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Literature summary week 5
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W5 Literature – OBPowell & Davies (2012) The struggle to improve patient care in the face of
professional boundaries. Social Science & Medicine 75
Professional boundaries make inter-professional communication, collaboration and
teamwork more challenging and jeopardizes provision of safe and high quality of patient
care.
Care is delivered by different individuals and teams with differing professions, cultures,
identities, cultural backgrounds, objectives and rewards. Hc professionals are aware of these
difference and difference in status between groups, and a key part of their everyday work
life is establishing, maintaining and defending this. Professional boundaries and identities
therefore impact work with others and therefore also the care patients receive.
Boundary work takes place in three fields: the legal sphere, public arena and the workplace.
Especially in the workplace professionals tend to have ongoing negotiations around the
acquisition, offloading and control of tasks (professional project). This work can involve
demarcating one profession from another. Professional identities and core beliefs differ: the
health professions differ in their views on such aspects as what constitutes evidence, safe
practice and high quality patient care, whether care should be acc to standardized protocols
and the importance of teamwork.
Hospitals are hierarchical status-conscious organizations in which power and status derive
from a combination of gender, profession and organizational role. Doctor’s clinical
autonomy has substantial power, and doctors belong to powerful professional bodies.
Doctors over nurses and managers. However, other professions might seek power in their
jobs too. Lower status professionals might use more and various legitimizing discourses to
define their professional boundaries than higher status profs.
Intra-professional boundaries in hospitals include boundaries between different medical
specialties and sub-specialties, between specialist nurses and ward nurses, between day and
night nurses, and between staff of different level of seniority. These boundaries and their
hierarchies lead to independent working and to members of same profession competing for
patients/resources/influences. This all has an influence on inter-professional
communication, knowledge-sharing and collaborative working. Hc professionals can resist
changes in their roles, using a range of strategies to defend existing professional boundaries.
Three ways in which a change was hindered by professional boundaries:
- Health professionals were reluctant to change their role (or acknowledge a new role)
and used a range of strategies to defend their professional boundaries
- By the impact of inter-professional boundaries (improving care requires extensive
communication and collaboration between (same) professions, e.g. nurse-staff)
- By the impact of intra-professional boundaries (effective and timely sharing of
knowledge and expertise between different professions can be hard, e.g. surgeon
and anesthetist)
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, The professional project is not only about professions enlarging their territory by embracing
new areas or new tasks, but also about defending the status quo and resisting the addition
of new tasks. This resistance can stem from professional or individual need for power, but
also from a sense of professional/individual weakness (fear of consequences of new role).
Professional norms and inter/intra-professional boundaries thusly have a strong impact on
how health professionals practice and how they work together.
Van der Veen (2013) A managerial assault on professionalism? In:
Professionals under pressure, the reconfiguration of professional work in
changing public services
Four trends characterize policy change in western welfare states:
- Privatization: a shift from public provision of services toward private provision,
introducing price mechanism and competition in public services.
- Activation: the protection of labour is traded for the promotion of work.
- Selective targeting: universal elements are replaced by more selective targeting.
Entitlements more and more limited to the needy and the deserving.
- Conditional solidarity: solidarity of citizenship exchanged for solidarity of
membership, unconditional social rights transformed in conditional solidarity of
shared membership (e.g. insurance).
Giddens: social investment state. From unconditional entitlements and social protection
toward provisional services, and from aftercare toward precaution/prevention. Focus on
results and effectiveness of public services. From bureaucratic legal state to managerial
state. In a managerial state, the rules and hierarchy are replaced by financial incentives and
market relations. Public officials become managers.
New Public Management: management philosophies on the private sector introduced and
lumped together in the public sector. It combines contradictory developments, e.g.
increasing freedom combined with increasing control (paradox). Giving choice to consumers
and introduction of quasi-markets (= freedom). Control by reducing discretion and
increasing obligations. Managers in this movement will be evaluated based on the outcome
and not on the legitimacy of their efforts. Following legal, organizational and policy changes
are generated in welfare arrangements:
- Reduction of discretion (deprofessionalization): in administration and provision of
public services, more precise legal rules and obligations of consumers.
- Introduction of financial incentives: delivery of public services by privatization of
services (quasi-markets and freedom of consumer choice)
- Institutional redesign: of the organization of policy sectors by dismantling complex
and interdependent structures and introduction of principal-agent relations.
Freedom of choice (leads to deprofessionalization?), two ways in which it gets enhanced:
- Personal budgets in health care: it’s a method to organise demand-driven care. This
type of care is seen as a threat to professionalism, because it undermines the
indispensable dialogue between profs and clients. The client chooses what care they
want, and the contradiction of a professional of a client’s opinion will then hold less
importance/strength. A PGB is a lump sum that clients can spend at their own
discretion. It gives people the opportunity to organize the care they need in the way
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