A social identity approach to COVID‐19 transmission in hospital settings

Abstract The COVID‐19 pandemic poses a substantial risk of disease spread among healthcare workers (HCWs), making it important to understand what impacts perceived risk of COVID‐19 spread in hospital settings and what causes HCWs to mitigate COVID‐19 spread by following COVID‐19 safety measures. One determinant of risk perception and safe behaviors is the influence of seeing others as group members. The current study aims to (a) evaluate how social identification as an HCW and trust in co‐workers may influence perceived risk of COVID‐19 spread and (b) explore how communication transparency, trust in leaders, and identity leadership are associated with self‐reported adherence to COVID‐19 safety guidance. Using a correlational design, HCWs of a Scottish hospital were invited to participate in an online questionnaire measuring their perceptions of risk of COVID‐19 transmission, measures of social identification as an HCW, perception of leaders as members of the team, trust in co‐workers to follow the COVID‐19 guidelines and perception of leaders to manage COVID‐19 prevention effectively. Results showed that increased trust in co‐workers was associated with reduced risk perception of COVID‐19 transmission. Perceptions of transparent communication about COVID‐19 were found to be associated with increased adherence to COVID‐19 safety guidelines. Findings show the importance of the association between social identity processes and reduced risk perception and highlight the relationship between transparent communication strategies and self‐reported adherence to COVID‐19 guidelines, identity leadership, and trust in leaders to manage COVID‐19 appropriately.

Whereas earlier in the pandemic, uncertainty, and some conflicting advice about the dynamics of COVID-19 transmission and its management led to confusion for HCWs and hospital managers, clear evidence now provides guidance on how to prevent COVID-19 transmission (Bak et al., 2021). Next to personal protective equipment, the implementation of physical distancing serves as a critical way to prevent the transmission of COVID-19 in hospital settings and has repeatedly been demonstrated (Arora et al., 2020;Lewnard & Lo, 2020;. Research on healthcare-associated outbreaks of  suggests that HCW-to-HCW transmission represented the likely source of outbreaks and insufficient physical distancing appeared to be one of the leading reasons for transmission (Jørstad et al., 2020;McMichael et al., 2020;Schneider et al., 2020;Schwierzeck et al., 2020). However, in their work environment, HCWs are around multiple people and face numerous challenges, which make physical distancing difficult, such as crowded administrative meetings and clinical workrooms, ward rounds, or signing out (Arora et al., 2020;Keller et al., 2021). how to adhere to guidelines that were lengthy and ambiguous and often felt overwhelmed because guidelines changed constantly. The level of support that HCWs perceived to receive from management influenced their responses to IPC guidelines. Many HCWs also highlighted the importance of workplace culture as an influence on whether IPC guidelines were followed or not. Workplaces, where all staff adhered to IPC guidelines, created a culture whereby HCWs had a sense of "pulling together" (Corley et al., 2010) whereas, in workplace cultures of complacency, HCWs were less likely to adhere to IPC guidelines (Zinatsa et al., 2018).
While substantial evidence shows how COVID-19 is transmitted and which safety measures can prevent transmission, a better understanding of social psychological processes that drive COVID-19 mitigation behavior is crucial to improve strategies and protect HCWS. Several topics from the social and behavioral sciences are relevant to pandemics, such as research on risk perception, social contexts, and leadership. The way that individuals perceive and respond to the threats of COVID-19 can be influenced by group processes and their norms of behavior. Leaders play an important role in the coordination of preventive COVID-19 measures and trust in leaders is especially important for adherence to  guidelines (Bavel et al., 2020).
This study aims to investigate two research questions. First, we investigate how social identification as an HCW and trust in co-workers may influence perceived risk of COVID-19 spread. Second, we explore the association between perceived communication transparency and self-reported adherence to COVID-19 guidance, and the role of trust in leaders and prototypical leadership for this association.

| Social identity and the role of trust in risk perception
To investigate how social identification may be associated with trust in co-workers and risk perception, it is important to investigate how psychological processes influence group processes. An established theoretical framework to understand group processes within organizational settings is the social identity approach (SIA, e.g., Reicher et al., 2010), which originated from social identity theory ([SIT]; Tajfel & Turner, 1979) and self-categorization theory (SCT; Turner et al., 1987). The key principle of the SIT describes that the sense of self-definition is not only derived from individual traits and qualities, but also from the groups that people categorize themselves as members of their social identity (Turner et al., 1987). In other words, social identity refers to the internalized group membership of an individual, defining the person's sense of ''who they are'' in a particular social context. This means that people self-define themselves as "we" instead of "I" when they see themselves in terms of their social identity.
SIT describes the existence of social identities for every person (e.g., as a member of your professional group, such as an HCW), where the group identity is shaped by certain behaviors and beliefs that are normative or nonnormative. In hospitals, HCWs from various professions collaborate to provide services to patients and their identity as an HCW consists of a well-constructed set of norms, values, motives, and experiences that define the professional role (Warren & Braithwaite, 2020).
The COVID-19 pandemic requires individuals to go against behaviors that were previously normative (e.g., HCWs comforting each other), and maintaining physical distance from ingroup members represents a unique challenge because people feel safe around group members (e.g., Alnabulsi & Drury, 2014;Neville et al., 2021).
Evidence suggests that social identification influences the desire of individuals for close physical proximity to ingroup members (Novelli et al., 2013) and ingroup relations have also been linked to attenuated core disgust toward ingroup members (Reicher et al., 2016). Although these studies were not conducted in hospital settings or the high-risk context of COVID-19, insights from social identity research are highly relevant for effective responses to the COVID-19 pandemic (Bavel et al., 2020).
Building on social identity theory and self-categorization theory, Cruwys et al. (2020) proposed a social identity model of risk-taking (SIMORT), which states that potential threats from ingroup members will be perceived as less risky and inspire greater risk-taking behavior, than potential threats from outgroup members. It is argued that, because ingroup members are typically trusted to a greater degree than outgroup members, this may systematically affect the degree to which ingroup members are seen as a potential threat as individuals tend to use shared group membership as a heuristic for ''safety.'' Across eight studies, including the context of COVID-19, findings showed that shared group membership might reduce risk perception, primarily because ingroup members are trusted more than outgroup members (Cruwys, Greenaway, et al., 2021;Cruwys, Stevens, et al., 2021).
The current study builds on Cruwys, Greenaway, et al. (2021); Cruwys, Stevens, et al. (2021) model in the high-risk context of a hospital setting to investigate the proposed mediating effect of trust in other HCWs to follow COVID-19 guidance on the relationship between group identification as an HCW and risk perception of COVID-19 co-workers (see Figure 1).

H1.
Social identification as an HCW will be associated with a lower perceived risk of co-workers transmitting COVID-19, and this will be mediated by trust in co-workers to follow COVID-19 guidance 1.3 | The role of communication and leadership in adherence to safety guidance 1.3.1 | Communication transparency and seeing hospital leadership as part of the team The second part of the study aims to explore the association between perceived communication transparency and self-reported adherence to COVID-19 guidance and the role of trust in leaders and prototypical leadership for this association. Even though there are detailed and available recommendations for COVID-19 safety practices in hospital settings, guidance might not be easily transferrable because healthcare systems are highly variable in terms of their structure and workforce composition (ECDC, 2021;Pavolini & Kuhlmann, 2016). During a pandemic, HCWs experience rapid, unexpected change and to ensure that HCWs are informed about the latest safety measures it is crucial that information is transparently communicated (Spalluto et al., 2020).
Communication is essential in hospital settings and promotes workplace health and safety practices (Mascioli & Carrico, 2016). To improve collegiality and responsibility throughout staffing conditions and healthcare situations, internal communication should be structured, organized, and integrated (Foronda et al., 2016). Throughout the COVID-19 pandemic, it is crucial that the communication between management and employees is timely and transparent when the latest safety-related information is provided (Lanz et al., 2020;Spalluto et al., 2020).
Communication transparency is defined as the extent to which relevant information is shared amongst all stakeholders in the workplace (Haesevoets et al., 2021). In recent years, the empirical evidence on the value and effects of transparent communication in crisis situations has become more prevalent. Transparent communication has been shown to stimulate employees' sensemaking and sense-giving process during a crisis, highlighting the importance of communication strategies and participation (Kim et al., 2021). We hypothesize that in the context of COVID-19 in hospital settings, higher perceived transparency of communication about safety guidance will be associated with higher levels of self-reported adherence to the guidance. Stranzl et al. (2021) investigated the role of transparent organizational communication as a resource for employees during COVID-19 and found evidence to suggest that transparent communication was crucial to uphold job engagement throughout the crisis.
Employees that did not perceive internal communication to be transparent were more likely to disconnect from their work roles.
Moreover, Lee and Li (2021)  The COVID-19 pandemic creates the necessity for leaders to effectively coordinate and communicate to guarantee adherence to safety guidance. Especially in hospital settings, leaders have to ensure adherence to safety guidance and support HCWs by coordinating interactions of individuals and groups (Menon & Goh, 2005;Spalluto et al., 2020). Leaders that create and embed a sense of shared social identity (e.g., a sense of ''we-ness'') and act as a prototypical member of the group can ensure that their guidance is followed (Abrams et al., 2021;Haslam et al., 2020).
F I G U R E 1 Association of social identification as an HCW and risk perception with meditator trust in group members. HCW, healthcare workers.
Effective communication is a key attribute of successful leadership during crisis and providing clear and transparent information (e.g., explain why behavior is necessary; inform how to follow guidelines; provide regular updates) is an important aspect of legitimate leadership (Nicola et al., 2020;Templeton et al., 2020).
Receiving clear information can enhance the perceived legitimacy of who provides the information and enhance the feeling of being part of the same group (Carter et al., 2013).
Although providing effective communication is key to successful leadership, research based on social identity theory and selfcategorization theory shows that another crucial element of successful leadership is being a prototypical leader. Being a successful prototypical leader involves acting in the same way the other group members are expected to act and acting in the group's interest (see Platow et al., 2015;Reicher et al., 2018;Steffens et al. (2013). In a hospital context, this would require staff in leadership roles to follow the COVID-19 guidance they are asking their team to follow and acting in ways that support their team to follow the guidance. The closest representation of leadership in hospital settings are line managers, and therefore they provide the primary source of information about COVID-19 safety guidance (e.g., through handovers or team meetings). Thus, leaders clearly communicating COVID-19 safety measures to team members is one important part of leadership, but so is following the guidance themselves and helping the team to follow the guidance.
The current study aims to explore how the perception of leaders as prototypical members of the team influences the relationship between perceived communication transparency and self-reported adherence to COVID-19 safety guidance. As such, we aim to explore whether H2. perceiving leaders to be prototypical members of the team will mediate the association between perceived transparency of communication and self-reported adherence to COVID-19 safety guidance.

| Trust in leaders to manage COVID-19 appropriately
Trust among HCWs is a crucial element for effective healthcare delivery, yet less is known about the role of trust in leaders (Calnan & Rowe, 2008;Graham et al., 2015). Trusting relationships with leaders are needed so that HCWs are willing to seek information, cooperate in teams and communicate effectively (Marshall et al., 2013).
Effective communication strategies (e.g., clear and actionable information) have previously been linked to increased trust in authorities and compliance with guidance (Carter et al., 2013). In a study on leadership, trust in leaders and safety compliance in a hospital setting, results showed that leadership may not be directly effective in improving the safety compliance of subordinate nurses unless a leader first develops a trust-based relationship with the subordinates. Among other factors, transparent communication strategies may be responsible for the subordinates' trust in the leaders (Enwereuzor et al., 2020).
The current study aims to investigate how trust in leaders to handle COVID-19 prevention appropriately might affect the relationship between perceived communication transparency and selfreported adherence to COVID-19 safety guidance in hospital settings. We hypothesize that the relationship between perceived transparent communication and self-reported adherence to COVID-19 guidance will be impacted by the extent to which HCWs believe that leaders can prevent COVID-19 appropriately (see Figure 2).
We aim to explore whether H3. trust in leaders will mediate the association between perceived transparency of communication and self-reported adherence to COVID-19 safety guidance.

| Sequential effect of prototypical leadership and trust in leaders
In addition to the hypothesized mediating effects of prototypical leadership and trust in leaders, both mediators might have a sequential effect on self-reported adherence to COVID-19 guidance.
A large body of work has demonstrated that communication and cooperation among ingroup members is more effective and that members of the same group are trusted to a greater extent (Brewer, 2008;Greenaway et al., 2015;Tanis & Postmes, 2005).
Leaders that are prototypical for the group tend to gain greater influence and be more trusted (Bavel et al., 2020;Haslam & Platow, 2001). The pivotal role of leaders for worker safety in F I G U R E 2 Proposed sequential mediation model healthcare settings has repeatedly been identified by researchers (e.g., Agnew & Flin, 2014) and evidence shows a relationship between trust in leaders and safety compliance in healthcare settings (Enwereuzor et al., 2020;Newman et al., 2014).
The current study also proposes a sequential mediating effect of both prototypical leadership and trust in leaders on the relationship between perceived communication transparency and self-reported adherence to COVID-19 safety guidance (see Figure 2). We included risk perception of COVID-19 at the workplace as a control variable for the model to account for differences in HCWs perceived risk of transmission that may impact variables such as We also aim to explore whether H4. the relationship between perceived transparency of communication and self-reported adherence to COVID-19 safety guidance will be mediated a sequential effect of perceiving leaders as prototypical members of the team and trust in leaders to mitigate COVID-19 infections.

| Overview of the current study
Clear evidence exists on HCW-to-HCW transmission of COVID-19 as well as physical and practical barriers in hospital settings, yet less is known about the social psychological processes that may impact self-reported adherence to guidance. The SIA offers an established theoretical framework to explain the influence of group processes on the behavior of individuals and the role of leaders (Bavel et al., 2020).
The main objective of the current study is to promote the understanding of psychological processes that may cause barriers to following COVID-19 guidance or facilitate adherence to guidance. This study will be divided to cover two research areas. The first part of the study will focus on the association between HCWs social identity and risk perception of COVID-19 at the workplace, attempting to conceptually replicate findings from Cruwys, Greenaway, et al. (2021) and Cruwys, Stevens, et al. (2021) in a novel hospital context (H1). The second part explores how the perceived communication transparency of HCWs is associated with self-reported adherence to COVID-19 guidance and specifically the role of leadership (H2-H4).

| Ethics and open science
The study was approved by the host institution's ethics committee (reference 282-2021/6). A full list of items used in this study and the scripts containing the described analysis can be found on the open science framework (https://osf.io/txua4/?view_only=417ce60735 4048c8b270d16f84dec9d4).

| Procedure
All participants were HCWs at a hospital in Scotland and responded to a survey that was advertised via staff intranet, flyers, and snowball sampling by email between July 28 and August 13, 2021. HCWs were invited to participate in an online survey via the platform Qualtrics. After obtaining consent, participants were presented with items related to perceived communication transparency, followed by self-reported adherence to COVID-19 safety guidance, social identification as an HCW, trust that co-workers were following COVID-19 guidance, perceived risk of COVID-19 transmission from co-workers and perception that hospital leadership were prototypical members of the team. The survey took 5-10 min to complete. To ensure that participants paid attention when giving responses, an attention check was included halfway through the survey (''This is an attention check. Please select 'All of the time'"). No monetary reward was offered for participation, but participants did have the opportunity to leave their contact information in form of an email address to be included in a prize draw for multiple £50 evouchers.

| Demographics
Demographic questions on gender, age group, and participants' position at the hospital were included (see Table 1).

| Analytical strategy
The R programming language version 4.1.0 (R Core Team, 2021) was used for all analyses. Because items were adapted to the context of COVID-19 and HCWs, an exploratory factor analysis using ordinary least squares with oblimin rotation was carried out using the psych package version 2.1.6 (Revelle, 2021). Descriptive statistics, including correlations between variables were obtained. The Lavaan package version 0.6-9 (Rosseel, 2012)  provided the regressions between each variable, the direct effects, the simple mediations via each mediator, and respectively the sequential mediation via both mediators in the second model.
In the first model, the independent variable (X) was self-reported social identification as an HCW, the outcome variable (Y) was perceived risk of being infected with COVID-19 due to a co-worker, and the mediator (M) was trust in co-workers to follow the COVID-19 guidance. In the second model, the independent variable (X) was perceived communication transparency, the outcome variable (Y) was self-reported adherence to COVID-19 safety guidance, mediator 1 (M1) was perceived leadership as part of the team, and mediator 2 (M2) was perceived trust in leaders to manage COVID-19 prevention appropriately.
A Sobel test was conducted to assess significant mediation effects using the bda package version 1.8 (Wang, 2021).
An alpha level of α = .05 was used for all statistical tests. 3.2 | Factor analysis and descriptive statistics Model 1

| Factor analysis
To conduct an exploratory factor analysis for the constructs social identification, trust in co-workers, and risk perception when interacting with co-workers, the data were checked for their suitability for factor analysis. Linearity was checked through inspection of the linear and lowess lines for the pairwise relations of the variables and factorability was confirmed using a KMO test which yielded an overall KMO = 0.7 with no variable KMO < 0.50 as recommended by Field et al. (2012). Based on the examination of the scree plot and the results of a parallel analysis, the number of retained factors was established. The item factor loadings for social identification ranged from 0.49 to 0.73 and for risk perception when interacting with coworkers from 0.58 to 0.91. The factor loading showed that trust in co-workers did not map onto an own factor but cross-loaded on social identification as an HCW (see Supporting Information: Table 1).
However, trust in co-workers was treated as its own factor throughout analyses due to its conceptual difference from social identification.  The results are visualized in Figure 4. All regressions were statistically significant.

| Mediation analysis Model 1
The mediation analysis was conducted to investigate the hypothesis that the relationship between social identification and risk perception of COVID-19 transmission will be mediated by trust in co-workers (H1). Table 4 shows the total, direct and indirect effects for the mediation analysis. The results are visualized in Figure 3.

| Direct effects
There was a significant direct effect of social identification as an HCW on perceived risk that co-workers would transmit COVID-19 (β = −.548, p = .020, z = −2.330). Specifically, increased perception of social identity with co-workers was significantly associated with reduced perception that co-workers posed a risk of spreading COVID-19.

| Partial mediation via trust in co-workers
In line with H1, there was a significant indirect effect of social identification as an HCW on perceived risk that co-workers would 3.5 | Factor analysis and descriptive statistics Model 2

| Factor analysis
To conduct an exploratory factor analysis for the constructs communication transparency, perception of leaders as prototypical members of the team, trust in leaders, and self-reported adherence to safety guidance, the data were checked for their suitability for factor analysis. Linearity was checked through inspection of the linear and lowess lines for the pairwise relations of the variables and factorability was confirmed using a KMO test which yielded an overall KMO = 0.9 with no variable KMO < 0.50 as recommended by Field et al. (2012). Based on the examination of the scree plot and the results of a parallel analysis, the number of retained factors was  Table 5 shows the individual regressions between each of the variables in this analysis.
Risk perception when interacting with co-workers was added as a covariate to all regression analyses. Increased perception that coworkers could transmit COVID-19 was significantly associated with

| Mediation analysis Model 2
The mediation model evaluated whether perceived communication transparency would increase self-reported adherence to guidance via two sequential mediators whereby leadership as part of the team was entered as the first mediator and trust in leaders as the second. The total, direct, and indirect effects can be found in Table 6. The results are visualized in Figure 4.

| Direct effects
There was a significant direct effect of perceived communication transparency on self-reported adherence to guidance (β = 0.508, p < .001, z = 5.593). Specifically, increased perception of communication transparency was significantly associated with increased selfreported adherence to guidance.

| DISCUSSION
Outbreaks of COVID-19 in hospital settings and infections of HCWs frequently originate from contacts with colleagues . Appropriate safety measures (e.g., physical distancing) are essential to prevent transmission among staff members and social processes might play an important role in safety behavior. The current aimed to (a) evaluate how social identification as an HCW and trust in co-workers may influence perceived risk of COVID-19 spread and (b) explore how communication transparency, trust in leaders, and identity leadership are associated with self-reported adherence to COVID-19 safety guidance.

| Overview of the current findings
Results of the first part of the study show that hospital staff members who identified more strongly as HCWs were more likely to trust their co-workers, and thus, reported lower levels of perceived risk that coworkers could transmit COVID-19. The results confirmed our H1, showing that the association between social identification as an HCW and perceived risk of co-workers transmitting COVID-19 is mediated by trust in co-workers to follow COVID-19 guidance. These findings replicate the SIMORT of Cruwys, Greenaway, et al. (2021); Cruwys, Stevens, et al. (2021) (Lanz et al., 2020;Spalluto et al., 2020). In particular, the results of the direct paths of Model 2 also show the important relationship between communication strategies, trust in leadership to handle COVID-19 prevention effectively and seeing leaders as prototypical members of the team.
Findings on the association between leadership as part of the team and trust in leaders are in line with previous literature on identity leadership, where higher levels of reported leadership prototypicality predict higher trust in leaders Krug et al., 2021)

| Theoretical implications
Findings from the current study addresses the understanding of group processes, specifically trust in group members, which is important to model safety behavior related to the transmission of COVID-19 in hospital settings. Trust in co-workers is important for efficient delivery of healthcare (e.g., Marshall et al., 2013) and a facilitator for cooperation and solidarity in the context of COVID-19 . However, trust in co-workers may pose an unnoticed risk for HCWs as it might reduce their risk perception of COVID-19 spread and hence make HCW-to-HCW transmission more likely. These findings illustrate how a better understanding of group Previous research suggested that physical barriers (e.g., insufficient space, scheduled huddles) were reasons for nonadherence to COVID-19 guidance (Houghton et al., 2020;Keller et al., 2021). The current study did not assess these additional factors that may have

| CONCLUSION
The present study shows new developments in understanding the underlying processes of perceived risk of COVID-19 transmission and self-reported adherence to COVID-19 guidance. Results demonstrate that trust in co-workers to follow the COVID-19 safety guidance may mediate the relationship between social identification as an HCW and risk perception of co-workers spreading COVID-19 in a hospital setting. Furthermore, it highlights the importance of communication transparency on the relationship to adherence to COVID-19 safety guidance and suggests that higher perceptions of transparent communication may be associated with viewing leadership as part of the team, and trusting leaders to know how to handle COVID-19 prevention. The results replicate prior findings on the mediating effect of trust in members of the same group for risk perception (Cruwys, Greenaway, et al., 2021;Cruwys, Stevens, et al., 2021) and demonstrate that the SIA and its empirical evidence can be applied to the novel context of a hospital setting.
The reduction in perceived risk of COVID-19 transmission due to social identity processes emphasizes the relevance and ability to utilize this theoretical approach when investigating health-related behavioral processes. Future research should aim to evaluate the behavioral impacts of reduced risk perception and increased social identity processes for high-risk work environments during