Abstract
This paper examines the factors that have led to the undervaluing of the medical science profession and how a union can take a strategic approach to strengthen the professional identity of its membership to overcome challenges. We draw on interviews with union officials and managers and focus groups with medical scientists in four health services in Victoria, Australia. Drawing on the union strategy literature, we argue that professional identity is related in a recursive way to the attitudinal context and the narrative capabilities of the union. We found that first, many medical scientists believed that medical science was invisible and undervalued contributing to a weak professional identity due to underlying structural and institutional factors. Second, this has been exacerbated by the attitudinal context in which the profession has been subordinated to the other stronger professions of doctors and nurses. Third, we report the union is attempting to strengthen the professional identity of medical scientists through developing union campaigns with a narrative around work intensification and the critical nature of medical science work. Union strategy underpinned by union campaigns seeks to transform medical scientists’ attitudinal context by harnessing their sense of associational power through narrative capabilities to strengthen professional identity.
Introduction
This paper examines the factors that have led to the undervaluing of the medical science profession and how a union can take a strategic approach to strengthen professional identity of its membership to overcome workplace challenges in public hospital pathology services in Victoria, Australia. The COVID-19 pandemic has highlighted the essential role of the public health workforce and value of doctors, nurses and paramedics who have been lauded as ‘heroes’ by governments and communities (Bartram and Cooke, 2022; Meacham et al., 2023). We focus on pathology services which are critical to ensuring high-quality health outcomes through the provision of accurate and timely diagnostic medical information to doctors, public health professionals and policy makers (McGregor and Moriarty, 2003). However, despite the increased importance of medical testing to fight against the pandemic, the work of medical scientists who carry out these tests has been largely invisible. Argue that medical scientists have less professional status than doctors and nurses, and that a range of factors contribute to this lower status. These include, limited professional autonomy, a lack of understanding of the work of medical scientists by other clinicians and the general public, underpinned by assumptions that medical science is monotonous, atomised and repetitive work, all exacerbated by the hidden nature of their work. Moreover, another characteristic of the medical science profession is that it is feminised (Cavanagh et al., 2021).
In Australia, the work of medical scientists has been impacted by technological advancement and new treatments, increased consumer demands and managerialism within a context of budget constraints (Cavanagh et al., 2023; Isouard, 2012; Legg and Associates, 2008). There is evidence that this has led to growing staff shortages, excessive workloads, unsociable work hours and a lack of respect from other clinicians (Cavanagh et al., 2023; Legg and Associates, 2008). There is also evidence of growing absenteeism and labour turnover (Cavanagh et al., 2021). In common with nurses, many medical scientists working in public hospitals in Victoria, Australia are trade union members, however, unlike nurses, they do not appear to have the same unified public voice, bargaining power or community support (Cavanagh et al., 2021; McGregor et al., 2003). We argue that at the core of undervaluing the medical science profession and subsequent challenges with the union's strategy (in this case the Medical Science Association of Victoria (MSAV)) on workforce outcomes, is a lack of a strong professional identity among medical scientists. A strong professional identity in health care is often associated with strong unions, for example, the Australian Nursing and Midwifery Association (ANMF) and the Australian Medical Association (AMA), who have powerful narrative capabilities, long and established professional values, and community respect and support. We see evidence of how unions such as the ANMF have leveraged professional identity to develop narratives within the workplace as a tool to support member commitment and activism, and garner community support for industrial campaigns (Buchan, 2005; Cregan et al., 2009; Stanton et al., 2022).
Recent research focuses on mobilising union membership to increase activism with the goal of union growth and renewal for the benefit of workers and the broader community (Ellem et al., 2020; Fiorito et al., 2015; Ibsen and Tapia, 2017; Lévesque and Murray, 2013). However, there has been less attention placed on the complexity of the meaning and the efficacy of union renewal from a strategic perspective (Hickey et al., 2010; Murray, 2017). Murray (2017: 9) argues that union renewal rests on examination of the ‘long process of democratic experimentalism in union purpose and practice needs’ which rely heavily on the ‘critical role of strategic capabilities and the need to develop these capabilities to experiment with innovations likely to reveal new sources of vigour for worker organisations’. There is a dearth of literature on the role of unions using or strengthening professional identity as part of union renewal, although there is ample anecdotal evidence that successful unions, especially in the healthcare sector, contribute significantly to developing professional identity and leveraging this to create social movements (e.g., union industrial campaigns) to bargain for improved terms and conditions (e.g., ANMF). Drawing from the union strategy and activism literature, we explore how workplace (e.g., hidden profession, low professional status) and institutional factors (e.g., enterprise bargaining agreement and government funding) have contributed to the undervaluing of the medical science profession and a subsequent weak professional identity. We use this as the basis for examining how union strategy can be used to strengthen professional identity and improve workplace challenges faced by medical scientists. More specifically in this paper, we argue that the development of professional identity is influenced by and influences (in a recursive way) the attitudinal context of the union membership (Fiorito et al., 2015) and narrative capabilities of the union (Gavin, 2021; Lévesque and Murray, 2013).
This paper is based on interviews with union officials and managers, and focus groups with medical scientists in four Victorian, Australian public hospitals. We ask two questions: (1) what are the factors that have led to undervaluing the medical science profession in public hospitals? (2) how can a union, such as the MSAV, take a strategic approach to strengthen the professional identity among its membership to overcome the workplace challenges of medical scientists?
Our key contribution to industrial relations literature is that first, we link union strategy and professional identity theories and second, we examine the factors including the attitudinal context that can contribute to a subordinate and undervalued identity among medical scientists. We unpack how undervaluing of medical scientists, and their working conditions have undermined their professional identity and how union action can improve this situation. Third, we offer new insights into how union renewal strategies can strengthen professional identity through developing union campaigns underpinned by narratives capabilities to stimulate greater collectivism among union members.
The medical science context in victorian hospitals
In Australia, there are 697 public hospitals (AIHW, 2022), most with in-hospital pathology services, employing over 16,000 medical scientists (ABS, 2016). While medically qualified pathologists are at the pinnacle of the discipline, pathology services contain four major areas of specialisation. These are anatomical, biochemistry, haematology and microbiology and it is medical scientists in these services who provide the diagnostic information that enables doctors to identify the nature, cause and effects of disease and prescribe appropriate treatment (Lippi et al., 2016b). In Australia, medical scientists are university graduates specialising in pathology which focuses on understanding the cause of disease and scientific investigations to support diagnosis (Legg and Associates, 2008). Difficulties associated with the medical science workforce in Australia have been of ongoing concern to the sector, as well as Federal and State Governments (Cavanagh et al., 2023; McGregor and Moriarty, 2003). In 2008, the Australian Department of Health and Ageing (now the Australian Department of Health) commissioned a report which noted problems of staff shortages, excessive workloads, unsociable work hours, and ‘work environments stressed with continuous driving for efficiency gains’ within public pathology services (Legg and Associates, 2008: 25–26). The work of medical scientists is crucial to diagnosis and treatment in healthcare and it is estimated that this work affects medical decisions in approximately 70 percent of medical cases (Lippi et al., 2016).
Pathology services operate continuously, 24 h per day 7 days per week, and rostering is a crucial aspect of work design. Evidence suggests that rostering has a major influence on the performance and job satisfaction of employees and quality of care and that poor rostering practices can lead to sickness and absenteeism (Cavanagh et al., 2021; Griffiths et al., 2019). Inadequate management training in best practice rostering techniques, as well as soft management skills (e.g., leader emotional support, conflict and negotiation skills) may also contribute to poor rostering practices, which in-turn may lead to workplace inflexibility (Knust and Xie, 2017), favouritism, gaming and over-work (Weekes et al., 2001). Coupled with the growth in demand for pathology services, these factors can contribute to work intensification, staff shortages, stress and burnout (Cavanagh et al., 2021; Legg and Associates, 2008; Weekes et al., 2001; Willis and Weekes, 2005).
In Australia, the provision of pathology services varies from state to state. As of 2021, there were 6342 Medical Laboratory Scientists employed in the state of Victoria (Australian Bureau of Statistics, 2021). In addition to medical laboratory scientists, pathology laboratories also employ large numbers of medical laboratory technicians (with Certificate or Diploma level qualifications) and laboratory assistants.
In Victoria, most large metropolitan tertiary hospitals have their own in-house pathology services. This is despite the fact that during the 1990s, Victorian government policy had encouraged outsourcing of pathology services to drive down costs and bring about workforce change and challenge the power of the union contributing to a legacy of fear (Young, 2002). There is a view that shifting pathology services to the private sector during this period reduced the influence of the union. However, most privatisation and outsourcing had taken place in smaller rural hospitals and the large tertiary hospitals were less affected (Young, 2002).
Medical scientists that practice within public hospitals operate within a complex institutional setting (Cooke and Bartram, 2015). Pay and working conditions of all medical scientists as, well as pharmacists, psychologists, audiologists, and dieticians in public hospitals in Victoria are governed by the same Enterprise Agreement (EA). There is a separate public sector EA for nurses and midwives, another for doctors (‘Medical Specialists’), and another for allied health professionals. While technically each public hospital has its own EA, as the State government funds public hospitals, the key terms and conditions are generally the same across all hospitals. The Medical Scientists’ Association Victoria (MSAV) which is a branch of the Health Services Union of Australia represents members in industrial relations matters (MSAV, 2020). It could be argued that being part of this generic professional union branch, while increasing overall strength and influence, undermines the distinctive professional identities of the individual professions. This contrasts with more profession-specific public sector enterprise bargaining for nurses and midwives (represented by the Australian Nursing and Midwifery Federation and, for enrolled nurses, the Health Services Union), and doctors (represented by the Australian Salaried Medical Officers Federation). According to the MSAV, the priority for the State government is to control costs while the priority for the union is to improve working conditions in the context of increasing workloads and related job stress (MSAV, 2020).
Professional identity
Professional status is often categorised in terms of attributes such as autonomy and independence, however, professional identity captures an individual's identity and the collective perspective of the group (Bartram et al., 2020). According to McGivern et al. (2015: 412) a ‘professional is an exclusive identity, developed through qualifications, training, and socialisation, creating social identity boundaries and enhanced careers’. In the management literature, professionals are regarded as privileged actors who seek to maintain their professional dominance (Currie et al., 2012). Their group identity enables this as ‘identity is constructed in relation to the groups people belong to and compare themselves with, contexts, categories, discourses, and social interactions’ (McGivern et al., 2015: 414). Identity is defined as ‘a shared set of meanings that define individuals in particular roles in society, as members of specific groups in society, and as persons having specific characteristics that make them unique from others’ (Stets and Serpe, 2013:31). Health professional identity has a number of components including professional commitment and devotion (e.g., commitment to remaining in the profession and building professional skills); emotional identification and belongingness (e.g., a sense of pride in being a healthcare professional); professional goals and values (e.g., healthcare is a respected profession and of value to society); and self-fulfillment and retention tendency (e.g., perception of self-worth in the profession and extent to which a person wants to remain in the profession) (Liao and Wang, 2020).
According to Stryker (2004) identities emerge out of social structures and are a set of meanings about role, and social and personal identity attached to the roles individuals undertake within a social structure. McGivern et al. (2015: 415) suggest that ‘actors engage in the everyday enactment of identities, altering institutional logics as they become aware of and attempt to resolve ambiguity’. Identity work has been found to underpin identity construction amidst competing institutional arrangements (Sveningsson and Alvesson, 2003), legitimating collective identities by shaping the perception of audiences, and outlining collective identities’ ‘purposes and practices and providing an interpretive basis for the maintenance or transformation of professionalism’ (Lawrence and Suddaby, 2006: 216). McGivern et al. (2015: 415) suggest that ‘identity work is the process of creation, transformation and maintenance of institutional arrangements……as well as professional identities’. Suddaby and Viale (2011: 435) argue that professionals can draw on their social capital, political and cultural skills to engage others and promote change through building a narrative which, ‘is a crucial weapon… and professionals are skilled rhetoricians’.
Much of the research on professional identity within the healthcare sector is related to nurses and doctors (Bartram et al., 2020; Currie et al., 2012). Reay and Hinings (2009), referring largely to doctors, argue that health professionals have distinct professional identities comprised of histories, cultures, practices, and values which often underpin the promotion of their dominance and autonomy, as they resist management efforts to organise their work. Evidence suggests that doctors use their power, prestige and control over the production process to influence and shape institutional and organisational drivers (McGivern et al., 2015). Bartram et al. (2020) found that doctors use their rhetorical power to create narratives about their work to advance their own professional projects and protect and extend their influence. The Australian Medical Association, while technically a professional association, also plays a trade union role for many of its members in public hospitals negotiating agreements and representing their interests (Bartram et al., 2020). Moreover, due to the large numbers of nurses in health services they are able to advocate for change that is in their interests and resist change that they feel is detrimental to themselves and patient care (Cregan et al., 2009). The ANMF has built up a strong professional identity (Cregan et al., 2009). Through a narrative of protecting and advancing patient care, the Victorian branch of the ANMF has been able to establish mandated nurse patient ratios in public hospitals which help control nurse workloads (Buchan, 2005; Thomas and Chaperon, 2013). The professional identity of nurses also leads to strong collective workplace action where nurse union members internalise and police the rules on a day-to-day basis (Stanton, Bartram and Bamber, 2022). We argue that the union has a role to play in identity work of medical scientists. However, there is limited examination of the professional identity of lower status medical professional groups such as medical scientists. McGregor et al. (2003) argue that medical science has undergone a process of professionalisation that arguably remains incomplete, with a widespread perception among practitioners that they lack appropriate professional status, respect and recognition. Medical scientists lack the power and prestige of doctors and the trust placed by the community in the nursing profession. The strengthening of professional identity is a key challenge for the MSAV and its members to enhance their sense of collectivism and subsequent enterprise bargaining outcomes. We examine the extent to which undervaluing of medical scientists and their poor working conditions has undermined their professional identity and the role of the union in improving such a situation.
Union strategy and professional identity
Strategic choice theorists argue that industrial relations (IR) actors make choices about what they do and how they do it motivated by a range of influences including political and economic interests and the external environment (Kochan et al., 1986). They suggest that the actors operate on three levels. The first is the highest level of long-term policy-making (macro level); the second is enterprise-level IR and human resource management (HRM) (meso level). The third is the workplace level, including individual and organisational relationships (micro level). The value of such an approach is that it recognises the interrelationships between the activities at the different institutional levels and how these may impact the development of union narrative capabilities to improve professional identity, especially around professional commitment and devotion, emotional identification and belongingness, professional goals and values, and self-fulfillment and retention tendency (Liao and Wang, 2020).
In healthcare, state and federal government policy, regulation, funding and forms of collective bargaining have a direct impact on trade union strategy and practice. Trade unions are a part of a complex web of powerful players that include state regulators, government policy-makers, hospital executives, non-union professional associations and consumer groups (Bartram et al., 2020; Gavin, 2022). While many HRM functions might be devolved to the organisational level, hospital industrial relations in many jurisdictions such as Victoria is still a centralised process (Stanton et al., 2010). Health-sector unions in Australia are often wedded to the centralised pay bargaining process more so than other forms of participation and collaboration as this is the domain where they have most power and influence (O'Donoghue et al., 2011). The success of this centralised approach can be seen (in the case of the ANMF) in the adoption of legally enforceable nurse patient ratios in the State (Stanton et al., 2022; Thomas et al., 2013).
One key question is how unions can use professional identity as part of their strategy of union renewal to improve collective bargaining outcomes. Ellem et al. (2020) argue that understanding union renewal is not simply a matter of unions examining their strategic options but understanding these options over time in terms of power resources they can muster, especially in relation to associational power (may derive from organising, changes to union structure, coalition building, partnership and political action) (Wright, 2000). Associational power and strategy must be thought of in terms of union purpose and the importance of ‘connecting immediate concerns to a wider purpose’ which galvanise and energise the collective interests of members (Ellem et al., 2020: 425). This sense of purpose is crucial to healthcare unions that also act as professional associations with a narrative underpinned by a strong professional identity (e.g., ANMF protecting quality of patient care through nurse-patient ratios). We argue that unions can influence the development of professional identity as a means for increasing their associational power at the workplace and broader institutional levels. This can be done by enhancing members’ sense of professional commitment and devotion, emotional identification and belongingness, professional goals and values, and self-fulfillment and retention tendency (Liao and Wang, 2020). We suggest that structural factors such as the hidden nature of medical science work, subordinated relationships to other higher status clinical professions and poor working conditions may impact professional identity. To strength professional identity union action may also be directed at improving professional status of members (Bartram et al., 2020). For healthcare professionals, the creation of such an identity can impact on and influence institutional arrangements such as collective bargaining outcomes (McGivern et al., 2015).
Attitudinal context refers to attitudes of workers towards the union and work (Fiorito et al., 2015). Narrative capabilities or resources ‘consist of the range of values, beliefs, shared understandings, stories and ideologies that aggregate identities and interests and translate and inform motive’ (Lévesque and Murray, 2013: 777). Lévesque and Murray (2013) argue that unions have control over their messages and that narratives matter. We argue that professional identity is critical to the development and enhancement of union narratives (possibly in a recursive way) especially in the healthcare sector where professional groups and unions are often the same organisation (e.g., ANMF, AMA). Clearly unions such as the ANMF and AMA have been able to appeal to the wider purpose of protecting quality of patient care to build their powerful narratives and extend their associational power and improve bargain outcomes (Bartram et al., 2020; Cregan et al., 2009; Stanton, Bartram and Bamber, 2022). However, an important strategic capability of unions is whether they can frame their narratives in ‘the context of power relations where other actors have greater or lesser degrees and types of capability and other sources of power’ (Lévesque and Murray, 2013: 794). Fiorito et al. (2015) explore the idea of context in their work on union activism and argue that the attitudinal context of the workplace, in particular the attitudes of core workers (i.e., medical scientists) and others around them is a key factor in understanding activism. Whether these attitudes are pro-union or more materialistic impacts on how workers respond to workplace and wider contextual challenges, and ultimately union narratives.
Lévesque and Murray (2013: 794) call for further research into ‘the relationship between different types of capabilities and power resources in varied and dynamic settings to gauge whether and how these relationships hold in the face of the asymmetries of power on the part of the actors at play’. There is some evidence that medical scientists perceive that they are less powerful than doctors and nurses which may contribute to an identity of subordination (Cavanagh et al., 2023). The relationship between union strategy, professional identity, and narrative capabilities is complex, multi-faceted and may be recursive in nature. For example, we argue that union strategy (Ellem et al., 2020) may be underpinned by attitudinal context (Fiorito et al., 2015) which in turn may influence the strength of professional identity (McGivern et al., 2015) and may directly impact narrative capabilities (Lévesque and Murray, 2013). Conversely, narrative capabilities may also reinforce the professional identity of members and impact on attitudinal context. These processes may have important implications for associational power and collective bargaining outcomes.
Recently, the MSAV has developed union campaigns around a narrative of work intensification and the unacceptable practice of unpaid labour - ‘No Pay, No Way!’ (MSAV, 2023a). The campaign seeks to ‘reduce unsustainably of high workloads, enforce workload clauses in our agreements, have fewer members doing unpaid work, eliminate injuries arising from high workloads and engage more members in the work of the union’ (MSAV, 2023a). The union encouraged members to say no to unpaid work and educate members that they cannot be forced to perform unpaid work and that their refusal is lawful. The MSAV is encouraging members to act collectively and spread the message of the campaign to others at their workplace (MSAV, 2023a).
The MSAV also promotes the essential service narrative of medical science work. In 2018, during workload and backfill discussions between the MSAV and a large health service, a commitment was made to the microbiology department of an additional 4.5 equivalent fulltime staff (EFT) (MSA, 2023b). However, the MSAV reported that this commitment was revoked. Through a union campaign of standing together, medical scientists working in a major regional hospital refused to carry laboratory tests and such tests were outsourced to other laboratories. There was a new workflow process that was problematic and the MSAV were asked to revert to previous processing arrangements with the proviso that they would be given the 4.5 EFT. One Union Official remarked, ‘I remind our members from time-to-time what power we have when we stand together’ (MSAV, 2023b).
We explore whether the above framework can cast light on the strategic choices open to medical scientists and their union to meet the many challenges they face.
Method
The original contracted study was to explore the rostering challenges that had been identified across tertiary hospitals as part of the enterprise bargaining process. The topic of rostering challenges formed an entry-point to discussion of related key issues for medical scientists, including around professional identify, the enterprise agreement, and union strategy. The study was initiated by the MSAV and supported and funded by the Victorian Department of Health. The Victorian Hospitals Industrial Association was also part of the Steering Group advising the project. Data were collected between September and November 2018 in pathology services across four large public health services in Australia. The four health services were purposefully sampled due to the numbers of directors, managers and medical scientists they employed. The Chief Investigator contacted each Health Service and obtained Organisational Consent. The research team contacted the prospective participants for interviews and focus groups, the purpose of the research was outlined and each participant was assured that this was a confidential and voluntary exercise (Schensul et al., 1999). Ethics approval was granted by the University.
Data collection
Data were collected from roster documents and a total of 76 participants through interviews and focus groups. First, interviews with carried out with three Directors, 18 Managers and two Union Officials. There were four health services in this research project, and we refer to each health service alphabetically as HSA, HSB, HSC and HSD. The two union officials are referred to as UO_1 and UO_2 and to protect their identity we do not separate them. Managers are referred to as MA_HSA and where there was a second and third manager MB_HSA and MC_HSA. Medical scientists are referred to as MS_HSA representing a medical scientist at health service A. To protect the identity of medical scientists we do not separate them.
The interviews lasted for us to 45 min and provided an opportunity for in depth discussion with key leaders and managers to fully understand their beliefs, perceptions and motivations and capture their personal reality. Second, nine focus groups were conducted of between 50 min to 1 h with a total of 53 Medical Scientists from Pathology Departments across the four Health Services to explore attitudes and experiences of employees on the same topics. The Focus groups also helped in obtaining a group view related to the role of professional identity and union strategy of medical scientists and workplace consequences in pathology work. In this way, the data were triangulated to ensure reliability and validity and also captured multiple perspectives (Creswell and Miller, 2000).
Data analysis
The recordings of interviews, handwritten interview notes and focus groups were transcribed and entered into NVivo (Weber, 1985). All data were de-identified and two researchers coded the data independently to ensure the reliability of the coding framework. Where there was disagreement between the coders, a third rater was consulted. The researchers searched for the convergence of different sources of information to formulate categories and themes within the data following the steps of content analysis outlined by (Weber, 1985). This process helped the development of the coding framework in which we identify common themes across interviews and focus groups, while keeping a close connection with participants’ lived experiences and unique perspectives. The themes were determined by the research questions. For the purpose of this paper, two clear themes emerged: first, structural and institutional factors impacting on identity and second, trade union strategy.
Factors influencing the professional identity of Medical Scientists in Victoria
Institutional and structural factors
When the researchers commenced talking with managers across the four medical services, they were keen to discuss contextual factors such as the impact of government policy and practice, a lack of staff, the organisation of work and the enterprise agreement as common themes. Managers described an increased volume of work, constant pressures around lack of resources, changing government requirements and a lack of understanding by policy and decision makers about the role of medical scientists. One manager (MA_HSB) argued, ‘it [pathology] is about automation, community expectations, new tests and research and development. Finances have changed managing pathology….our work's about meeting Government requirements….it's becoming more difficult’.
Indeed, our research project on pathology rostering was initiated by issues arising in a union membership survey in 2016 which also underpinned the union's claims in the ensuing Enterprise Agreement. The EA covers all aspects of employment and work rights of Medical Scientists and other relevant healthcare professionals to improve ‘annual leave, rostering, workload and leave back fill provisions which…..provide improved benefits, by making jobs more decent, sustainable and less harmful’ (MSAV, 2017). A written priority for the Union was to ‘improve working conditions, particularly in the context of spiraling workloads and related stress and injury’ (MSAV, 2020).
The managers were very critical of the EA, arguing that the current rostering provisions restrict managerial prerogative in a situation where they have limited resources and few options thereby increasing their sense of powerlessness and frustration. It's difficult to meet the EA’ requirements….we don’t have enough EFT to meet the requirements (MA_HSA).
The two fulltime union officials recognised ‘there are challenges for medical scientists in public healthcare because there is growing demand for public hospital services’ (UO_2). There are also challenges in the EA and one of the key issues is around shortages of staff which have led to non-compliance with the EA. The first official claimed that ‘a huge amount of unpaid work was being undertaken by their members which is effectively ‘wage theft’’ (UO_1). The second official estimated that ‘75% of the workforce was working systematic unpaid overtime’ (UO_2). Both union officials cited a lack of resources (e.g., medical science staff) as a critical issue.
Both union officials concurred that their role is to ‘listen to members, understand their issues, and develop strategies’ (UO_2). They talked about medical scientists and used words such as ‘work intensification’, ‘burnout’ and ‘extreme stress’. There are ‘more complex tests today than ever before’ (UO_1) and the ‘increase in testing puts enormous pressure on medical scientists’ (UO_2). Both officials agreed ‘there is no recognition of the importance of their (medical science) work’ (UO_1) because ‘medical science always takes a back seat to doctors and nurses’ (UO_2).
The union officials expressed their main aim is ‘to instill a sense of collectivism and bring people together to build recognition for medical science’ (UO_1). This has been achieved in part by ‘establishing a narrative about who medical scientists are and the critical work they do’ (UO_2). The officials agreed that they do this by ‘developing campaigns around key issues that face the medical science workforce’ (UO_1). They also aim to ‘get the community to understand what medical scientists do’ (UO_2). Another is to ‘get other clinicians to better understand the essential services that medical scientists provide’ (UO_1).
Being a medical scientist isn’t attractive any more….there's a cultural issue….part-time staff are valued enough but full-time staff aren’t valued….we don’t have any personal issues with part-time staff, but management has created the culture (MS_HSB).
There's less and less fulltime staff every year…the pressure of medical science is only getting worse…I couldn’t….or wouldn’t recommend medical science to a school leaver wanting to find good profession….we are not valued by anyone…..many of us want to leave (MS_HSC).
Attitudinal factors
Overall, medical scientists expressed that their work was not understood by government and hospital decision makers and not valued by other professional groups. In the focus groups medical scientists identified three major concerns, the EA did not account for the needs of medical scientists, work intensification was reflected in management's poor rostering practices and a lack of appreciation of the value of their role.
Medical scientists were unanimous in their views that individually they had a weak professional identity and power and even as a collective we heard doubt in their voices, that they would never be heard: I love my job…love science…we have no say in our work….we’re a forgotten, dying race’ (MS_HSD)
We are invisible to management….lost creatures of the depths of the hospital (MS_HSC)
Work's so intense… we don’t have the energy to think about fighting for who we are or how we should work….. to have autonomy it's just a pipe dream (MS_HSA).
The upper hierarchy doesn’t acknowledge we exist let alone give us the authority to perform how it would work be best for us (MS_HSB)
Work intensification was seen as doing more with less but also the increasing complexity and the short time frames to complete the work. …..for us [medical scientists] the complexity of work has intensified because of new and various tests that have to be done and everything has to be done ‘now’….no one wants to wait any more….. (MS_HSD). Another participant commented on senior executives and stated: They don’t understand the nature of our work…..we make a contribution to society, but upper management doesn’t recognise that….we don’t make money… (MS_HSA).
Medical scientists believed that challenging relationships with other health professionals impacted on how they feel about their professional identity, particularly self-fulfilment and retention as medical scientists and made their work conditions much worse: Medical doctors have changed the way they practice because they used to send down for a specific test….now they ask for a whole range of tests…..they’re [doctors] impatient and get their nurses to contact us…harass us….nurses even come into the lab and stand over us….it's intimidating….to the point of bullying….many of us feel as though we are just machines…invisible (MS_HSB). Every area of care depends on medical science but we’re not treated kindly, we’re not treated with respect……doctors and nurses talk….or rather…scream down at us and we feel insignificant (MS_HSA). The demands have increased and doctors, nurses and relatives of patients want everything ‘now'…..there's no consideration for the time it takes to produce the results……(MS_HSD). Sometimes we receive a doctor's request for the same tests…. for the same patient, every day for a week… nurses phone the lab and scream at us to get the test results asap…..we understand doctors are concerned about litigation but we need the hierarchy to know how this impacts on us as human beings and the intensity of our work….staff are sick of it, we are burnt out and we think about leaving the profession (MS_HSB). Look where we work…..it's the dungeon of the hospital…..the walls are still painted 1970's yellow and we don’t even have one window….it's depressing (MS_HSA). Pathology is buried…..out of the way from the rest of the hospital…..there's a labyrinth of corridors to find where we are….it's miserable.…we’re nobodies, only medical scientists after all…(MS_HSD). Day becomes night and we don’t even know because we work in the vault (MS_HSC). Our staff [medical scientists] have to deal with excessive pressure and even abuse from doctors who want tests immediately…. (MA_HSC). Doctors don’t seem to get it that there's a lot of pressure and the workload for medical scientists is almost criminal…..our scientists are subjected to name calling and being told we’re too slow…sometimes we question why we even do this job (MA_HSA). Staff work in pathetic conditions….no windows…labs and rooms with paint peeling off the walls….there's old linoleum on the floors that could well be on display in a museum….it's pretty hard to feel good about the workplace let alone yourself (MB_HSA). The hierarchy and the government need to do something about workplaces for medical scientists….they (medical scientists) are not well looked after…..most people couldn’t find the labs in a hospital….we’re down in the depths of the hospital…our staff are the forgotten ones…we’re neglected (MC_HSD).
Union action
Union officials described the MSAV as a relatively young union, which had the highest percentage of its members in public hospitals, with a 70% union density. The union officials also spoke of the ‘mismatch between supply and demand’ (UO_1) of medical scientists and highlighted the need to raise awareness of the work and value of medical scientists. They argued that healthcare culture is dominated by nurses and doctors and that executives need to be more inclusive of other professionals. They felt that this was exacerbated by the actions of the State government for example:
In a recent Facebook post from the Premier – he congratulated all the graduating nurses but said nothing to allied health. (UO_1).
Extra funding goes to the most powerful groups – doctors and nurses (UO_2).
Union officials also claimed that in the face of such a non-inclusive culture ‘medical scientists are the worst at selling themselves’ and ‘the conditions of work make it very challenging for them to promote their identity’ (UO_1). The union is attempting to change this through greater militancy and public campaigns designed to raise the profile and value of the medical science profession. Medical scientists do have some industrial power. In February 2019, union members at a large tertiary hospital implemented a successful work to rule claiming that the healthcare network had reneged on an agreement reached through the Fair Work Commission in regard to staffing levels and workloads and claiming that testing had increased by 40%. Strong industrial campaigns and collective action by the union are attempts to enhance professional commitment and devotion to medical science profession, as well as creating a sense of belonging. However, the Union officials felt that while this action was successful many medical scientists were fearful of taking industrial action due to previous government outsourcing policies. Union officials quoted medical scientists fear of being out of a job ‘If we make a big fuss, we will get outsourced’. The Union strategy was to argue for a stronger role for the FWC and put pressure on the Victorian Labor Government. Both union officials agreed that the government needs to act ‘as there is no point in legislating against wage theft if you don’t look in your own back yard’ (UO_1).
Medical scientists claimed that even though they do not get the management support they need, informally they try to support each other when they can, for example, ‘If we have excessive shifts we know it will impact on how we feel and how we work….we help each other out and swap shifts (MS_HSC). However, they also knew that they could rely on the MSAV for critical situations, but they had a sense of helplessness on their day-to-day identities. Through all the interviewees and focus groups participants gave examples of union members turning to their union when they were ‘pushed to the limit’ to seek redress under the protection of the EA on a range of issues. For example: There was a major case that one scientist had…..she returned from extended sick leave and was expected to go back to night shifts….she took it to the union and won (MS_HSD).
A few years ago there was a big union case….it was hush hush…..we weren’t allowed to talk about it….the staff member was reinstated (MS_HSB).
We’ve had a lot of support from the union about the enterprise agreement….we’re all invested in how much time off we get after night shift….they kept us informed but we still have day-to -day issues (MS_HSC).
There's still a sense that we don’t have much of a voice…..we could potentially call the union every day, but we don’t because we have to get on with our work (MS_HSA).
Discussion
In this paper, we examined the undervaluing of medical scientists and how a union can take a strategic approach to strengthen professional identity among its membership to overcome workplace challenges. First, we examined the factors that have led to the undervaluing of medical scientists’ and their suggestion that they are hidden workers in Victorian public hospitals. Among many medical scientists there is an overall feeling of invisibility and not being valued by the key players in the workplace which may have contributed to undermining their professional identity. It was identified that government budgetary controls (institutional challenge) have meant resources have not kept up with demands and stretched resources have led to inadequate staffing, greater unpaid work, and an increase in part-time work for medical scientists. Medical scientists reported a lack of opportunities for training and development and career progression. It was identified that inadequate staffing and poor rostering have increased employee reports of burnout which have led to excessive sick leave and some medical scientists wanting to leave the profession.
One of our main findings was that medical science is an undervalued profession due to underlying structural and institutional factors (Ellem et al., 2020). We find some evidence that structural (e.g., hidden nature of medical science work, lack of respect from other clinician groups, lack of resources and work intensification) and institutional factors (e.g., enterprise bargaining agreement, lack of government funding) may have an impact on the components of professional identity. More specifically, many medical scientists reported they are ‘invisible’, misunderstood by senior managers and policy makers and subjected to abuse from doctors and nurses. This finding largely reinforces previous research that characterises medical scientists as largely unseen and undervalued by other health professionals, government (e.g., lack of funding for additional staff), the wider community, and even medical scientists themselves (Legg and Associates, 2008; McGregor et al., 2003). Some medical scientists are questioning their professional commitment to remaining in the profession and are often struggling given their day-to-day working conditions and lack of respect from other clinicians. This work context is also affecting medical scientists’ emotional identification and belongingness as a number of them have a reduced a sense of pride in the profession. As a consequence, of some medical scientists have a low perception of self-worth as a professional and have indicated that they may even quit the profession (Liao and Wang, 2020).
We sought to find out how a union, such as the MSAV, can strengthen professional identity among their members to overcome workplace challenges. We found that union strategy (Ellem et al., 2020) seems to be underpinned by union campaigns that seek to transform medical scientists’ attitudinal context (Fiorito et al., 2015) through harnessing narrative capabilities (Lévesque and Murray, 2013) to strengthen professional identity (McGivern et al., 2015). A key part of improving the attitudinal context has been to develop collective campaigns to change the structural and institutional challenges. The research identified the MSAV is attempting to strengthen professional identity for medical scientists through developing union campaigns around work intensification and the critical nature of medical science work to the health system and broader community. Moreover, the MSAV is also effectively utilising the FWC to enforce and improve the EA. The MSAV has developed narrative capabilities to promote the importance of medical science work to key players such as doctors and nurses, government, patients, and the community. Such narrative capabilities are critical to changing the fragmented nature of medical science work and build a stronger sense of collectivism and pride in their profession and union. This union action may go some way to strength medical scientists’ professional identity.
We contend that medical scientists have had a ‘subordinated’ identity which can be understood in the context of the attitudes of other professionals towards their work (Fiorito et al., 2015). Doctors are high-status professionals and are subsequently powerful players in the healthcare sector (Bartram et al., 2020; Currie et al., 2012; McGivern et al., 2015). Nurses are regarded by the broader community as bastions of virtue and due to their sheer numbers and their powerful union they command respect within the healthcare sector (Buchan, 2005; Cregan et al., 2009; Dube et al., 2016). In contrast, medical scientists do not have a high profile within the community or healthcare system and the MSAV is trying to rectify this through union campaigns. This is exacerbated by the hidden nature of medical scientists’ work (often undertaken in isolation, away from patients and the public and even other clinicians and positioned in remote areas within hospitals). Further compacting the low status of medical science is that in the workplace they provide their services to doctors who make the actual diagnosis. Many doctors do not have a strong understanding of the nature of medical science work (Legg and Associates, 2008), or the complexity of the tests and the time it takes to complete the tests accurately. The contribution of their work is again invisible to the impact on patient outcomes.
Moreover, there was no evidence that doctors and nurses understand the complexity, work intensification or value of medical science work (Bartram et al., 2020; Lawrence et al., 2006). Nurses, in the case study, acted as agents of doctors, policing and pressuring the medical scientists, adding to their sense of victimhood and job-related stress. The medical scientists regarded these actions of doctors and nurses as undermining their professional status. This was exacerbated by the clear, siloed boundaries between professional groups and the fractured practices within the profession itself especially between part-time and full-time workers (McGregor et al., 2003). The MSAV is rectifying this through union campaigns that seek to promote shared interests amongst all medical scientists (e.g., around member work intensification and health outcomes). Managers (many are union members) recognised the pressures that medical scientists faced, however, due to limited resources they continued to pressure medical scientists to work longer hours (that often do not comply with the EA), and cover staff on sick leave. Their professional identity is influenced by the challenging relationships and the attitudinal context (Fiorito et al., 2015) between medical scientists on the one hand, and management, the hierarchy, doctors and nurses on the other. Despite the historically weak and fragile subordinated professional identity of medical scientists (Cavanagh et al., 2023), there is evidence that the MSAV is attempting to strengthen this identity through collective union action around narratives that resonate with members (Lévesque and Murray, 2013).
Third, despite this subordinated professional status, as essential workers, medical scientists have potential associational power which until recent they have been reluctant to exercise due to fear of retribution. A belief in a lack of status and associational power has acted as a barrier to building a strong narrative. As a traditionally subordinated and lower status profession and because of the often introverted and focused (on the science) nature of many medical scientists they have found it difficult to raise their profile (McGregor et al., 2003) and subsequently strengthen their professional identity. However, recently, the MSAV has developed campaigns to raise awareness among key players of critical workforce issues such as work intensification and the critical nature of medical science work (especially during the pandemic). There is evidence in the data to suggest that medical scientists’ through union campaigns are making important efforts to relinquish their identity of subordination (McGregor et al., 2003). Through union campaigns the MSAV and its members are attempting to develop a compeling narrative that would build and reinforce their professional status (Lévesque and Murray, 2013; McGivern et al., 2015). The MSAV is building medical scientists’ professional identity through collective campaigns with a compeling narrative using industrial relations institutions such as the FWC. By developing a stronger professional identity, the MSAV similarly to higher profile unions (e.g., ANMF) is hoping to leverage related associational power and a stronger union narrative to improve enterprise bargaining outcomes (e.g., increase in workforce capacity and stop unpaid work). In the case of the ANMF, their members police the implementation and enforcement of the enterprise bargaining agreements (e.g., nurse patient ratios within the workplace) (Buchan, 2005; Thomas et al., 2013). Through public campaigns such as ‘No Pay, No Way!’ the MSAV was attempting to change the hidden nature and subordination of the medical science profession by enhancing members sense of emotional identification and belongingness (bringing members of the profession together through collective action), as well as professional value (celebrating and promoting essential service nature of medical science work) and self-fulfilment of members and retention tendency (attempting to correct poor working conditions). Such campaigns are an important way for members to demonstrate their professional commitment and devotion.
Implications for industrial relations theory and union practice
We contribute to industrial relations theory by examining the importance of professional identity of members for union strategy. We examine the undervaluing of medical scientists and unpack how the MSAV can take a strategic approach to strengthen professional identity among its membership to overcome the workplace challenges. By systematically examining the key elements of union strategy literature including attitudinal context (Fiorito et al., 2015) and narrative capabilities (Lévesque and Murray, 2013), we provide a better understanding of the recursive process of enhancing members’ professional identity, which may influence their perceptions of being valued by other institutional actors (e.g., doctors, nurses, hospital managers and administrators) (Legg and Associates, 2008; McGregor et al., 2003; Weekes et al., 2001). In a context of high union density as is the case of the MSAV, the union can influence professional identity through the socialisation associated with union campaigns and narratives around critical workforce challenges that resonate with members (McGivern et al., 2015; Stryker, 2004). Given that professional identity emerges out of social structures such as those enhanced through collective union campaigns, unions have the capacity to influence and enhance professional identity to improve their bargaining outcomes through associational power. Supported by the union, professionals can draw on their social capital to engage others and promote improved terms and conditions of employment through campaigns that promote a critically important narrative that galvanises members’ sense of collectivism and professional identity (Suddaby et al., 2011). Moreover, the celebration of union wins is also another narrative tool to strengthen solidarity and efficacy of collectivism and commitment to the profession. Unions can do this through ‘identity work’ as they create, transform and maintain institutional arrangements; this can be undertaken through building narratives to change the attitudinal context of union members (by improving structural and institutional conditions) from an identity of subordination to an identity that builds upon a privileged professional position (McGivern et al., 2015). Union action can enhance emotional identification and belongingness and enhance self-fulfillment in the profession. This is especially the case post-COVID as the public profile and essential service nature of medical science has been widely recognised and celebrated by governments and the broader community.
An implication for union practice is that if medical scientists choose to, they have potential associational power (e.g., over 16,000 members) to disrupt institutional arrangements that are exploitative given the essential services nature of their work. There is evidence that industrial action has been successful for the MSAV especially around improved staffing. If medical scientists took industrial action, they could grind hospital operations to a halt. Our findings have shown that the attitudinal context can strengthen professional identity of medical scientists (Fiorito et al., 2015) by the MSAV developing union campaigns around critical workforce issues. The use of such campaigns may contribute to reinforcing their commitment to the profession, sense of belonging, and professional status (Bartram et al., 2020; Currie et al., 2012), which consequently influence associational power by improving respect and recognition/value (Ellem et al., 2020; McGivern et al., 2015).
Finally, the use of a strong professional narrative for medical scientists about their work may help them to advance their own professional projects and extend their influence to their fellow clinicians, hospital management, and wider community (McGivern et al., 2015). This can ultimately contribute to the enhancement of their professional identity and the management of workplace challenges such excessive workloads, understaffing issues, and work intensification. Therefore, in line with union renewal literature (Ellem et al., 2020), we suggest that unions in partnership with their members, can strengthen professional identity (providing they have high union density rates) through reframing the attitudinal context and developing their narrative capabilities especially around the unfairness of work intensification and essential service nature of their profession (Ellem et al., 2020; Lévesque and Murray, 2013).
Conclusion
Our study contributes to the industrial relations literature by examining the factors that have led to the undervaluing of the medical science profession and how a union can take a strategic approach to strengthen the professional identity of its membership to overcome structural and institutional challenges. Our study highlights the key role of a union in reframing strategies to enhance medical scientists’ professional identity and recognition (Ellem et al., 2020; McGivern et al., 2015) and more concretely, in helping this profession and members to address the many challenges they face.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Biographical notes
Professor