world . this difficulty has led contact theorists to develop increasingly elaborate techniques to encourage the generalization of newly acquired attitudes . this individualistic approach , which locates the problem in personal attitudes and stereotypes , is incompatible with a group - based perspective . the latter , because it views stereotypes as a symptom of a system of group relations that entrenches intergroup conflict , sees context as the necessary target of intervention . contact theorists preoccupation with decontextualized stereotypes has created ironic situations ; for example , researchers downplayed an ipe program 's successes with team function or client outcomes , lamenting instead that pencil - and - paper tests detected no change in stereotypes ( barnes , carpenter , and dickinson 2000 ; carpenter et al . the  contexts for contact  approach 's attentiveness to social categorization represents an advance over approaches that ignore groups or treat them as a nuisance . but without a substantial focus on identity content or social structure , this approach misses a lot of what is social about social identity , and falls short of harnessing the power of social identities to stimulate change . fiol , pratt , and oconnor ( 2009 ) have advanced a sequential , sia - based model for resolving intractable identity(-based ) conflict ( iic ) ( e.g. , between physicians and hospital administrators ) . in such cases , each in - group draws part of its identity from negating the out - group , making collaboration impossible . the iic model holds that de - escalation of such conflict must progress through the following stages : ( 1 ) readiness ( to come to the table ) , ( 2 ) mindfulness ( openness to other ways of conceptualizing the situation ) , ( 3 ) positive in - group distinctiveness ( ensuring a secure in - group identity without the need to negate the out - group ) , ( 4 ) simultaneous intergroup differentiation and unity ( cooperation around specific objectives while maintaining separate , distinct groups ) , and ( 5 ) integrative goals and structures . organizations may take steps to help a fractious relationship progress from one stage to the next . however , attempts to achieve a higher stage before lower ones have been completed ( e.g. , making appeals to unity while each group still views the other as a threat ) are likely to backfire . the sequence of stages 1 through 4 was borne out in a canadian study of the relationship between physicians and regional health authorities ; the parties might have ultimately progressed to stage 5 , but the government dissolved the regional system ( reay and hinings 2009 ) . in an australian study , allied health professionals appeared to traverse stages 3 through 5 , progressing from unidisciplinary identities to targeted collaboration and finally dual ( disciplinary and allied health ) identity ( boyce 2006 ) . in its bottom - up approach to the development of a superordinate identity , a handful of articles described successful organizational - development initiatives that put intergroup issues front and center ( van de vliert 1995 ) . staff have been invited to participate in collective reflection on group dynamics , and the insights derived from this process used to develop or implement new structures and working practices ( context changes ) that support more positive group relations ( bate 2000 ; bleakley et al . although the literature abounds with warnings that the mere establishment of a team does not guarantee true teamwork , some studies with a longer follow - up have reached more optimistic conclusions . a british study ( hudson 2002 ) found that effective teamwork between health and social care providers had begun to develop in practices where providers were co - located and informal working patterns were shifting . a longitudinal study of an interdisciplinary health team traced members gradual progression from defensiveness and stereotyping to a shared team culture in which roles were less differentiated ( farrell , schmitt , and heinemann 2001 ) . such findings suggest that what are seen as intractable problems with multidisciplinary teams may actually just be growing pains . there is some evidence , however , that role revision and teamwork are more likely to become realities when social identity is taken into account . a study of an unsuccessful attempt to introduce an enhanced nursing role suggested that the change process failed to engage with the entrenched social identity dynamics associated with a rigid professional hierarchy ( currie , finn , and martin 2010 ) . despite its superficial adoption , the new role was assimilated into the existing social structure and produced little real change . furthermore , a single organizational intervention may not suffice ; context change may entail addressing broader environmental factors that impede collaboration . for example , such contextual factors as organizational integration , resource availability , and various facilitators of long - term working relationships strongly influenced whether the introduction of teams reproduced or transformed professional hierarchies ( finn , currie , and martin 2010 ) . interprofessional education ( ipe ) is the only area in which sia - influenced interventions have been tested through controlled experiments . however , the interventions studied have not mined the depth of the social identity approach . this may be because their foundation is not actually the sia but the more interpersonally oriented contact hypothesis , which prescribes intergroup contact as a remedy for prejudice ( allport 1954 ) . many ipe articles noted that health care professionals propensity to categorize themselves in terms of a uniprofessional identity can impede interprofessional collaboration ( lidskog , lofmark , and ahlstrom 2008 ) . the literature also reflects an awareness of the various options for reshaping social categorizations ( hean and dickinson 2005 ) . two possible approaches are decategorization ( encouraging people to see themselves and each other as individuals , not group members ) and recategorization ( emphasizing a common in - group identity , not subgroup identities ) . however , both these approaches can provoke identity threat and  backlash  from highly identified health care professionals . most of the contemporary sia - influenced literature advocates a third option : acknowledging and valuing both a common superordinate identity and distinct subgroup identities . in contrast to the bottom - up approach of the aspire model ( haslam , eggins , and reynolds 2003 ) , the strategies reflected in the ipe literature are top - down : they involve controlling participants experiences in order to influence their attitudes in specific , planned ways . whereas the bottom - up approach makes identity content the driver of change , the top - down approach tends to treat it as incidental . proponents of contact - based interventions have maintained that structural issues are beyond their sphere of influence ( carpenter and hewstone 1996 ) . unfortunately , the enterprise of creating favorable interprofessional contexts within an inegalitarian social structure is fraught with challenges and contradictions . first , it is not always possible to create equal - status contact between unequal - status groups  as illustrated by a shared education program in which the location and curriculum had been arranged to meet the needs of medical students , thereby marginalizing dental students ( ajjawi et al . second , even if an equal - status  bubble  can be created , attitudes developed under such artificial conditions may evaporate when participants return to the real world . this difficulty has led contact theorists to develop increasingly elaborate techniques to encourage the generalization of newly acquired attitudes . this individualistic approach , which locates the problem in personal attitudes and stereotypes , is incompatible with a group - based perspective . the latter , because it views stereotypes as a symptom of a system of group relations that entrenches intergroup conflict , sees context as the necessary target of intervention . contact theorists preoccupation with decontextualized stereotypes has created ironic situations ; for example , researchers downplayed an ipe program 's successes with team function or client outcomes , lamenting instead that pencil - and - paper tests detected no change in stereotypes ( barnes , carpenter , and dickinson 2000 ; carpenter et al . the  contexts for contact  approach 's attentiveness to social categorization represents an advance over approaches that ignore groups or treat them as a nuisance . but without a substantial focus on identity content or social structure , this approach misses a lot of what is social about social identity , and falls short of harnessing the power of social identities to stimulate change . fiol , pratt , and oconnor ( 2009 ) have advanced a sequential , sia - based model for resolving intractable identity(-based ) conflict ( iic ) ( e.g. , between physicians and hospital administrators ) . in such cases , each in - group draws part of its identity from negating the out - group , making collaboration impossible . the iic model holds that de - escalation of such conflict must progress through the following stages : ( 1 ) readiness ( to come to the table ) , ( 2 ) mindfulness ( openness to other ways of conceptualizing the situation ) , ( 3 ) positive in - group distinctiveness ( ensuring a secure in - group identity without the need to negate the out - group ) , ( 4 ) simultaneous intergroup differentiation and unity ( cooperation around specific objectives while maintaining separate , distinct groups ) , and ( 5 ) integrative goals and structures . organizations may take steps to help a fractious relationship progress from one stage to the next . however , attempts to achieve a higher stage before lower ones have been completed ( e.g. , making appeals to unity while each group still views the other as a threat ) are likely to backfire . the sequence of stages 1 through 4 was borne out in a canadian study of the relationship between physicians and regional health authorities ; the parties might have ultimately progressed to stage 5 , but the government dissolved the regional system ( reay and hinings 2009 ) . in an australian study , allied health professionals appeared to traverse stages 3 through 5 , progressing from unidisciplinary identities to targeted collaboration and finally dual ( disciplinary and allied health ) identity ( boyce 2006 ) . in its bottom - up approach to the development of a superordinate identity , prior research has provided a rich description of how power structures , group norms and values , strength of identification , and contextual factors interact with various social identifications to produce different patterns of group behavior . the social identity approach has the potential to serve as a coherent framework for synthesizing this diverse information and identifying the most promising mechanisms for change . in order to realize this potential , it is important to take advantage of the full depth and complexity of the approach , rather than stop at the basic insight that people engage in social categorization . further research should also focus on deepening our understanding of the currently neglected group level , rather than assume that a potpourri of group - based and individualistic approaches can offer a better or more complete analysis . it also is essential that research be sensitive to the unique features of the health care context  not because transferability is unimportant , but because overlooking social identifications , structures , or elements of identity content that are highly salient in a particular context can result in shallow or misleading analysis . finally , since much of the literature has concentrated on the micro level of interprofessional silos and clinical teams , future research might emphasize the macro level of interorganizational silos and system integration . while the same basic mechanisms may apply in both contexts , two directions for future research are ( 1 ) in - depth exploration of social identity dynamics during system - integration efforts ( e.g. , development of accountable care organizations in the united states ) , with a focus on identity mobilization and context change ; and ( 2 ) further testing of the aspire and iic models in health care systems . a recurring theme in literature from disparate traditions is the importance of identity mobilization and/or context change in driving system transformation . change seems most likely to occur when both mechanisms are present : without mobilization of valued identities , attempts to impose context change may provoke identity threat and invite implementation failure ; without changes to the real conditions under which people work , identity mobilization may amount to  just another staff development workshop . the two processes may also reinforce each other cyclically : mobilization of shared identities can facilitate the adoption of concrete changes ( graham and steele 2001 ; kerfoot 2007 ) , while changes in working arrangements can stimulate the reshaping and reinterpretation of social identities ( farrell , schmitt , and heinemann 2001 ; hotho 2008 ) . the aspire model ) ; however , context change can be the impetus for identity reconstruction . in a study of primary care reform , changes at the institutional and organizational levels ( capitation , multidisciplinary teams , co - location , etc . ) created a context for physicians to reframe teamwork , preventive medicine , and guideline adherence as identity congruent ( chreim , williams , and hinings 2007 ) . whereas managerial attempts to  colonize  staff identities are likely to be resisted or subverted , context changes that can be meaningfully incorporated into existing identities may stimulate constructive engagement ( levay and waks 2009 ) . in the course of such engagement , providers not only reconstruct their identities to fit the intervention but often reconstruct the intervention to fit their identities . although such reconstruction may sometimes serve narrow professional interests ( mcdonald , harrison , and checkland 2008 ) , in other cases the result advances the interests of professionals , managers , and , most important , patients ( waring and currie 2009 ) . in advancing a social identity perspective on health care silos , we do not mean to imply that silos are wholly a function of social identity dynamics . the sia recognizes that individual and interpersonal factors remain important , particularly when group identification or social - identity salience is low . moreover , although practical and operational problems often have a social - identity component , solutions can not be found by addressing social identity alone . the contribution of the sia is to articulate when and how various factors will be relevant and to prevent misconstrual of a group - level issue as an interpersonal or purely operational one . we suggest the sia as a framework , not a replacement , for other group - level theories ; for example , while the sia highlights the ubiquity of politics in organizations , it is not a theory of politics , and other approaches delve more fully into structural relations or power enactment . in short , our claim is not that everything is a social identity problem , but that every problem involving interactions within or among health care groups probably has a social identity dimension , and that understanding this dimension will enable more effective responses . because this is not an evidence review but we do offer the following guiding questions for health care leaders confronting the problem of silos : who are the relevant groups , and what are their relationships ? how might social identity be playing a role in current organizational problems or conflicts ? which groups need to be around the table to develop new ways of working ? can they come together immediately , or does intergroup tension necessitate that they first work separately ? what change messages ( and messengers ) will fit the values and attributes cherished by each group ? how might day - to - day factors that reinforce silos and conflict be replaced by others that promote more cooperative and equal interactions ? as change proceeds , how can identity threat ( to valued groups existence , status , distinctiveness , values , etc . ) be minimized ? as the more than 300 reports in our review reveal , social identity is a powerful reality in the functioning of the health care system . rather than attempt to ignore , expunge , or manipulate social identities , we can embrace the opportunity to work with and through them to unite providers around the values that all health care professionals share . social identity thinking can unlock new options for overcoming silos and bringing about a harmoniously functioning , well - coordinated health care system .