cardiff school of nursing and midwifery studies ysgol astudiaethau nyrsio a bydwreigiaeth caerdydd...

Cardiff School of Nursing and Midwifery Studies

Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd

Centre for Social Research in Health and Health Care, Sociology of Health

and Illness Foundation Seminar



Working Across Professional Boundaries



The Riches of Healthcare Work

• Technological rich

• Multiple organisational and agency interfaces

• Complex division of labour

• State intervention



Division of Labour

• System orientation

• Connections and inter-relations

• Work and workers

• How is work organised in a given historical/social context?

• What is the basis for the bundle of tasks aligned with particular occupations?



Work as a Social Activity

• Work has social meaning

• Individual and collective identity

• Distinctive occupational socialisation processes



Professional Dominance

• The medical profession is dominant and key point of reference for all other groups

• All other workers are paramedical professions

• Paramedical professions stand in an ambiguous relationship to medicine

(Freidson 1970)



Professionalisation

Traits of a Profession• skill based on exclusive body

of theoretical knowledge• an extensive period of

education• public service and altruism• a code of ethics• professional self-regulation• testing of competence of

members for admission to the professions

Uses and abuses of professionalisation

• Alerts us to the aspirations of occupational groups

But…

• assumes a linear path of development

• encourages a focus on individual professions, when the professions’ fates are interdependent



Proletarianisation

• The logic of capitalist development leads to all workers (including professions) being absorbed into the mass of workers

• Professions incorporated into factory-like production processes

• Progressive loss of autonomy and skills

(McKinlay)



Deprofessionalisation

• Changing professional-client relationships

• Loss of monopoly over health knowledge

• Loss of cultural authority

(Haug)



The System of Professions

1. System of professions 2. Larger social forces – social, political and

technological - generate new areas of work and destroy old ones

3. Differentiation within individual professions – generate and absorb system disturbances

(Abbott 1988)



Jurisdiction

• Each profession is bound to a task area by jurisdictional ties

• Professions are distinctive because of the role of abstract knowledge in creating ties of jurisdiction

• Abstraction = process through which tasks become constructed into professional problems

• Jurisdictional claims are made in Public, Legal and Workplace arena

(Abbott 1988)



Jurisdictional Settlements

• Full jurisdiction• Subordination of one profession to another• Retention of intellectual jurisdiction• Splitting of a jurisdiction into two interdependent

parts• One profession retains an advisory control over

certain aspects of the work• Division of labour not according to the content

of the work, but according to the nature of the client

(Abbott 1988)



Sources of System Disturbance

• Technological change

• Organisational developments

• Different social values

• State intervention

(Abbott 1988)



Intra-professional Differentiation

• Status• Client• Work organization• Career patterns

“Were there only one professional status, workplace, and client type in a given profession, any shift in these actualities would at once become publicly evident. But since there are many varieties of each, great changes can occur in their relative importance without forcing any great shift in the public image of professional life”.

(Abbott 1988)



Division of Labour as Social Interaction

…it seems accurate to see the division of labor as a process of social interaction in the course of which the participants are continuously engaged in attempting to define, establish, maintain and renew the tasks they perform and the relationship with others which their tasks pre-suppose.

(Freidson 1976: 311).



Negotiating Work/Role Boundaries

• Boundary blurring

• Boundary maintenance

• Moral division of labour (who I am)

• Technical division of labour (what I do)



Boundary Blurring

• Strain towards blurring of technical division of labour

• Negotiation, routine and custom which embed situation-specific jurisdictions

• Workplace assimilation

• Intra-organisational division of labour replaces an inter-professional one



Boundary Maintenance

• Boundary-work (Gieryn)

• Symbols

• Actions

• Texts

• Talk



Summary

• Division of Labour• Social meaning of

work• Professional

Dominance• Professionalisation• Deprofessionalisation• Proletarianisation

• System of Professions

• Boundary Blurring• Boundary

Maintenance• Technical/Moral

Division of Labour• Boundary Work



Food for thought….

• If our concern is with safe prescribing across professional boundaries, what kind of boundaries are we referring to?

• Is the issue that of working across professional boundaries or about the salience of boundary construction in the context of new ways of working?

• Where are the primary sites of boundary construction and what are the consequences for work organisation and patient safety?



More…..

• The loss of medicine’s monopoly over prescribing has created important shifts in the technical division of labour, but is this sufficient to change the moral division of labour in health care?

• Can we consider the implications of non-medical prescribing for professionalism in isolation from the multiple external social forces which are currently shaping healthcare work?



And finally…..

• What would the world of healthcare work look like if we turned away from professions for one moment and considered the occupational niches which are emerging?

• To what extent would we see an intra-organisational division of labour replacing an inter-professional one?

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