Autonomy, Accountability, and Professional Practice: Contemporary Issues and Challenges
Whiteford, Gail, New Zealand Journal of Occupational Therapy
Contemporary society holds numerous challenges to professionals. These include coping with the information explosion, responding to heightened consumer awareness and demands on services, and in meeting ever increasing regimes of compliance within an era of mangerialism and accountability. This article explores these issues and posits some responses for professionals including developing robust communities of practice to enhance context specific knowledge generation and in enhancing the political profile and representation of professional groups within decision making fora.
Postmodernism, autonomy, regimes of compliance, communities of practice, politicisation
Whiteford, G. (2007). Autonomy, accountability, and professional practice: Contemporary issues and challenges. New Zealand Journal of Occupational Therapy, 54(1), 11-14
My objectives in this article are three fold: First to consider the broad terrain of professionalism both statistically and conceptually, then to consider some of the challenges to professionalism paying particular attention to knowledge development, competency and accountability. Finally I will posit some suggestions or strategies for the future, including the politicization of our professional agendas.
Professions in New Zealand: Scanning the terrain
The 2001 Census (Statistics New Zealand, 2006) revealed that there were 217, 000 professionals in New Zealand and, according to the Standard Classification of Occupations, these professionals fall into 70 broad categories. As a more specific breakdown in numbers, the Census identified that there were 60,000 teachers and 14,000 university and vocational education teachers.
As for health professionals, there were 31,000 nurses and 12,000 other health professionals and 9,000 medical practitioners who include anaesthetists, surgeons and specialists. The Census also identified 9,000 barristers and solicitors and other legal professionals as well as 18,500 accountants--of interest one of the fastest growing professions which may tell you something about the times in which we live and work. With respect to regulation, there are currently 19 Registration Authorities, and just to focus in on one area, in 2005 there was a total of 1124 complaints made to the Health and Disability Services Commissioner with most related to deficiencies in assessment and treatment, lack of care coordination, poor communication and inadequate record keeping. So, whilst this data may give us some indication of the quantum of professionals currently in the country (or at least those we have not lost to better paid overseas destinations), who is a 'professional' and what characterises a profession?
What does it mean to be a professional?
In 1906 George Bernard Shaw suggested that professionalism as a concept is, in fact, a form of protectionism, stating that "all professions are conspiracies against the laity" (Catto, 2005, p. 315) which, being a fairly disparaging view of professionals, signals a sense of differentiation at best, and elitism at worst. But if professionals are distinct in their own right, what makes them so? Definitions abound on what constitutes professionalism from Bosser et al's (1999) statement that a "profession is autonomous, self-directing and embodies trustworthiness through adherence to ethics and knowledgeable skill" (p.117) to a more recent and perhaps fluid version that "professional practice is about doing, knowing, being and becoming" which is characterised as being "people centred, purposeful, based on informed action, individual, located in a specific context" (Ewing & Smith, 2001, p. 16). Phillips more recently presents a definition more focussed on the attributes and actions of the individual practitioner in suggesting that "the essence of professionalism is to be able to call upon the honour, probity and principled judgement of the practitioner" (Catto, 2005, p. 314). However, whilst there is no firm agreement on what characterises professionalism, the criteria most often cited in the literature include: that it is founded on intellectual activity; that it has definite and practical purpose; that its techniques that can be communicated; that is effectively self organizing; that it has a highly developed Code of Ethics; and, that it assumes a lifelong commitment (Schein, 1972).
Historically, what has been expected of a profession is that they are self regulating with respect to standards of practice and the conduct of members. The conduct of members is bound by, and judged against, the professional Code of Ethics, that form the basis of everyday actions whatever the setting or context. Additionally, the profession is expected to determine the level of education or skill required for entrance into that profession. It is interesting to note, however, the content of entry level curricula have increasingly become zones of contestation between universities, professional associations and accrediting bodies and or registration authorities.
The more fundamental issue, I would argue, that should concern us all more than debates over minutiae of entry level professional curricula, is how continuous critique and development of the knowledge base underpinning the profession concerned is undertaken and supported. Professionalism requires commitment to a specific knowledge and skill set (Bosser et al, 1999), and, as Allen, Oke, McKinstry, and Courtney (2005) suggest:
... professions are considered to be based on intellectual activity; primarily knowledge development and continuous learning. Professional knowledge is characterised by applied theory and professionals have a responsibility to not only continually expand and critique their own knowledge, but to contribute to the development of their profession's knowledge base (p. 92).
However, knowledge generation and utilisation has become increasingly complex in an era of mass information access: what is relevant, important and fundamental to professional practice requires real attention and reflection, no less than an epistemic reflexivity (Bordieu & Wacquant, 1992). All up, there are just more attendant pressures for professionals to maintain not only a valid and current knowledge base, but one which allows them to generalize their unique knowledge and skills blend fluidly across national, cultural, political and economic contexts.
As if these challenges are not demanding enough, all this is occurring in an historic moment when the whole notion of professionalism has become itself subject to debate if not deconstruction. Whilst I don't want to do a critique of postmodern thought here, there are some features of postmodernism that have required a closer examination of issues such as representation, voice, knowledge protection, access and, most importantly, power relationships. Postmodernism, as we know, describes itself as rejecting the grand narratives of modernism (science, for example), and creates new modes of interaction as the distinction between insider and outsider, expert and lay person becomes less distinct. Indeed, Patti Lather (1991) suggests that postmodernism has created "an affective space in which we feel that we cannot continue as we are ... because the modernist project of control through knowledge has imploded: collapsed inward" (p. 88).
Whether you accept the challenges of such postmodern writing as valid, or concur with the description of postmodern discourse as a "playground for frustrated poets who offer us their musings about the disintegration of knowledge" (Constas,1998 p. 27) it seems incautious for us as professionals not attend to the very serious issue of knowledge production and transference in a context of mass information access. Concomitantly, we need to reflect on the modes of interaction between professional and so called 'client' in an era of heightened consumer education and empowerment. Increasingly, consumers want transparent decision making processes and a partnership model in which responsibility is shared, not abrogated.
A climate of accountability
It is not only consumers demanding greater transparency of the actions and activities of professionals, however. Increasingly we find ourselves in what has been aptly dubbed by Onora O'Neil in her 2002 Reith lecture series as, fuelled by a techno-rationalist mentality that potentially reduces professional practice to a series of procedures and actions driven by a need to meet instrumental reporting and recording requirements. Whilst there is little argument that professional groups must be open to scrutiny, expectations that all aspects of professional intervention can be measured and monitored (in what is increasingly becoming the era of 'surveillance') are not only unrealistic but threaten to undermine autonomy in a serious if often tacit way. Ultimately, this drive towards increasingly unreasonable levels of accountability (often with questionable motivations) has been fuelled by diminishing levels of trust, however:
"Every day we read of aspirations and attempts to make business and professionals, public servants and politicians more accountable in more ways to their stakeholders. But can a revolution in accountability remedy our crisis of trust?" (O'Neil, 2002, p. 4). Given these issues, it is crucial that professions take a leading role in establishing monitoring or accountability systems that satisfy the profession as well as assure employers and external groups that practice is based on sound processes, as:
The alternative, namely external regulatory dependence, implacably leads ... to a rising mass of codified petty regulation, swollen by the need for rules to enforce rules and to counter their avoidance. The very equality of treatment such regulatory complexity is nobly designed to ensure, in fact makes it impossible. What is more, state regulation in such areas is apt to drive out self policing and the force of individual conscience (Catto, 2005, p. 315).
To summarise thus far: professions and professionalism per se have increasingly come under threat: on the one hand, from the historico-cultural rise of postmodernism that has centrally concerned itself with interrogations of the tacit dimensions of power and control that underpin the enactment of elite systems of knowledge; and, on the other, from the fiscal rationalism that characterises late Western Capitalism that requires ever more draconian regimes of accountability leading to questionable practices in the name of compliance.
Clearly these are threats which represent a timely call to action. Indeed, if ever there was a time when professional groups need to engage in intense self reflective processes, it is now. Additionally, professional groups need to mandate themselves to interact more critically and publicly with the machinery of government and the policy environment of institutions. Ironically, however, it seems that there is a good deal of inertia. Personally, I have been frustrated for years by a staggering lack of motivation to not just respond to, but to shape the terrain in which we practice. Yet, as the criticism that under an increasing regulatory environment universities have become increasingly silent is a truism, it is very possibly true of the professions also.
One of the areas that I think we have been particularly silent and generally compliant in, is the area of evidence based practice and how it has been adopted within institutions. As I have argued in my recent book in a chapter titled 'Knowledge, Power and Evidence' health professionals have been far too quick to ask the question 'how do we do evidence based practice?' rather than 'why should we do it?' and 'what does it mean?' (Whiteford, 2005). Whilst some commentators have denied that viewing evidence based practice as a cost saving measure is a myth (Law, 2002), others contend that the emergence of evidence based practice cannot be separated from the fiscal agenda of managerialism (Taylor &White, 2000; Muir Gray, 2001; Davies, 2003). Paradoxically, it seems that the knowledge base of professionals is at once relied upon and undermined by managerial framing, of evidence based practice (Davies). This has been described as a process in which the "efficient choice" (p.99) message is promulgated, assuming autonomy and choice in the identification and utilisation of research, whereas, in reality, autonomous action is discouraged in most contemporary institutions (Estabrooks, 2001).
Clearly, it is the responsibility of all professionals to be actively and critically engaged in this era of evidence. We need to ask the question of new data gathering requirements 'whose purpose does this serve?' and in doing so maintain our focus on our clients and their needs. In the health professions we need to continue to champion the cause of the people we have traditionally served, i.e. those often living at the margins of society with little voice or representation (Wilcock & Whiteford, 2003). This is particularly important in the prevailing context of accountability when social and community based programs are attracting greater scrutiny with respect to concerns as to their cost effectiveness as opposed to their societal value. Overall, we must centralize our right as autonomous professionals to address the needs of clients in context with diverse sources, including the knowledge of the client, family and community, as well as the experience of the professional, which in traditional hierarchies of evidence, (which I do not conceptually support) appears at the bottom, to inform our practice. Indeed, "the idea that professionals can be shaped by evidence legitimised by managers and funding bodies and by coercive policies that mandate action on the basis of evidence, belies the complexity of professional work" (Davies, 2003, p. 101).
Strategies for the future
Enough of setting the scene: the question begged is how do we address these issues of threatened reductionism in practice, surveillance, increasing compliance requirements, diminished public trust and a potential corresponding diminution of professional commitment?
The first arena is enculturation. From day one of their health professional education, students learn the values, norms and codified behaviours of their profession, they are immersed in the culture that tells them, everything from what we believe is important, where we stand relative to other professionals, how we interact with power and authority, through to how we dress and socialize. It is true, but largely unconscious and invisible. What I suggest is that we all become a bit more conscious of how we influence new comers to the profession, asking ourselves "is this what I really want to transmit, is this what the next generation will find useful?" Students absorb every word, every conversation around the tea table, every gesture and action mostly uncritically and it has a powerful and lasting effect. I think we can do a better job.
The second strategy I think we need to address is to orientate our educational programs a little more strongly towards the moral and ethical basis of practice and the development of notions of citizenship. Mostly, health professional programs are guilty of burdening their curricula with content, with every speciality area vying for pole position in terms of coverage. I would argue that as important as content (much of which will be quickly redundant) we need to focus on creating reflective, wise professional citizens, capable of working across context, empowered with skills of critical thought and excellent communication and advocacy skills.
The third strategy I suggest, and is very much linked to enculturation, is to develop robust communities of practice as a response to the increasing pressures and isolating effect of many practice environments. The term 'communities of practice' refers to the social phenomenon in which people group together around a shared enterprise, in other words:
... a social structure that focuses on knowledge and explicitly enables the management of knowledge to be placed in the hands of practitioners ... communities of practice are groups of people who share a passion for something that they know how to do, and who interact regularly in order how to learn to do it better (Wenger, 2004, p. 2).
Although there is not sufficient space in this article to go into great detail on communities of detail, the main point is that they can be accidental and characterized by largely unconscious processes in which members learn fairly passively, what the norms, identities, values of the community as well as the body of knowledge or they can be more consciously created and developed to maximize learning, currency, relevancy, resiliency and, most importantly, societal contribution. In developing a community of practice, Wenger, McDermott and Snyder (2002) drew upon the experience of working with a group in Silicon Valley and developed a series of principles on how to make a community of practice vital and 'alive'. These include:
1. Focusing on core values
2. Combine familiarity and excitement--balance between routine events that create stability and those that encourage divergent thinking and spontaneity e.g. journal clubs vs. invited speakers
3. Creating a rhythm for the community--a contextually related ebb and flow of activities, such as this conference held every other year
4. Design for evolution--plan for growth and encouraging diversity--diversity of thought and action
5. Open a dialogue between inside and outside--to maximize learning and increase responsiveness to change, learn from other groups
6. Invite different levels of participation--people will want to engage at different levels and in different ways, that is fine, not everybody needs to be core or in leadership position
7. Develop public and private spaces--allow for individual, small group and large scale interactions.
Finally, and as a matter of some urgency, we need to politicise our activities as professionals. Allied health professionals are notoriously a-political and generally conservative. However, I would argue that such passivity is no longer viable given the future we face with respect to issues such as the development of the generic health work worker, workplace agreements, and creeping credentialing (in which the entry level qualification of professions keeps moving upward). We need to politicise ourselves as a health professional bloc, as well as within our home profession over key social issues in which we can and should have a voice.
In closing, my hope is that we find new ways of firstly understanding the complexity of the endeavors that engage our energies and passions everyday, that we find ways to capture the embedded knowledge of our expert practitioners (a key issue in a looming demographic scenario of an ageing population and a shrinking workforce) whilst also growing diversity and cultural inclusion in our professional communities, that we create new ways of working with those who require our knowledge and skills in more equitable, power sharing arrangements, and finally, that we take responsibility for our destinies whilst remembering our collective social contract. All this is essential because, as the saying goes, "we won't get the future we want, we will get the future we deserve".
This article is based on a plenary address to the New Zealand Association of Occupational Therapists Conference in Wellington in September 2006.
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Professor Gail Whiteford BAppSc (Occ Therapy),MHSc (Occ Therapy), PhD Head of Albury Wodonga Campus Professor and Chair, Occupational Therapy Key Researcher, Research into Professional Practice, Learning & Education Charles Sturt University, PO Box 789, Albury NSW Australia
Address for correspondence Tel: + 61 2 60519806 Email: GWhiteford@csu.edu.au…
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Publication information: Article title: Autonomy, Accountability, and Professional Practice: Contemporary Issues and Challenges. Contributors: Whiteford, Gail - Author. Journal title: New Zealand Journal of Occupational Therapy. Volume: 54. Issue: 1 Publication date: March 2007. Page number: 11+. © 2008 New Zealand Association of Occupational Therapists. COPYRIGHT 2007 Gale Group.