Attributes on their journey toward being fully professional.

Status, they suggest, attaches to

the degree to the which a group is professionalized, and we migh suppose that the longer a
profession has been in exitence the more opportunities it will have had to acquire Reviews
These attributes and the higher status it will have. Intiuitively Often this is appealing, in that
many of the higher status professions are Also the older ones. But there are problems with
this arumentt too.

The hall-and Oppenheimer sociologists have suggested that in contem porary society,
there is a definite and widespread process of de-professionali zation, and that there are there
distinct processes through the which this takes place. The growth of bureaucracy is one, in
the which professionals working in bureaucratic settings Often find Reviews their autonomy
undermined by the hier archical structure of rules and authority. Fragmentation into
distinctive and separate grouping asresult of the development of knowledge is anothe. And
the third is the pressure from new professionals and para-professionals to take over and
encroach upon the domain of the most prestigicus and established professions.

Furthermore, According to the hall and Oppenheimer, professions working within

bureaucracies are subject to the procces of proletarianization, involving the following
features:

1. An extensive division of labor in the which the worker performs a limited number of
tasks.
2. The conditions of work, the nature of the workplace and the character of the work
processes are set and determined by a higre authority, rather than by worker
3. The wage is the primary source of income and this is determined by the market place
rather than by individual negotiation.
4. The worker, in order to protect himself or herself from the transformation of Reviews
their work, has to from some association or union to bargain Collectively for
improvements.

We can see that time Gives opportunities for both professionalization and
deprofessionaliz-ation and Tus that the ge of a profession is no predictor of status.

Two other sociologists, jamous and peloille. Have suggested that the relationship
between the patient and the client can be Discussed in terms of an "indeterminacy /
technicality ratio" this is perhaps a confusing term, apart from anything esle Because it is
not a ratio. However, it describes an idea that i think is helpful. It suggests that the nature
of the knowledge base held by the professionals is an important factor in their status. The
definiti''e more harder, more technical, it is, then the higher the status is Likely to be. So if
a profession can give definitive answers Likely to have a higher status than one Whose
vocabulary relies such as it depends, in this context, let's wait and see

However if the knowledge base is totally technical then it is possible for it to be

codified into processes that can automated and mechanized (as described above by the
economisis), and hence Carried out by a machine, as happened when the cottage weavers
were replaced by menchanical spinning machines during the industrial revolution.you
 Might like, in this context, to reflect on the way in the which the delivery of pathology
services has changed in recent Decades in the light of advance of technology. So if a
profession is to retain a high status muts Also there be a strong element of indeterminacy:
the knowledge base must be interpreted and applied differently in diffrerent cases. The
highest status of professions will therefore have a definitive knowledge base and this
interpretative abilities. Neither alone is enoungh.

Now I am not suggesting that this is a defnitive answer to the guestion of status
differentials in professions across the board, especially when we look outside health care.
Jamous and peloille Themselves were focusing on health care professions. But it seems to
me, and Often to people I work with, that does enable us to predict and understand some
important dynamiscs between professional groups, and Also to challenge the thinking of
some of the professions attempting to raise Reviews their status. I think this will Become
more apparent as we work on through this chapter.

It may also help us to understand the reactions of professions to initiatives of certain

kinds. If we do try to deprofessionalize or proletarianize a professional group, by
reducing the amount of interpretation we allow them when applying their expretise (by
introducing strict protocols,perhaps) or by paying them on a piecework basis,then we can
expect a reaction that may well include the withdrawal of other professional attributes,
such as altruism.

So, while decisions of this kind may be desirable, as the needs of society change, the
need to be taken with great care, and with some thought as to whether there are ways of
achieving similar results in ways than do not jeopardize the good will of professionals.

Other ways of thingking about the dynamics within and between professions

Status certainly affects the way professions engage with each other, but there are other
ways of visualizing the dynamics between professions and in this section we look at a few
of them.

The hierarchy of clinical descriptions

Let us consider how clinical conditions are described. An individual may feel tired
and thirty;his family experience this as’dad’s too tired to play fcotball;his doctor having
performed a urine test will talk of blood sugar levels and diagnose diabetes. We already have
three different wasy of describing one clinical condition. We can expand this further, to a
hierarehy of descriptions in wnich each lower tier is at the next level of detail.

Level +2 patien’s community

Level +1 patien’s family

Level 0 patient as a whole

Level -1 majoe body part (e.g.chest, abdomen,head)

Level -2 physiological syste (e.g. cardiovascular system, respirstory system)

Level -3 system part or organd (e.g. heart,major vessel s,lugs)

Level -4 orgampart ot tissue (e.g.myocardium,bone marrow)

Level -5 cell (e.g. epithelial cell,fibroblast,lymphocyte)

Level -6 cell part (e.g. cell membrane,organelles, nucleus)

Level -7 macromolecule (e.g. enzyme,structural protein, nucleic acid)

Level -8 micromolecule (e.g. glucose,ascorbic acid)

Level -9 atoms or ions (e.g. sodium ion)

In this ‘hierarchy of natural descriptions’ ,entities (on ‘nominals ‘)at one level
combine together to form an entity at the next level up. So the nominals at one level become
attributes at the next. However, they are not the only attributes at the higher level, as others
emerge with the combination. This is an aspect of ‘ systems thinking’ a means of identifying
order in complex systems that was developed not only by biologists but by engineers and a
number of other scipllines in the 1930s and 1940s. the ‘knowledge network’ in table
2.1expresses the hierarchy of information statements, where the nominals are the left and
the attributes to the right of the // sign. The emergent attributes have been distinguished from
the attributes that are simply the nominals from the nexs lower level in the hierarchy, by
pitting them in italics.

The early systems thinkers identified a number of features that pertain to hierarchies
of this kind.

 First, we can focus ourattention on only one level (and those immediatelyabove and
below it) at a time . you may rejevt this as a proposition, knowing that you can
consider all the different levels.however, their observation was that while we can
track berween the different levels,and experience of a particular hierarchy increases
the speed at which we can do this. At any one moment our attention is fixed on one
part of the hierarchy so we are able to trace the part from hydrogen atoms to a cabinet
reshuffle, from the effect of medication on blood electrolytes to tne relief of a
patient’s discomfort,but we are only focusing on oneclevel a time. This feature is
what allows someone to say, for example. That there is no such thing as society,there
are individual men ana women, and there are families.’ The anger evoked when
Margaret thatcher expressed these sentiments arose from a bellef,on the part of others,
that important attributes emerge when individuals are combined into society.
 Second, as we ascend the levels, individuality increases and uniformity decreases.
One electron looks very much like any other electron and is readily distinguished
from a neutrom or proton. However,classifying both a Chihuahua and a great dane as
dogs and distinguishing between the class of dogs and that of foxes is much less
 straightforward. At the higher levels classes and terms are more ambiguous, more
fuzzy, and open to different interpretations.
 Third,ateach level we need a different level of language. If we use a lower-level
language at higher level, it is overdescriptive and tedious without adding
anything.describing the heart in terms of all of its constituent cell takes a long timeand
is not necessary. Conversely,The use of a higner level language at a lower level result
in confusions or nonsense because it is too rich it tries to ascribe attributes that do not
emerge until higher levels to lower level items (e.g. colour has no meaning at the
molecular level; neither does sentience at the level of cells or of organs)
 Fourth, numbers are often uselful at lower levels (blood electrolyte levels, for
example). They enable expression of a degree of abnormality and a measure of
whether things are getting better or worse. At higher levels, quantification is more
diffilcult. Where high level descriptions are converted to numbers (e.g. activities for
daily living scores), they should be used with great care, since they are attempting to
represent a rich, ambiguous, fuzzy, multifaceted reality. Just as word need to be used
differently at different levels, so do numbers. We cannot manipulate numbers
referring to high levels in the same way as those at lower levels.

While the four features described above to all hierarchies of this kind, there are also a
number that relate specifically to health care. To avoid confusions I continue the
numbering.

 Fifth, different professions tend to have exprertise at different levels; indeed,many

of the health care profession emerged as knowledge of the different layers
developed. For example, although there are exceptions, typically psychologists
and occupational therapists will focus on level c, +1 and +2 and general nurses
(say, working in intensive care) on levels -1,-2 and -3 within professions, different
disciplines also focus on different levels, so although the medical proffesion as a
whole includes those with expertise at levels-1 to -9 (and the length of the medical
training results from this), hospital-based consultants in many specialties
concentrate on levels lower than their colleagues in general practice.
 Sixth, no level is right or wrong, or better or worse than any other level, defining a
problem completely involves covsiderstion of all the levels affected. In a
multidisciplinary situation, the ‘clout’ is ofter held by those operatng at the lewest
levels (they have hingher status, because, as we have seen, this is where the
knowledge base is most definitive, and because the length of training requered by
people operating at this level is longer),but each levdl required expert
consideration in its own right, interestingly,where no lewer level malfunctions
have been identified (for example, in many mental health problems),the dynamics
between the various professions involved are defferent. It will be intertesting fo
see whether these relationships change if research correlates certain
neuroendocrine pictures with particular mental health diagnoses and strarts to
identify the mechanisms linking the intervening levels.
  Seventh, we do not need to understand everything about every level to be able to
understand explanations of the links between them.
 Elghth, patients somitemes hold invented hierarchies that difter from those
understood by their clinicians. These are rarely explored but they impede insight
into the patient’s condition,compliance and satisfaction with outcomes.

There are a number of implications that arise from this hierarchy and its properties.

Firs, if health care organizations are concerned with health (rather than only
illness), then they have to address between them all of these levels. But individual
HCPs can focus on only one level at a time and our organizational systems should not
expect them to do otherwise. Somehow our systems need to encourage HPCs to fight
a valiant battle at electroyte as sociable humans and family members. These need;
inlude dignity meaning, and thus at a particular time, the need for a good death this is
one of the most significant challenges to health care organizations and we consider it
again in chapter 7.

Second, HCPs will naturally find communication problematic, since they use
different levels of language. We need not berate each other for that, but we may need
to ensure that interpretation is available. We must also recognize our interdependence
and the virtue of patients receiving specialist expertise, rather than amateur
intervention, for each of the levels that is malfunctioning. This will be easier if those
concerned remember that it is not necessary to understand everything about every
level to be able to follow explantions that track from lewer to higher levels. Greater
exploitation of such tracking would enable multidisclinary teams to work effectively,
with each member being aware multidisciplinary teams to work effectively, with each
member being aware of the reasoning behind an opinion. If the team then gave the
responsibility for taking decisions where there conflicting opinions to the
responsibility for taking decisions where there are conflicting opinions to the
profesional mest skilled at teh level manifesting the greatest problems, then we might
move towards a system in which multidisciplinary teams are truly teams. Clarifying
the familiarity required with each of the hierarchical levels also enables decisions to
be made about how best to staff a service, which professions will be most able to
contribute abd what knowledge bases are necessary.

It is sometimes not realized that it is the hierarchical levels of which professions have
knowledge that determine the uses to which they put their skills. These skillis, particularly of
those individuals intervening at higher levels, may appear nonsensically disparate to an
outsider. An occupational therapist in mental health may appear to be very different from an
occupational therapist working with young physically disabled clients. However, they both
share a core knowledge base and reasoning process, and this fact needs to be appreciated
when decisions on skills mix are taken.
 Third, if it is only at the lower levels that we can be definitive,then we need different
research methods at lower and higher levels. The researcher’s’gold standar ‘ of the
randomized controlled trial, preferably double-blind –better still, double-blind and crossover
– requires that the control group is matched precisely ( i.e. that all the features of the entities
in those groups are matched,leaving as only variable the subject of the study ). However, as
we ascend the hierarchy, it become more and more difficult to match perfectly because of
the increasing complexity and ambiguity. Whereas at lower levels we can ask a question and
get a devinitife answer ( ‘yes’ or ‘no’or in χ per cent of cases…’)’at higher levels, unless
very large sample sizes are used, the answer have to be qualified (‘in these circumstances
this is what we found ‘; ‘if your circumstances are similar , then you may find the same’).
Higher levels, then , are illuminated by qualitative research, research that rarely yields
definitive answer applicable in all setting, but qualified answer conditional on context. That
applying the wrong research method is dangerous is summed neatly in the phrase ‘to even the
most complicated of problem there is one simple, easy-to-understand, wrong answer’.

Qualitative researchmaybe conducted as rigorously , independently and objectively as good

quantitative research , or it too may suffer from poor design and execution . in the first
edition of this book l wrote that:

The fact the result of even excellent qualitative research are qualified , as we have shown, can
lead to it being written off as wooly and inferior by. In particular , the medical profession.
This is unfortunate for two reason : first , dictor ‘behaviours and judgements are not informed
by such research is not subjected to the rigorous criticism at which the profession excels.this
allows too much sloppy qualitative research ( quasi-journalism in some cases ) to be
undertaken and disseminated.

L recognize that there has been much progress since then in the way qualitative research is
viewed and used in healt care – but there is still talk of the hierarchy of research evidence,
with the randomized controlled trial at the top, when in may situations, especially in the field
of health care management, this type of model and approach will not be the most appropriate
or helpful. So l suggest that there is still some danger of us being wedded to one particular
type of research ‘paradigm’ here (see also the next section).

The other aspect of the fact tha we can be more definitive at lower levels than at higher ones
related bac to what we have considered about status. We explored the idea that the more
devinitive the knowledge base a profession works with, the higher status it is able to have (
as long as there is a large degree of interpretation that is needed to aply it to a particular case
). If we combine these two ideas we can suggest that professins working at higher levels . we
can also suppose that groups who expand their knowledge into lower levels will increase
their status. You might like to reflect on the role of clinical nurse specialists in this regard.

The corollary to this is that status is unlikely to be added by enlarging a role with the
addition of activities at the same level in the hierarchy , regardless of which professional
group may have undertaken them before. For this reason nursing for example, is unlikely to
increase its status by taking over from junior doctors’ tasks at the higher levels in the
hierarchy. There may be ( and are ) many good reasons for nurses to consider doing so, but
this should not be one of the.

The spectrum of views of disease

Just as different levels of professions , professionals in different care settings, concentrate on

different levels of the hierarchy , so too do they gravitate towards different points on a
spectrum of views of disease. Traditionally, there have been two contrasting views of disease
is an isolatable entity having a life of its own; in onther words, a disease is regarded as
something that is pretty much the same whether it is experienced by one patient or another
this is the ontologic view and has been used for millennia; for example , plato describe
disease in this way. We adopt this view whe nefer we talk of the ‘course of a disease ‘, or
when we describe a disease a entirely in terms of its attributes and without any reference to
patients. The second is that a disease is the change seen in a patient when not in good health.
Here the sick patient is the focus of attention. This has been called the ‘biograpical’ view
disease and can be recognized in the work of Hippocrates, famous for his highly detailed case
histories. Over the centuries, both views have held sway . however, as we have come to
understand more and more about humans and the disease we experience, we recognize that
neither view alone is satisfactory in all circumstances.

In practice , there is a spectrum of views ot disease ,with a few individuals operating at each
end ,but most HCPs some where between:

The position of an HCP on the spectrum trends to depand on how well defined the
disease is and on how well they know the indivual patient. A general practitoiner, for
example, will operate further towards the biographical end of the spectrum than a
 hospital specialist similary, doctors will tend to view patiens more ontologically than
nurses.

In ensuring that patiens receive the most appropriate care, we cannot say that one end
of the spectrum is right and the other wrong we will need attention to both. However,
there is potential for strire, when proffessional involved with the same patient have
different concerns and feel that those concerns are not being addressed by others.

Degree of structure in the clinical problem

There is a another cause of disharmony between, the latter needs the maximum
cognitive span, since the patiens concerns could turn out to be antything or nothing,
one of thousands of disease or none at all. The process that follows (of conversation,
hostory-taking, physical examinations, differential diagnosis) introduces more and
more sructure into the problem. At point A, the problem could be anything at point B,
the possibilities have been progressively reduced and the altcrnaives are now few.

People working at different parts of the funnel can sometimes undervalue each others
skills, yes the expertise required to funnel down from point A to point B is no less,
just different from that required to offer specialist assessment and management once
poit B has been reached. The reverse is also true. Many of the communication
problems that arise between primary and secondary or tertiary care workers appear to
have at their root an undervaluing of the skills of the professionals on the other side of
the boundary. Recognizing that different roles require different skills, rather than
greater or less skill, is essential if seamless care is ever to become more than just a
slogan.

Causes of misundestanding between professionals

The factors we have been looking at so far in this chapter are inherent results of the
nature of health care needs and the ways that evolved to meet them. However, there are
other factors, more to do with the cultures of the profesions, Also that foster
misunderstanding when they try to berinteraksi. These are where we turn our attention
now.

Sets of ethical principles

What principles do you turn to when you decide whcther a particular action is right or
wrong? Reviews These philosophers have argued about for millennia and students of
ethics can describe a range of different approaches to answering the guestion .most of
us, however have absorbed our ideas about ethical behavior without being aware of any
principles underpinning them, and in our lives prefessional much of that absortption
happened early on in our pro-fessional education, as part of the that, polany argues, is
part of the paradigm or framework within the which we Operate. paradigm that is
invisible to us, Because it is the way we structure our thinking, and not something we
can Easily bring into what Polanyi calls focal awarenes while we are actually in the
proces of using it.As Thomas Khun Obseves, scientist never learn concepts , laws and
theories in the abstract. Instead Gradually they learn to think like their teachers.

Different sets of principles will lead us to different conclusions about the degree of
right or wrong of a particular course of action,so if our set leads us to reason one whay
,while that of semeone else produces a different rationale,and we have not been aware
they were approaching this from a valid but alternative direction,we may be incensed
and uncomprehending.It is helpful,therefore to be aware of these alternative and thus
able to recognize not only our own beliefs but those of others.

One way of thinking about ethicel theories is to divide them into three schools:
utilitarian, deontological and virtue ethics. At its simplest, utilitarians are concerned
wiht the consequences of an action. In making a choice, a utilitarian will decide between
two courses of action based on the which leads to the gretest good for the greats number
of poeple. If that requires the telling of a