Professionalization and Expertise in Care Work: the Hoarding and Discarding of Tasks In

Nurse Professionalization and the Assistant Role

PROFESSIONALIZATION AND EXPERTISE IN CARE WORK: THE HOARDING AND DISCARDING OF TASKS IN NURSING

Abstract

Although health and social care workforces are heavily professionalised, the mainstream human resource management literature has been slow to engage with debates in the field of organizational studies on this distinctive group of employees. This lacunais addressed by focusing onhow the search for more flexible working practicesin care services has impacted on the professions and especially on their relationship with their assistant co-workers. The character of this relationship isseen as contingent on the logic of professionalization, in turn based upon differentnotions of expertise, with implications for the allocation of tasks. The article distinguishes between a specialist expertise, encouraging the profession to discardroutine tasks, and a holistic expertise, nurturing the hoarding of tasks. This distinction is used to explore the nurse professional project in Britain,a critical case where the statutory regulation of the nursing workforce has remained relatively weak. Whilenoting shiftsover the years in the British nursing professions’ adherence to these two logics, workplacedata on the nurse-healthcare assistant relationship reveal a fragmented pattern of nursing work consistent with a specialist-discard logic, albeit underpinned by a residualambiguity amongst nurses about their preferred professional logic.

Keywords: Professionalization; Nursing; Assistant Role, Britain.

Introduction

It is difficult to examineapproaches to human resource management (HRM) in health and other care services without devoting considerable attention to the professional component of the workforce (Gittell et al, 2008). Professionals comprise a significant proportion of care workforces, reflected not least in the acute healthcare setting where a large majority of employees is drawn from the medical, nursing and allied health professions. Yet while there is a well developed organizational studies literature on the care professions (for summary see Muzio et al, 2013), mainstream HRM has devoted relatively limited attention to this distinctive group of employees.

The relative neglect is all the more noteworthy given recent attempts by governments in many developed countries to reform the delivery of their public services, placing the status and role of the care professional under pressure. In the eighties and nineties, reforming efforts were often tied to the principlesof new public management (NPM) (Hood, 1991) which in championing ‘customer sovereignty’ in the public services,challenged‘producer capture’, mainly seen toreside in the power of the professional.The‘marketization’ of public services provided a vehicle for this challenge, creatingopportunities for the exercise of ‘user choice’ whichweakenedcustodial forms of management founded upon professional authority and discretion (Ackroyd et al, 1989; Kitchener et al, 2000).

The prevalence of this management paradigm was reflected in an influential prescriptive rhetoric emanating from the OECD (1995), a ‘prominent global advocate for the new public management’(Pal, 2007).This rhetoric belied theunevenimplementation of new public management practices (Pollitt, and Bouckaert, 2011),but countriessuch as Britain and New Zealand, embraced such an approach, seeking to introducea range of related practices. These typically included thestrengthening of ageneral management cadreacross the public services, establishing anewauthoritative source of decision making alongside the professional, with considerable influenceover target-driven organizational performance (Power, 1997).

Despite theassault on the professions during these years (Alaszewski and Mathorpe, 1990), there wasmuch debate onits consequences for the care professions. Some argued that theprofessions welcomed these public service reformsas providing them with greater scope for entrepreneurial activity and the opportunity to develop hybrid roles which combinedtraditional expertise with a new managerial authority (Exworthy and Halford, 1999; Ferlie and Geraht, 2005). Others suggested that the care professions had fared more unevenly, with some vulnerable to pressure for change and less able to resist it (Kirkpatrick et al, 2005).

More recently, OECD governments in further developing their public service reform agendashave recognised the resilience of the care professions and adopted a more nuancedapproach to their management (OECD, 2010). While continuing toprivilege the users’ voice (Clarke et al, 2007), the essential role of the professional in giving effect to changes in care delivery has been acknowledged, not least reflected in enhanced state sponsored rewardsfor involvement in the ‘modernization’ process (Bach and Kessler, 2012:101-104). These rewards have, however, often come with a reciprocal obligation on the part of the professions to adopt a looser approach to the organisation of work. User-centred public services have prompted the search formore flexible forms of working, challenging the professionals’ prerogative to perform certain, traditionally protected tasks.

This articleexplores how nurses in acute healthcare have come to view and deal with the re-calibration of tasks between themselves and healthcare assistants, particularly in the context of their ongoing attempts to professionalize.In doing so, the article focuses on Britain as a critical case. With the distribution of nursing tasks relatively weakly regulated,nurses in Britain have beenpresented with an unusual range of options on how to pursue theirprofessionalization project, raising a number of research questions: What options have British nurseschosen in seeking to professionalize? How have these choices affectedthe distribution of nursing tasks and theirviews of healthcare assistants in this context?How have the choices impacted on nurses’ working lives and particularly on their engagement with healthcare assistants at ward level?

The article argues that nurse views on and engagement with healthcare assistants are contingent on the underpinning rationale for or logic of professionalization,this logic, in turn, beingrelated to different conceptions of expertise and their implications for task performance. In Britain, nurse uncertainty over the choice of logic in pursuit of professional status is seen to leadto a residual ambiguity about how they view and relate to healthcare assistants. In advancing this argument, the articlenot only seeks to deepenunderstanding of the professionalization project amongsta key group care workers, nurses, but in broader terms to sharpenanalysis of similar projects across the range of care occupations, not least in terms of clarifying the positioning of the assistant role within them.

The article is divided into the following parts: the first explores how the relationship between the assistant and the professional has been dealt with in the research literature; the second focuses on the assistant role in healthcare and how it has been positioned within the nurse professional project; the third articulates the research questions and approach; the fourth presents the findings; and thefinal sectionsprovide a discussion and a conclusion.

Professional Logics and Positioning the Assistant

The distribution of tasks and responsibilities has long been at the centre of the research literature on professionalization.Viewing professional projects as thecompetitive and power-driven pursuit of labour market status and reward by self interested occupations (Larson, 1977), this literature was initially inclined to emphasiseeconomic and social closure,the former restingon control over the performance ofparticular tasks, the latter onthe search fora broader cultural legitimacy over the exercise of such control (Parkin, 1971; Weber, 1978). Abbott (1988) deepened this interest in the nature of professional work, highlighting the fragility ofclosure andthe instability ofoccupational boundaries designed to protect it. Abbott articulated various bases for jurisdictional claims, in the form of a right to perform broadly definedexpert tasks, often contested and leading to a range of settlements. Indeed, more recently, neo-institutional theoristshave been drawn to theunstable, dynamic, task-centrednature of professional projects (Muzio et al, 2013). The notion of institutional work (Lawrence and Suddaby, 2006) has been used to explore how occupations mobilize a diversity of techniques to ‘disrupt, create and maintain’ the distribution of tasks and responsibilities as occupations seek to preserve their professional status (Kitchener and Mertz, 2010; Currie et al, 2012).

Despite this increasingresearch focus on the nature of professional work, there remains a need for greater conceptual and analytical precisionin exploringapproaches to the allocation and performance of tasks adopted by occupations in pursuit of their professional project. The literature hasoften been predicated on the assumption that full closure over expert tasks is the most assured and therefore the ‘preferred’ route to professional status.The professions havetypically been presented as voracious and predatory, keen to acquire and retain tasks as the basis for this expertise. As Suddaby and Viale (2011:431) note, professions ‘further their projects by expanding their knowledge base and their jurisdiction’.

Suchassumptions, however, begquestions about the nature of professional expertise and the tasks to be retained in establishing it. While definitions of a profession have usually included reference to expertise(Abbott,1988) therationale for such expertise in advancing claims to professional status might be seen to have assumed different, arguably mutually exclusive, forms. In general terms, two such rationales, or what might be labelled professional logics, can be found within the literature, with contrasting implications for the divisions of tasks and responsibilities, and, more specifically, for how the profession views adjacent occupational groups such as assistants or support workers.

The firstprofessional logic rests on specialist expertise. It is reflected in Hwang and Powell’s (2009:268) assertion that ‘The occupational category of professional has historically referred to individuals who derive legitimacy and authority from their formal education and claims to specialist expertise.’ It is a logic which sharpens and narrows the professional project by basingit on the exclusive right to perform a tightly defined setof advanced technical tasks.Such a logic centres not on the crude acquisition and retention of tasks, but on a more selective approach rooted in the performance of those tasks which sustain claims to specialist expertise. It implies that tasks which weaken such claims need to be discarded, withany assistant role becoming a convenient depository forthem.

Thislogic has been particularly to the fore inthe literature on the professions.Abbott(1988:72) stresses the importance of professionals passingon ‘dangerously routine work’to assistants. Similarly Hughes (1993:307),more specifically referring to the healthcare sector,notesthat ‘Nurses, as they successfully rise to professional standing, are delegating the more lowly of their traditional tasks to aides and maids.’This discard approach is summed up by Kirkpatrick et al (2011: 492) who, in drawing upon Larkin’s (1983)notion of occupational imperialism,statethat ‘professions seek to advance their aims through the acquisition of high status roles and skills, while at the same time delegating less desirable tasks to subordinate groups.’ Arguably such an approach equates less to ‘imperialism’ than to a ‘scorched earth’ policy, with tasks not only acquired but readily cast-off if and when they weaken the professions’ standing as a specialist expert.

The second professional logic is based on what might be termedholistic expertise, the capacity for an occupation to undertake the full range of tasks needed to provide care. In such circumstances rather than discarding tasks, it becomes imperative for the profession to hoard them. Abbott’s and Hughes’ discard approach assumes an agreedcore of specialist professional tasks protected from dilution by the mundane. A hoarding approach implies that locating sucha core might well be problematic.In noting the ubiquity of segments within any given profession, Bucher Strauss (1961:328) haveargued that ‘members of a professionnot only weigh auxiliary activities differently but have different conceptions of what constitute the core – the most characteristic professional act – of their professional lives.’

Alongside difficulties in locating a professions’ core,there might well be risks to a profession in discarding tasks. Holistic expertise restson the view that an occupation is uniquely placed to deliver a servicein ‘the round’.By retaining the full range of tasks from the routine to the more technically sophisticated, the occupation acquires independence and a distinctive capacity to address the service users’ needs in a full and integrated way. It follows that any attempt to pass on the ‘dangerously routine’ fragmentsservice delivery, undermining the very holism which gave the occupation a distinctive claim to labour market privilege in the first place. In such circumstances, theassistant taking on tasks, however routine, becomesa challenge to the profession, a threat to the provision of a holistic service.

The importance of these claims to holistic care is often implicit in debates on the de-skilling of public service professions, seen as arising where the discretion to perform certain tasks is undermined by managerial systemswhich seek efficiency and employer control through the division of labour (Harris, 1988).The difficulties faced by a care profession in discarding tasks are further highlighted by Freidson (1970:66), who notesthat nurses in the US were presented with serious challenges in moving away from the delivery of holistic bedside care to administrative forms of work: ‘The curious dilemma of nursing is that it may be seen to be forsaking the tasks distinctive to it in order to change its position in the paramedical division of labour.’ Stevenson (2007) makes a similar point in arguing that the provision made in a recent national union-employer agreement to re-distribute‘non-essential’ tasks from teachers to teaching assistants in British primary and secondary education risked weakening teacher claims to meet the full learning needs of pupils.

These two professional logics – specialist- discard and holistic-hoard- with differentimplications for the role of the assistant, inevitably raise questions related to their adoption and pursuit, considered in the next section by reference to the nursing profession.

Nurse Professionalization

A Divided Profession

The nurse profession in many developed countries might be characterised as a ‘divided self’ in relation to its preferred approach to professionalization. Modern nursing philosophy and practice have longcontained elements embracingbothprofessional logics. This has lentthe nurse professional project an uncertain and contested quality, apparent in debates within the professionas to the preferred means of advancing its occupational interests and more tangibly in different national settlements on the regulation of the nursing workforce.

The two logics have been articulated and conceptualized in different ways within the literature on nursing, with some scholars concentratingon the nature of the expertise- that is the specialist or holistic dimension- and others on the distribution of tasks- the discard or hoard dimension. The specialist-holistic dimension has been particularly to the forein debates on the relative merits of task- and patient-centred nursing. Task-centred, sometimesreferred to as functional, nursing is conceived asa narrow,specialist approach to care delivery. As Adams et al (1998: 1213) note: ‘Functional nursing is oriented to completing tasks. Care is conceived as being a series of distinctive tasks which are best accomplished by nurses with given skills specialising in, or completing, the same task for each patient.’In contrast patient centrednursingviews tasks as best delivered in an integrated and holistic way. Pontin (1999: 584) describes such an approach as ‘including the following concepts: the patient as a whole person with individual differences; tailored care to meet individual needs; and holism as an organizing principle.’ Indeed a patient-centred approach findsfurther expression in primary nursing (Manthey, 1980), a style which rests on the total care of any one patient being the responsibility of a single nurse.

Debate on the discard-hoard dimension,related to distribution of nursing tasks, has often been more preoccupied with the nurse-doctor than the nurse-HCA interface (Dent, 2008). This reflects aninterest amongst feminist theoristsin the patriarchalnature of relations between thenurse and medical professions seen as constraining the nurse professional project (Witz, 1992). An exception is Thornley’s (1996) articulation of ideal workforce types, which explicitly revolve around the relationship between nurses and HCAs.Her‘professional model’, based on task closure by nurses,envisages limited, ifany, HCA involvement in nursing,and closely aligns to thehoard approach. The‘traditional model’ rooted in the more flexible performance of tasks, acknowledges extensive HCA engagement in nursing, and broadlycorresponds tothediscard approach.

Whether, how and with what consequences the tension between a nurse professional project based on a specialist-discard or a holistic-hoard logic plays itself out, varies by country (European Commission, 2000). Such variation has been closely related to the national regulation of the nursing workforce, institutionalizing different approaches to the occupational division of nursing tasks. Thus, the scope to discard tasks is crucially dependent on the availability of an adjacent occupation, such as the assistant, to act as a depository, and on the scope to transfer tasks to it in a relatively unfettered way. In some countries, such as Japan (Sawada, 1997), healthcare assistant roles have remained undeveloped. Nurses have secured extensive closure and the holistic-hoard approach has become institutionalized. More typically, different tiers ofnursing have emerged, in some countries,such as Britain, based on a simple registered nurse-assistant dichotomy, in others,such as the US (US Bureau of Labor Statistics, 2011)and Germany (European Commission, 2000), with this dichotomy mediated by a third tier of accredited nursing staff. In countries with thesetwo or three tiers,a distinction can be drawn between tightlyand loosely regulated nursing workforces. Where regulation is tight,all tiers of nursing, including the assistant tier, are controlled through registration or licensing, so ordering the distribution of tasks. Where regulation is looser,the lower tiers of nursing, in particular the assistant tier, are not controlledby mandatory forms of accreditation, facilitating a more flexible distribution of tasks.

The British nursing workforce falls within this latter, loosely regulated category. It is the category which presents the most searching questions for the nursing profession in terms of its preferred professionalizing logic. The aspiration of full closure based on holism-hoard, remains, but a viable alternative route to professional status grounded ina specialist-discard logicopens up, given the ubiquitous presence of assistants and the limited constraints on the delegation of nursing tasks to them. The availability of this choice of logics has been manifest in ongoing debate, uncertainty and oscillation within British nursingover the last century.