Introduction
In recent years, questions have been raised about whether nursing is a profession or an occupation. An occupation is a job or a career whereas a profession is a learned vocation or occupation that has a status of superiority and precedence within a division of work. Characteristics of a profession are: a defined knowledge base, power and authority over training and education, registration, altruistic service, a code of ethics, lengthy socialization and autonomy (McEwen and Wills, 2006). A profession must also have an institutionalized goal or social mission as well as a group of scholars who work to advance the knowledge of the profession through research, with the goal of improving practice. Until recently nursing was viewed as an occupation rather than a profession. This was because the services provided by nurses were seen as an extension of those provided by wives and mothers. Historically, nursing was seen was subservient to medicine and nurses have delays in identifying and organizing professional knowledge. Moreover the education for nurses is not yet standardized and the three tier entry level system can been found inadequate in the professional context (diploma, associate degree, bachelor’s degree). Finally autonomy in practice is incomplete because nursing is still dependent on medicine to direct much of its practice. On the other hand, nursing does have some of the characteristics of a profession. It has the social mandate to provide health care for clients at different points in the health illness continuum. There is a growing knowledge base, authority over education, altruistic service, and a code of ethics and registration requirements for practice (McEwen and Wills, 2006). Although the debate is still ongoing, it can be successfully argued that nursing is an aspiring, evolving profession (McEwen and Wills, 2006).
Main body
“Professionalism is the enactment of the values and ideals of individuals who are called, as physicians, to serve individuals and populations whose care is entrusted to them, prioritizing the interests of those they serve above their own” – says the AAMC Professionalism Task Force (AMSA, 2008). This definition shows that professionalism is not one that is acquired by some academic qualification or through registration. It is the practice that makes a job professional. The key characteristics of a profession are that its members demonstrate accountability and that the profession demonstrates accountability and autonomy (Girard et al, 2005). Styles in Gray & Pratt asserts that “the professionalism of nursing will be achieved only through the professionhood of its members”. This implies that all nurses must embrace accountability for practice to be considered truly professional. According to the Royal College of Nursing in Australia (2008), self regulation is the key to professionalism. Self-regulation is “the governance of nurses by nurses in the public interest” (RCNA, 2008). The processes of self-regulation are aimed at “providing evidence that practitioners are meeting society’s expectations and maintaining expected standards of practice”. Professional self-regulation contains a number of elements each of which contributes to and is accountable for the overall purpose of the protection of the public. Elements of self-regulation include: setting of professional standards; development of a Code of Ethics and a Code of Professional Conduct; peer review; participation in professional activities and continuing education; research; uncovering new knowledge; professional publications; developing and monitoring advanced practice, and credentialing and certification processes (RCNA, 2008). Individual professional accountability and consumer expectations also contribute to self-regulation through expectations of standards of practice and behavior. It has been found that if nurses do not act responsibly and professionally, they will not be able to maintain their professional status and non nursing groups will try to control nursing.
According to Parsons (1951), the professional role is characterized by traits of universalism, functional specificity, affective neutrality, achievement and collectivity orientation. Collectivity orientation means the professionals are expected to be altruistic and work towards the well being of their clients. Freidson added another criteria to the professional role – professional dominance. Physicians and nurses are expected because of their advanced training and presumed expertise, to exercise authority over their patients. This authority also contains elements of paternalism so that when medical professional are making decisions on behalf of their patients, they are assumed to be acting in their patients’ best interest. Typically the patient shares this assumption.
Professional dominance refers to the notion that physicians have been traditionally placed in a dominant controlling position in health care. The medical profession “is portrayed as dominant in a division of labor in which other occupations are obliged to work under the supervision of physicians and take orders from them” (Freidson, 1985). Freidson argues that the basis for professional dominance is organized autonomy. He argues that the profession of medicine is self governing because its work tends to be very complex. Hence nurses and physicians operate independently from other structures. For Friedson, the professional dominance of medicine was problematic. In his view, due to the issue of professional dominance, the relationship between doctors and nurses (and doctors and patients) was characterized more by tension and conflict than by consensus and cohesion (Taylor and Field, 2003).
Between 1945 and the present, three general periods relevant to hospital organizations can be identified and the first period, 1945-65 is considered to be one of professional dominance combined with localized controls (1945-1965) which was followed by a period of increased federal involvement in both the funding and regulation of hospital care (1966-1982), and a period of increased reliance on market mechanisms and on managed competition (1983-present) (Ruef and Scott, 1998). The early period was known for the unique role played by physicians in establishing appropriate coordination and control mechanisms within the medical sector. The logic of this regime is one of professional dominance. In the American healthcare field, professional dominance emerged in the early twentieth century after medical education and licensing standards began to be consolidated under the auspices of the AMA following the Flexner report (Starr, 1982). A related feature of this era was the decentralized nature of medical care organizations. Throughout this professional dominance period, many hospitals assumed a voluntary, nonprofit form and operated as independent organizations under localized community controls (Burns, 1990). This period ended in the mid-1960s, when this regime was increasingly challenged by the encroachment of the federal government into medical affairs – in particular, through the Medicare/Medicaid acts of 1965. Funding decisions became highly centralized, and a number of regulatory structures were put in place.
Critics of professional dominance argue that the autonomy of the profession has eroded because of the loss of its monopoly over medical knowledge and its diminishing authority over patients (deprofessionalization), or because of its loss of control over key occupational prerogatives (proletarianization) (Weiner, 1997). The professional dominance of medicine may, however, be more valuable to the profession’s own neglect of its avowed public promise to regulate itself than to external forces resulting from changes in the health care delivery system (Weiner, 1997). The threat to physician autonomy may have a lot to do with trends that are cross-national in scope as well. As several authors have pointed out, the potential for the “de-professionalization” or “proletarianization” of medicine (Weiner, 1997) is clearly present in most major industrial nations. These forces include the growing availability of medical information from books, computer networks and the media, as well as the development of new physician- extender occupations, the rise, of a vigilant consumer movement and the growing cost of health care in almost all societies. Each of these changes pose significant threats to the previously unchallenged dominance medicine has taken for granted (Friedson, 1993). Nonetheless, Friedson (1993) and others argue that while physicians may have had to concede control over the context and conditions of work (pay, organizational type and so on) they remain in control over the content of medical work. They alone decide on what is a proper diagnosis and appropriate treatment. Even if an individual doctor is following a protocol for treatment, the protocol was written by other physicians, so the profession has not lost dominance, though each individual physician may experience some loss of autonomy. This view of medicine’s ability to withstand these changes without a real loss of professional dominance has not gone unchallenged.
One of the ways that physicians maintain their dominance over their clients is through information control. The literature in medical sociology contains many examples of how the medical profession maintains its dominance by refusing to share information with the patient especially in the case of chronic and terminal illness. Physicians use various techniques to control information, including denial of truth, stalling, and passing the buck by making a referral to another physician. Sometimes, they do tell patients the truth but use technical jargon or euphemism, so that the patients do not understand what they have been told. For example, instead of telling they the patients have cerebral palsy or mental retardation, physicians have told parents that they children had “motor delays” or were “slow for their age” (Darling, 1994). Professional dominance in the form of information control leaves the patient with a sense of meaninglessness and powerlessness. In fact studies indicate that patients intuitively know when something is wrong with them, and when their fears are not immediately confirmed they undergo stress. This results in disillusionment with the medical profession. Although professional dominance still exists, new roles have been emerging for both clients and professionals that are based on mutual authority and respect.
Professional dominance is mostly about power. Generally in the healthcare domain there are three major models of care that aim to describe the distribution of power between the professional and the patient: traditional medical model, transformed medical model and consumerist model.
The traditional medical model does not allow the patient to take an active role in the care process and there is professional dominance leading to questions regarding patient rights. The extreme opposite to this relationship is observed in the consumerist approach to medical care. Here, the consumer is active and elicits power by making choices depending on their financial status. Consumerism is a strong feature of private health care. But this has not found to be always desirable as consumerism was empowering to the patient only when he was comfortable with the shift in dynamics. Between the extreme models of traditional medical care and consumerist medical care, there is the transformed medical care that describes the ultimate professional client partnership, where there is a harmonious balance between the two. The professional claims expertise regarding clinical advice, whereas the client provides expertise concerning pain, symptoms and self perceptions (Basford and Slevin, 2003).
Darling calls the transformed medical model as the partnership model. According to Darling, professional dominance is being replaced by the partnership model where the clients and the professionals are viewed as equal partners. The professional’s contribution to the relationship is specialized knowledge, based on training and experience, and the client contributes particularistic expertise based on experience in his or her culture and daily routine (Darling, 2000). The professional acts as the facilitator or consultant to families who then decide on a course of action. In the partnership model, patients are involved as equals to the medical professionals in the decision making process (Darling, 2000). A partnership perspective is often very productive, because the professional works alongside the client until they share a common definition of the situation (Darling, 2000).
Professional dominance can also happen in the case of physician/nurse relationships. From a control or influence perspective, physicians hold a position of professional dominance in many hospital and frequency resist decision making discretion by nurses. As one physician expressed” “There are nurses and there are doctors. “The highest ranking nurse is lower than the lowest ranking doctor, and that system will not change.” (Flarey and Blancett 1996). Professional dominance has often been a feature of organized health programs. Many sociologists have criticized the nondemocratic results of this situation. “Medical chauvinism” is another characterization of professional dominance. Yet, over the decades, the degree of professional dominance in organized health programs is found to be steadily declining. The dynamics of group activity and the professionalization of allied health personnel are generating more democratic patterns of work (Roemer, 1991). Ayer (1984) and others have suggested that professional dominance has resulted in self help activities by families (Darling, 2000). Although many of the patients begin by submitting to professional authority they come to play an entrepreneurial role in order to secure appropriate services. This role includes seeking information, seeking control and challenging authority.
Conclusion
The healthcare system today is characterized by conflicting tendencies. While professional dominance is being promoted through commonly used reimbursement systems such as Medical Assistance, they are at the same time being eliminated in many sectors and new approaches promoting partnerships between clients and professionals are becoming increasingly popular. Professional dominance is seen today as a criterion for professionalism. Nursing profession continues to be one that is affected by the concept of professional dominance in two ways: domination by the physicians on one level and dominating the patients at the other level. But more recently professional domination is declining and being replaced by a transformed medical care model.
Bibliography
AMSA (American Medical Student Association) (2008). Professional Integrity, Development and Student Well-Being.
Basford, Lynn and Slevin, Oliver (2003). Theory and practice of nursing: an integrated approach to caring practice. Nelson Thomes Publication.
Burns, Lawton R. (1990). “The transformation of the American hospital: From community institution toward business enterprise.” In Craig Calhoun (ed.), Comparative Social Research, 12: 77-112. Greenwich, CT: JAI Press.
Darling (2000). The Partnership Model in Human Services: Sociological Foundations and Practices. Springer Publications.
Flarey, L. Dominick and Blancett, Smith Suzanne (1996). Handbook of Nursing Case Management. : Health Care Delivery in a world of Managed Care. Jones and Bartlett Publishers.
Friedson, E. The Reorganization of the Medical Profession. Medical Care Review (41:1), 1985, pp. 11-36.
Girard, Francine; Linton, Noreen; Besner, Jeanne (2005). Professional Practice in Nursing: A Framework. Nursing Leadership – Online Exclusive. Web.
Gray G and Pratt R (1989). Accountability: Pivot of professionalism in Gray G & Pratt R (Eds.) Issues in Australian Nursing. p 156.
McEwen, Melanie and Wills, M. Evelyn (2006). Theoretical Basis for Nursing. Lippincott Williams and Wilkins.
RCNA (Royal College of Nursing, Australia) (2008). Position Statement – Professional Self-Regulation. Web.
Roemer, I. Milton (1991). National Health Systems of the World. Oxford University Press.
Ruef, Martin and Scott, Richard. A Multidimensional Model of Organizational Legitimacy: Hospital Survival in Changing Institutional Environments. Administrative Science Quarterly. Volume: 43. Issue: 4. 1998. Page Number: 877+.
Starr, Paul (1982). The Social Transformation of American Medicine. New York: Basic Books.
Styles, M. Styles. Professionalism and professionhood. Mosby, St. Louis (1982), pp. 7–9
Taylor, Steve and Field, David (2003). Sociology of Health and Health Care. Blackwell Publishing.
Weiner, S. Terry. An International Perspective on Health Care: The Case for Terms Abroad for Physicians- The State and Professional Domi Health Care. Frontiers: The Interdisciplinary Journal of Study Abroad. Vol. 3. 1997. Web.