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 Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd Working Across Professional Boundaries

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd The Riches of Healthcare Work Technological rich Multiple organisational and agency interfaces Complex division of labour State intervention

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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?

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd Work as a Social Activity Work has social meaning Individual and collective identity Distinctive occupational socialisation processes

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd Deprofessionalisation Changing professional-client relationships Loss of monopoly over health knowledge Loss of cultural authority (Haug)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd Sources of System Disturbance Technological change Organisational developments Different social values State intervention (Abbott 1988)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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).

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd Negotiating Work/Role Boundaries Boundary blurring Boundary maintenance Moral division of labour (who I am) Technical division of labour (what I do)

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd Boundary Maintenance Boundary-work (Gieryn) Symbols Actions Texts Talk

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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?

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd More….. The loss of medicines 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?

Cardiff School of Nursing and Midwifery Studies Ysgol Astudiaethau Nyrsio a Bydwreigiaeth Caerdydd 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?