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The Plasticity of Professional Boundaries
A case study of collaborative care in maternity services
Karen Lane
Deakin University
Abstract
A case study of twenty-nine midwives and nine obstetricians working in a regional, public sector Australian hospital demonstrates the plasticity of professional boundaries within a post-welfare state.
Driven by new discourses of globalisation, marketisation, managerialism and consumerism, professional boundaries in health care are being blurred, reordered and reconstituted. Government policies that call for a new interdisciplinarity between maternity professionals may be seen as responses to the above pressures.
However, there remain considerable barriers to achieving collaborative models including conflicting interpretations of risk, of women's bodies and of childbirth; the veto power of decision-making retained by obstetricians; questions of professional accountability; and diversity over appropriate styles of micro-interaction.
Collaboration demands a new egalitarianism to eclipse the old vertical system of obstetric dominance and this means that midwives need to create a distinctive professional specialty, or new object of knowledge. Midwives' skill in 'emotion management' could provide this speciality in addition to their rational-technical knowledge and thus elevate midwifery to an equivalent professional status with obstetrics but as yet neither obstetrics nor midwifery have realised its professionalising potential.
Keywords
sociology, childbirth, professional boundaries, 'emotion management', emotional labour, gendered discourses of knowledge
Article Text
Globalisation, 'reflexive modernisation', a growing awareness, real or otherwise, of contextual risk and recruitment crises in some professions have prompted neo-liberal post-welfare states (eg Australia, Canada and the UK) to apply new mechanisms of corporate governance to the public sector (Giddens 1990, Beck 1992, Dent and Whitehead 2002). These mechanisms or discourses, known broadly as marketisation, managerialism and consumerism, have posed challenges to the existing boundaries of many professions, including the health professions, by calling for new interdisciplinary, collaborative practices. The disruption to market privileges enjoyed by elite professional groups as a result of these discourses has revealed that professional boundaries are not natural enclaves organised around a specific object of knowledge (positivist knowledge or knowledge as 'a given'). Rather, they are contested spheres of practice - cultural artefacts produced by a 'labour of division' (Fournier 2000). This paper reports on the responses of professional workers within an Australian maternity unit to the challenges of collaborative care. Boundaries are simultaneously being blurred, fortified and renegotiated around conflicting interpretations of 'risk', the veto power of decision-making retained by obstetricians, who will be professionally accountable for adverse outcomes and how best to manage microinteractions with consumers. I argue that the exemplary skill of midwives in 'emotion management' (Bolton 2002, Hoschchild 1983) in addition to their rational-technico knowledge represents a potential to disrupt old boundaries and to facilitate realignment between midwives and obstetricians along more egalitarian lines. However, responses by midwives and providers to these opportunities remain the lynchpin to the full transformation of the old professional boundaries.
The 'cultural work' of boundary maintenance
Abbott (1988) discusses the 'cultural work' that actively maintains separate professional spheres and shores up the boundaries of the dominant group. Representing knowledge as a series of abstractions defying codification, standardisation or popularisation is a common device in this usurpation of power as are practices like claiming a public service ethos over pecuniary self-interest and labelling competitor groups as amateurs or 'snake oil merchants'. Such strategies stigmatize the 'other' and simultaneously create a sense of anxiety and fear in the public. With marketisation of public sector agencies, multidisciplinarity has become a key strategy in rationalising resources and delivering services. As the utility of old professional boundaries have been questioned, so the basis of the professions has come under fire. Rather than being seen as derived from an organic division of labour around a special skill or 'natural' object of knowledge, professions and professional boundaries are seen to be culturally created through a 'labour of division' (Fournier 2000).
Marketisation, the 'audit society' and the post-welfare state
Professional boundaries existed as unremarkable jurisdictions so long as governments approved of such protective mechanisms. Since the 1960s and in the wake of globalisation, however, professions have been challenged by the new discourses of globalisation, marketisation, managerialism and consumerism. Although pervasive among Western nation states, the precise formulation of these discourses is contingent upon local political, social, cultural and economic factors (Ball and Malik 1998). Australia has been particularly jolted by globalisation due to its marginal position in relation to European, US and Asian economic power blocs and trade agreements. From 1996 onwards with the election of the Howard Liberal government, market reforms in Australia were informed by a minimalist and managerialist ideology. This approach emphasised 'steering at a distance' via various disciplinary technologies (such as policy directives, competitive contracts and accountability measures) to achieve market efficiencies rather than strategies that would combine efficiencies with social equities. A key strategy has been to encourage competition between public sector agencies, such as those in the hospital, school and university sectors (Blackmore and Sachs 2006).
The 'audit society' (Power 1999:53) or the 'evaluative state' (Neave 1988) is symptomatic of marketisation, that is, the extrapolation of market logic to governance of public sector agencies, such as hospitals. The 'audit society' refers to a culture 'engaged in constant checking and verification ... in which a particular style of formalized accountability is the ruling principle' (Power 1999). It involves regulation of both private and public sectors and works not by direct controls but indirectly by appealing to the 'incentive structures of regulatees and for effective structures of voluntary self-regulation' (Rose and Miller 1992). In its political ramifications Giddens (1990) refers to this as the 'disembedding of social relations' in late modernity. It means that authority relations tend to disintegrate if they represent anachronistic barriers to market efficiencies. Within maternity services in Australia, more recent economic rationalisations were built upon a system of health care that had cemented medical dominance since the 1950s via commonwealth support for private health insurance and direct reimbursement of 85% of private fee costs. This system of public/private funding for medical and hospital care within a federal system of government was not seriously dented by the neoliberal reforms of more recent times and positively benefited private obstetricians and privately-insured women (see Reiger 2006 this issue). This is not to say, however, that professional privileges remained unscathed by encroaching market efficiencies especially in relation to public sector maternity services, as the present study revealed.
The incessant push of auditing under marketisation incidentally uncovered the historically contingent nature of professional knowledge. That is, the market privilege long enjoyed by the professions had been secured by reference to a specialized body of formal knowledge with associated skills and techniques (Friedson 2001). Weber (1987) argued that this 'incommensurability' characteristic of the professions, the features that distinguished them from other specialised occupations and quarantined them from market competition, was maintained primarily by defensive political strategies. State regulation has been the most significant instrument in guaranteeing to elite professional groups (such as obstetricians) the political power to exclude other groups and to protect their own members via the formation of boundaries or exclusive jurisdictions. Political power came first from which sprang the creation of specialised skills and the object of knowledge. This then became the instrument to exclude others, to justify their market privileges and rationalise their elevated social status (Friedson 2001). But as Foucault has argued, the professions were constituted, not through an organic evolution of groups possessing already-constituted specialised skills and knowledge, but as a series of independent fields as a result of social, historical and economic contingencies (Foucault 1975, 1977, 1980). Far from being a 'given', knowledge can be revealed as dependent upon and constituted by the 'professional gaze' (Foucault 1975). As Fournier (2000:180) argues, professional knowledge is really:
...performative and malleable, as an achievement ... rather than as a discovery and reflection of the 'true nature' of some independent reality [and] suggests the possibility for the professions to reconstitute their field and knowledge in line with the version(s) of reality popularised by recent discourses celebrating the value of the market and enterprise.
Marketisation has exposed the formation of the professions in the 19th and 20th centuries as historically contingent fields that produced a given object of knowledge. Although I have argued that the audit society constitutes an intensification of surveillance, other discourses around marketisation, managerialism and consumerism have weakened the old boundaries supporting elite professionals especially in relation to cost-savings. A parallel example is evidenced in the case of higher education. Universities no longer constitute the authoritative voice in what is defined as knowledge. Privately-funded research centres outside universities and newly established commercial arms within them now compete with established faculties and disciplines to determine a new hierarchy in the objects of knowledge (Blackmore and Sachs 2006). Under these circumstances of openly contested spheres of knowledge construction we could expect to find conflicts, challenges and rivalries at the interactional level around the 'ownership' of tasks and skill-sets. A case in point is obstetrics and midwifery where the new discourses demand the constitution of a new kind of worker bearing a new professional identity.
Discourses of 'the new professional'
The 'old-style professional' of the 1930s whose status, class and supreme cultural authority assured a naïve and trusting lay public (Freidson 2001) has come under siege by the emergent discourse of the 'new professional'. He/she is a flexible, multi-skilled, reflexive, team-worker and lifelong learner who slots easily into innovative service arrangements while adding new skills to provide unmet needs (Power 1999:5, Dent and Whitehead 2002). In the health field, for example, the nurse-practitioner and the case-load midwife are constituted from bureaucratic challenges to the political power held by the dominant professions. Midwifery-led units, the 'horizontal substitution' (Nancarrow and Borthwick 2005) of tasks (for example the taking over of some low-level GP tasks by a subordinate group such as nurses) and the introduction of evidence-based medicine as the new 'gold standard', all stand as institutional correctives to medical idiosyncrasy, arbitrary authority, alarmingly-high rates of avoidable adverse events and increasing costs of health care (Lane 2005). The 'old professionalism' entailed unequal relations between professionals because members were socialised into separate 'silos' through professional education, training, and clinical practices. It led to vertical lines of authority and accountability (Degling et al 1988, 2000). But these arrangements are far too resistant to market efficiencies, the realisation of which demands collaboration among equals with different and complementary skills and knowledge (Tully and Mortlock 2004). The 'new professional' under collaborative care is not just an industrial relation add-on, therefore, but emerges as a key factor in production. This is particularly challenging for midwifery and obstetric professionals because new government policies, notably in NSW and Victoria (DSH 2004, NSW 2000), require them to transcend the old structures and boundaries that ordered them hierarchically. For example, midwifery-led models such as team and caseload schemes imply complementary spheres of practice built on trust in the skills and professional integrity of the 'other'. In short, maternity professionals are being asked to transform themselves into professional equals presenting significant challenges on both sides, as the study later reveals.
Consumerism
Calls for interdisciplinary collaborative care in maternity services extend to the consumer, not as the naïve 'patient', but as the knowing participant. In a remarkable twist, marketisation thus reconstitutes the pliable and passive 'patient' as a robust and knowing 'consumer' much along the lines of rational-choice theory within classical Liberalism. The new 'sovereign consumer' is encouraged to actively participate in their own healthcare decision-making via access to government-funded internet databases (such as the Cochrane Collaboration). When such codified knowledge is translated into lay terms it has the effect of neutralising the 'mysteriousness' and esotericism of professional knowledge (Larson 1977) thus potentially transforming the traditional dependency relation between expert and patient. The outcome is an expectation on the part of the (ideal) consumer that the medical visit will involve an egalitarian exchange of ideas among equals. When consumerism is institutionalised at the state level, professional performance is judged not just on internal criteria set by the professional body by also by external, state-prescribed criteria such as national performance measures, professional benchmarking and consumer satisfaction levels. In effect, therefore, consumerism as constituted and endorsed by the state possesses the potential to reorder to some extent the old boundaries between expert and lay person. Fournier (2000) cautions against an overly-simplistic interpretation of this dynamic arguing that dependency relations are often recreated in other ways. However, it is salient to note that consumerism may be seen as partially challenging medical supremacy.
Managerialism
A further instrument in realigning the professions comes from managerialism. Until the 20th century, state licensure and regulations protecting professional monopolies were maintained through vigorous lobbying by medical agencies and professional bodies (Nancarrow and Borthwick 2005). Since the late 1980s and early 1990s and the spread of marketisation, the state has ceased to support monopolisation. Old boundaries are assailed where it can be shown that other, proximate, occupational groups may perform equally well in delivering equivalent outcomes, such as safety, and still accomplish economic efficiencies. Managers become key actors in operationalising the new regulatory mechanisms applied to public sector agencies, like hospitals. The overall effect is that professions such as medicine are currently experiencing a decline in their exclusive authority relative to managers who become the drivers in collaborative care schemes that inevitably challenge hierarchical relations.
Boundary realignment
I have argued that globalisation, heightened competition and workplace shortages in the new millenium have promoted generalisation, flexibility and inter-disciplinarity over narrow specialisation. This is not to say that such forces entirely dismantle the privileged space accorded to the dominant professions. Marketisation, managerialism and consumerism may shift boundaries rather than dissolve them (Fournier 2000). Nancarrow and Borthwick (2005) propose that such shifts may occur by (1) constructing new areas of work or (2) by adding on roles formerly performed by others either as a way of subsuming the professional 'other' or by enacting mutual agreement about which tasks will be transferred. Either strategy may achieve four possible trajectories: diversification, specialisation, vertical substitution or horizontal substitution. The first two offer potential advantages to midwifery to attain professional equivalence with obstetrics because they specify the adoption of a different philosophy (diversification) or a claim to expertise (specialisation). Horizontal substitution (of low level tasks) is certainly possible but is more likely to increase workloads without achieving a revaluing of tasks and achieving equivalent status. Vertical substitution is unlikely to involve obstetricians taking on midwifery work - like being with women during labour and midwives. In the reverse case, midwives are unlikely to take on caesarean sections. However, it is possible for boundaries to shift if 'normal labour', having formerly been defined as obstetric load, is redefined under collaborative strategies, like midwifery caseload or team-midwifery. This effectively upgrades midwifery status to professional equivalent.
The plasticity of boundaries: a re-negotiated order between midwifery and obstetrics
Calls for collaborative work present a radical turnaround for both professions given the demarcationary strategy of deskilling that relegated midwifery to subsidiary status to obstetrics (Witz 1992). The remainder of this paper reports on the interplay between midwives and obstetricians as they contemplate a re-negotiated order around the expanded skill-set, knowledge bases and professional autonomy of midwives. If Foucault (1977) is correct, that professionalism is the process that constitutes knowledge and identities, then we need to document the social processes involved in the construction of professional knowledge as it reconfigures professional relations of equivalence as well as continues the work of 'the labour of division' (Fournier 2000).
Boundary shifts, a re-negotiated order
Discourses directed towards cost efficiencies, transparency and accountability in professional services have blurred the traditional boundaries between midwifery and obstetrics in Australia. The evidence from this study shows that the 'cultural work' (Abbott 1988) or 'labour of division' (Fournier 2000, Weber 1987) involved in maternity care comprises complex processes involving the blurring of boundaries, the renegotiation of new formations as well as a rear-guard action in fortifying old boundaries. This happened on both sides. The study showed that professional boundaries are plastic but that genuine egalitarianism under collaborative care arrangements will be achieved partially and gradually. New structures, like case-load, will allow some midwives to achieve professional parity. Other midwives who reject up-skilling and autonomy will remain in more traditional roles. Even those who aspire to autonomous practice will need to balance their flexible working hours with personal domestic demands to avoid burnout (Sandall 1998, Sandall et al 2001).
'Emotion labour' has the potential to redefine midwifery as a profession of equivalence with obstetrics because of its demonstrated capacity to sustain the normality of normal birth, to normalise a potentially abnormal birth, to deliver safety and satisfaction and to achieve considerable cost savings. It would constitute what Nancarrow and Borthwick (2005) call a 'specialisation'; a new object of knowledge around which midwives could claim exclusive expertise and professional equivalence. But is this likely to occur? 'Emotional intelligence' (Goleman 1995) is increasingly written into organisational theory as a factor of production at the leadership level at a time when consumerism situates the consumer as the arbiter of professional performance (Lane 2000, Morgan and Murgatroyd 1994) and when birthing women resoundingly call for continuity of care. But at this time neither midwives nor obstetricians have fully grasped its professionalising potential.
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