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Challenges for the contemporary health care professional
Jan Fook
Professor/Director, Centre for Professional Development, La Trobe University, Bundoora VIC
Abstract
Increased economic competition brought about through globalisation (Dominelli, 1996) has led to a more managerialised and technocratised workplace – in order for services to remain competitive they must be measurable and marketable. This adds up to an increasing deprofessionalisation as managers seize control of how jobs and skills are defined in order to maintain this competitive edge. Work defined in value-based or professional terms is often seen as antithetical to efficiency and effectiveness.A related trend is that jobs are framed in more fragmented or program-based ways. For instance, in Australia, deprofessionalisation is manifesting in more short term, contract and low wage employment (MacDonald, 1999), and in professionals like social workers taking jobs which are either not defined as social work positions, or which only require a lower level of qualification (Hawkins et al, 2000). The tendency to deprofessionalisation can also engender competition between professions, as, for example, we all jockey to claim dominant expertise in practice areas like case management (Fook, 2002, pp. 149–50). There is a resultant value on multi-disciplinarity.
In terms of social and cultural changes, globalisation is associated with postmodern thinking (Parton, 1994), which calls into question the nature of knowledge and the legitimate forms of its generation. The traditional hierarchical divisions between generalisable and tested theory developed though "scientific research" produced by elite researchers on the one hand, and everyday practice knowledge which is generated and changed through concrete interactions and experiences of "ordinary" people, are questioned. This clearly challenges the position of the professional as the privileged keeper of specialist knowledge, and the exclusive right of the professional to develop and define that knowledge. In addition, postmodernism thinking recognises that knowledge-making is both interpretive (Ife, 1997, p.131) and reflective (Fook, 1996) thereby challenging the idea that professional knowledge is necessarily "objective" and unchangeable.
In keeping with this challenge to the privileging of professional knowledge, is the challenge to "professional dominance" (Friedson, 1970) and the call for professions to be more accountable and transparent in their dealings. The move towards evidence-based practice can be seen as part of this trend. Although perspectives on what evidence-based practice actually entails may vary (Trinder, 2000), there is broad agreement that the movement hopes to ensure that professional practice is based on the best available knowledge of what constitutes effective methods. Whilst the evidence-based practice movement does not necessarily constitute a challenge to professional privilege, it does constitute a move for professionals to ensure that they do not use their privileged knowledge base to protect their interests at the expense of service users.
In short, there are three broad challenges facing the contemporary professional:
- how to practice effectively in uncertain and complex contexts when the possibility and desirablity of certain and unchangeable knowledge is also called into question – what is needed are legitimate forms knowledge, and ways of generating it, which allow for effective and responsive practice in changing, complex and uncertain environments;
- how to provide value-based service in an increasingly technocratised environment – what is needed is ways of relating service technologies to less measurable values and ideals; and
- how to maintain position and credibility in an environment calling for increased accountability and transparency – what is needed are ways of establishing legitimacy in ways which include and value the interests of all stakeholders.
Given these broad challenges, what are some of the specific directions we might take as professionals?
Some suggestions might be provided by scrutinising the practice of "expert" professionals. Over the last decade I undertook a major study of professional expertise with colleagues Martin Ryan and Linette Hawkins (Fook, Ryan & Hawkins, 2000). We documented descriptions of practice from practitioners identified as "expert", and found that the situations they encountered, and the work they undertook, could be characterised in ways which actually addressed many of the above issues. We found that professional expertise included the following features:
- the ability to handle uncertainty and change – this involved flexibility in applying preconceived ideas, and creativity in inventing new responses or strategies. It also called for the ability to create their own knowledge or theory about how to practice, and to transfer (or translate) the applicability of this knowledge between different contexts, rather than imposing a fixed idea on a new context. (Fook, Ryan & Hawkins, 2000, pp. 187–193);
- contextual abilities – this involves the ability to work in a holistic and integrated way with a whole situation, rather than individual players within it, and to see themselves as part of the situation. This also involves an ability to see themselves as able to act upon and in the situation (Fook, Ryan & Hawkins, 2000, p. 194). A contextual perspective also involves a commitment to broader values, what I have elsewhere termed a "grounded and transcendant vision" (Fook, 2002, pp 158–9). Many expert practitioners were able to avoid burnout, because they saw their immediate workplace or job as merely one means to achieving their professional ideals, rather than as the sole expression of their professional values;
- the ability to work with complexity and contradiction – skills of prioritising, of being able to work simultaneously at a number of levels, to separate macro and micro levels of work, are all important in handling complexities. (Fook, Ryan & Hawkins, 2000, p. 197).
In short, expert practising professionals were able to create flexible knowledge, to work with and within complex contexts taking into account different stakeholders and interest groups. They were in fact already exhibiting many of the abilities needed to address the challenges raised in the contemporary environment.
From the findings of this study, I would argue that we already have many of the new directions for working successfully in our changing environment. We are already practising in ways relevant to the challenges we face. What we do need though, are ways of conceptualising our professionalism and our practice which values and legitimates our work in terms recognised in the contemporary environment. We need to be able to communicate about what we do in ways which can legitimate our professional practice in at least both technological and value-based terms, and in ways which are accessible to different stakeholder audiences.
In a more recent book of mine (Fook, 2002) entitled Social Work: Critical Theory and Practice, I attempt to outline a more detailed model for what social work professional practice might look like, based on the above conceptualisation of professional expertise, and also incorporating postmodern ways of thinking. This model takes into account the specific challenges of the postmodern and global age, and the need to maintain ideals for empowering service users, and changing inequitable systems and structures. Although the book is primarily targeted at social workers, many aspects have relevance to health care professionals more generally, since all professionals in the health field are confronting similar issues.
One of the approaches and skills which underpins much of this orientation is that of critical reflection. Reflective practice, as developed by Donald Schon (1983) is familiar across the health professions. Nurses in particular have adopted and developed this approach well in their own tradition (Taylor, 2000). Critical reflection is an approach, set of processes and skills which focus on the power dimensions of practice and thus the transformative potential of reflective practice. It can be used in many ways for the research and evaluation of ongoing practice, but also in developing and creating new forms of practice knowledge. As such it is vital in the repertoire of professionals who need to keep updating practice and knowledge so it is relevant and effective in changing, complex, and unpredictable situations.
The broad model for practice which I outline in my recent book (Fook, 2000) illustrates how a critical reflective approach and skills can be used for empowering service users and workers. The approach is also used to help readers engage with the ideas presented in the book. In this way I hope to contribute some very concrete ideas for professional practice which is responsive to contemporary challenges.
Article Text
It is commonly agreed that professional practitioners face new challenges in the contemporary environment. These challenges have the potential to radically alter the nature of professionalism and professional practice. How then do we as professionals need to remake ourselves and our practice in order to respond effectively within the current changing environment?
Let us first detail the sorts of challenges we are currently facing.
The contemporary environment of globalisation carries with it economic, political, social and cultural changes which impact directly on professional practice (Pugh & Gould, 2000). The social and cultural environments in which we work are rapidly fragmenting, ironically at the same time as there is a global technological and economic "compressing" (Robertson, 1992). The uncertainties of the old orders mean that the ability of professionals to act with any certainty on the basis of tried and tested knowledge is undermined.
References
Dominelli, L. (1996) "De-professionalising Social Work: anti-oppressive practices, competencies and postmodernism", British Journal of Social Work, vol. 26, pp. 153–75.
Fook, J. (ed) (1996) The Reflective Researcher, Allen & Unwin, Sydney.
Fook, J. (2002) Social Work: Critical Theory and Practice, Sage, London, Thousand Oaks.
Fook, J., Ryan, M. & Hawkins, L. (2000) Professional Expertise: Practice, theory and Education for Working in Uncertainty, Whiting & Birch, London
Friedson, E. (1970) The Profession of Medicine, Dodd Mead, New York.
Hawkins, L., Ryan, M., Murray, H., Grace, M., Hawkins, G., Mendes, P. & Chatley, B. (2000) "Supply and Demand: a study of labour market trends and the employment of new social work graduates in Victoria", Australian Social Work, vol. 52, no. 1, pp.35–41.
Ife, J. (1997) Rethinking Social Work: Towards Critical Practice, Addison-Wesley Longman, Melbourne.
MacDonald, C. (1999) "Human Service Professionals in the Community Services Industry", Australian Social Work, vol. 52, no. 1, pp. 17–25.
Parton, N. (1994) "Problematics of Government, (Post)modernity and Social Work", British Journal of Social Work, vol. 24, pp. 9–32.
Pugh, R. & Gould, N. (2000) "Globalisation, Social Work and Social Welfare", European Journal of Social Work, vol. 2, no. 3, pp.123–38.
Robertson, R. (1992) Globalisation, Sage, London.
Schon, D. (1983) The Reflective Practitioner, Temple Smith, London.
Taylor, B. (2000) Reflective Practice: A Guide for Nurses and Midwives, Open University Press, Buckingham.
Trinder, L. (ed) (2000) Evidence-based Practice: a critical appraisal, Blackwell, Oxford.
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