Professionalism - Healthcare

Chapter 1 highlighted the idea that whilst the attainment of competencies is necessary, employability is also reliant on an individual’s capacity for self-awareness. The ability to reflect well on one’s own values and performance is paramount. Chapter 2 also stressed the importance of understanding one’s values and the ways in which they ‘fit’ with a career path. Chapter 2 and the associated exercises are aimed at helping you to understand who you are. One of the roles you play in life is as a professional person. This chapter will now help to unravel what that means and what the associated responsibilities are. Through having a broader understanding of the concept, you will be better equipped to reflect on your own level of professionalism.
Before we can go on to describe professionalism though, we need to understand what the term ‘profession’ means.

What is a profession?
Writers have been debating the meaning of the noun ‘profession’ since the early part of last century. Partly this is because it is a socially constructed concept: that is, it only exists because human beings have created it and talked about it, valued it and used it as a measure to judge people. It is a symbolic thing and an important one but it is constantly evolving and, like the proverbial jellyfish, it is very difficult to pin on a wall. After much academic debate and argument, in 2004 Cruess, Johnston and Cruess generated a working definition to assist medical educators in their teaching of professionalism. It is a very good place to start:
Profession: An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.Cruess, Johnston and Cruess, 2004, p. 75
Let us see if we can tease this out a bit more by looking at individual terms. Firstly, ‘social contract’.What is meant by a ‘social contract’
For those professions in the public sector a relationship of mutual dependence has developed between them and the state that employs them. Members of a profession are committed to integrity and are expected to abide by a public service ethic. The state needs professions it can trust to fulfil its social welfare commitments and the professions need the state to allow them an exclusive right to work for it. Professions won this right by persuading the state that competence and trustworthiness could be guaranteed through arduous educational programmes and strong regulatory processes (Wilding, 1982; Freidson, 1994). Under these circumstances the state is prepared to sanction the names of individuals who are certified with the appropriate qualification to appear on an official register: hence, only registered health practitioners can work in the NHS. In return, the state grants the profession a monopoly over the use of its knowledge base, the right to autonomy in practice, the privilege of self-regulation and financial reward (Stevens, 2001; Cruess, Johnston and Cruess, 2004). Under the terms of this contract any deviance from ethical behaviour must be stringently disciplined.Why is a ‘complex body of knowledge and skills’ important?

For this we need to look back at history. Skilled expertise and knowledge-based services became significant to society following the Neolithic Revolution (very early history!). When settled agriculture developed and the struggle for survival became more organised, knowledge was unified, which created the opportunity for the cultures of arts and sciences to emerge. Organised religion, philosophy, mathematics, astronomy, medicine and law all began to evolve (Perkin, 1996). The Renaissance (early fifteenth century), the Reformation (early sixteenth century) and the Enlightenment (early seventeenth century) all allowed independent thinkers and innovators to flourish in Europe (Macdonald, 1995; Perkin, 1996). Polyani (1957) called this ‘the great transformation’. Knowledge became a source of power, which was then used by occupations to advance their status. For example, in medieval times, law, medicine and the ministry, the classical professions, were under the tutelage of the Church but they were only accessible to a chosen few whose knowledge base was both shrouded in mystery and considered esoteric. Between the eleventh and thirteenth centuries these professions had a closer association with universities (Oxford and Cambridge), where knowledge of Latin distinguished them as ‘learned’ and still gave them an association with elite society. It was an education based on classical culture rather than practical skill, however (Larson, 1977). Doctors were highly educated and esteemed in society but were very limited in their ability to treat patients effectively (think of purging and leeches). In contrast, people such as tradesmen, scriveners, spectacle makers, apothecaries and barber–surgeons, were associated with and managed by, craft guilds. Their skills were acquired through an apprenticeship with a master (this is where the term ‘mastery’ comes from). They were very skilled and gradually became respected as society realised the value of their expertise. Thus, Larson (1977) concluded, work could be used to define the place of an individual on a social scale that measured the esteem with which the public held an occupation.

The Industrial Revolution of the eighteenth century onwards introduced enormous changes to the way that people lived. Inventive developments such as piped water, gas and electricity and so on needed to be supplied by people with specific knowledge. A free market had been created and occupations, from engineers to quantity surveyors, proliferated (Perkin, 1996). Freidson (1984) was of the opinion that many people have the ability to learn all of these skills but there is insufficient time in one person’s lifetime to undergo the training necessary to learn and sustain competence in every type of skill necessary. Therefore, unless someone lived a very simple life indeed, reliance on the expertise of others had to be established.

This provided the opportunity for groups to improve their status. Larson (1984) outlined the way in which professional leaders realised the importance of knowledge as a form of power and set out to build an ideology of expertise in a defined skill based on the traditional ethic of craftsmanship, emphasising the intrinsic value of work and an ethic of community, emphasising duty. For example, from the sixteenth century, the Royal College of Physicians had monopolised license to practice medicine in London but, elsewhere, medical practitioners from the lower branches, such as apothecaries, were increasingly able to demonstrate that their knowledge of the safe use of drugs was far superior to that of the classically educated doctors. By the eighteenth century, although they had not matched the position of physicians, apothecaries were recognised as genuine medical practitioners and their status had risen. In this way, apothecaries became pharmacists, spectacle makers became optometrists and barbers became surgeons (Larson, 1977). The more closely the knowledge base of emerging professions could be associated with science (emphasising the complex nature of the skill), the better. These developments meant that expertise became a commodity for new professions to use in the employment market (Larson, 1984). For health professions it became necessary to convince the state that they were experts whose competence was superior to others in order to establish a secure footing in NHS employment (Larson, 1984). Although this remains the case today, it is now also recognised that scientific knowledge needs to be applied to unique and complex human problems. There are elements of professional knowledge that cannot be standardised and which must be applied using judgement and artistic interpretation (Schon, 1983): hence, Cruess, Johnston and Cruess’ (2004) inclusion of the phrase ‘practice of an art’ in their definition.Is vocation still relevant to today’s professionals?

The vocational element of being a health professional also has an historical importance. Before the 1930s, virtually all writers on the topic thought that professionalism offered a way of life morally superior to the world of business (Haskell, 1984). It had been assumed that a professional would always act in the best interests of the client, put self-interest aside and provide the highest standard of service (Johnson, 1972). The ideology of specialised knowledge, public service and permanent dedication was considered attractive to people who anchored their identity on such values and, by implication, would be more likely to prove trustworthy in putting the client’s interest before their own (Freidson, 1994; Evetts, 2003). It also conveyed the idea that work could have intrinsic value. Finding fulfilment through work is a notion that stems from craftsmanship rather than business ideals. It was in contrast to the norm for the working classes during the industrial revolution, when any work, no matter how unpleasant, was undertaken to avoid starvation, and, therefore, the value was extrinsic (Larson, 1977).
‘Vocation’ was closely linked with a service ideal, providing it with a religious association. At its most extreme the Florence Nightingale image epitomised the moral pinnacle that must be reached. Traditionally, for example, a nurse:
Must have quelled any desire to enjoy any life which might impinge upon her life as a nurse.(Alavi and Cattoni, 1995, p. 345).

Today this seems quite extraordinary to ask of anyone.

Subsequently, attention has focused on the idea that, in reality, professionals are just as motivated by self-interest as any other group but the rewards are other forms of ‘self-aggrandisement’ (status and reputation, for example) rather than financial (Larson, 1977; Haskell, 1984). The image of the selfless professional lingers to a degree (perhaps it is a hope rather than an expectation) but modern reactions to it have been damaged (Freidson, 1994). Governments since the 1980s have questioned the motives behind professional protestations of a service ideal (Foster and Wilding, 2000) whilst Nixon (2003) has reported that since Margaret Thatcher introduced market-driven policies, with a model of private sector managerial professionalism, society has lost sight of the public service ethic.
However, it is also argued that the pursuit of self-interest is not necessarily the antithesis of public interest if it drives the achievement of personal excellence (Haskell, 1984; Evetts, 2003). Since the 1990s there have been calls for a reassessment of the ideals of professionalism to accommodate the changes in the way that professions are organised (Evetts, 2003; Jones and Green, 2006). A study of early-career general practitioners (GPs), for example, revealed that the traditional view of medicine as a vocation, in which a GP would have a therapeutic relationship with a patient from the point of registration until retirement and that they would never be off duty, had been discarded (Jones and Green, 2006). The replacement is a view that medicine is a job with high intrinsic value and that it is important to retain a good work–life balance. Rather than commitment and status in the community, the important moral values now concern the quality of the work undertaken. The implication is that it is more reasonable to expect high-performing excellence from a GP who is able to have a quality home life than from someone who is burnt out from continuous work (Jones and Green, 2006). It is becoming more common for health professionals to expect a right to a private life (Ross et al., 2013).
 Another study of nursing students also found that the 24 hour per day on-call service had been discarded but there had been benefits in terms of improved person-centred care and more honest communication, so that patients were no longer hidden from the truth about their prognosis, for example (Johnson, Haigh, and Yates-Bolton, 2007). The notions of vocation and altruism are now regarded in a more pragmatic way. Rather than being seen as a detrimental change, the view is that enhanced quality of care is more likely to occur when the expectation of 100% devotion to duty is confined to work hours.