Professional “Status” for Nurses and All Those Other Professions

It was really interesting to read the responses to my recent bit on CBC’s White Coat Black Art. In particular, yikes… did I offend a few nurses! Some respondents were pretty choked that I would suggest that nurses pursue credentials just to gain status, instead of out of a commitment to their patients and their profession.

The only thing is, that wasn’t really what I was suggesting at all. Hence a follow up blog. In the WCBA interview, I talked about the ways in which higher/more education credentials can help professional groups to jockey for status, especially when they are forced to compete for control over a given type of work. It goes something like this:

“We are more qualified to do this kind of work than you are because we learned how in (insert valuable education program here), and here’s the credential to prove it. Do you have this credential? No you do not.”

The response of the rival group is either a) to increase its own credential requirements to prove equal or superior capability; or b) to dismiss the knowledge and skills as something you don’t need to “learn” how to do at school.

The example I used in my earlier blog on this topic was the shoring up of the nursing profession in the face of the growing presence of Physicians’ Assistants in the field. The increasing use of practical nurses is another case in point. Practical nurses perform many of the tasks as nurses do, and are solidifying their educational requirements to prove they can capably do this work. The more it is accepted that PNs can do the work, the less it seems necessary to pay more expensive nurses to do it. The nursing profession as a whole must respond in a manner that protects and hopefully even enhances the importance of RNs to good healthcare.

Although I have focused on nurses, the point of my discussion was never to “dis” the nursing profession, or any one profession for that matter; as I hope will become clear, all professions have incentives to be highly regarded. And of course individual people pursue their occupations (usually) out of passion and commitment and interest, not in order to gain status. But individual people are not the same as the organizations or institutions they are caught up in. And professional organizations, industrial lobby groups, political parties, and chambers of  commerce are diverse examples of organizations that benefit their members by promoting the legitimacy and value of what those members do [1].

Institutionalism

So let me explain that person versus organization distinction further. The thing that makes credentialism[2] so interesting is that it is not the consequence of individual motivations, but of what we can call “institutional actors.” This line of thinking comes out of institutional and (to some extent) organizational theory, and examines how institutions “act” in response to other institutions and environmental cues. [3]. It’s sort of like the personification of corporations in the (aptly named) documentary, The Corporation [4]. So we set aside the fact that institutions (companies, schools, professional organizations et al.) are ultimately made up of individual people and treat the institution as a whole. We work with the assumption that the whole is different somehow from the sum of its parts – just like we can’t reduce a person to a catalogue of his or her body parts!

Then we ask questions like, “How does this institution respond to changes in its environment?”  Just like you’d have to meet new people, change your habits and learn new things if you moved to a new city, an organization might have to change in response to, for example, a new policy or a new kind of technology. Think, for example, of how companies have had to change their marketing strategies in response to the growth of the internet.

Here’s another great example: some years ago, Edmonton Public Schools began to operate as a “quasi-market.” This means that schools are still publicly funded and subject to Alberta’s education legislation, but are encouraged to “market” themselves to attract students by offering innovative programs and learning environments. The idea here is that the parent/student “consumers” of public education get the benefits of a market – competition and innovation – without the risks, because the system is still public [5].

So if you want evidence of how this policy change has affected education in Edmonton, Alberta, you just need to attend to the growing proliferation of roadside signs as schools re-invent themselves in order to attract parents and students. One of our neighbourhood schools, for example, has recently niched itself as an all boys academy; another is now offering Spanish bilingual education for elementary school age students. Because boundaries are open, schools are free to attract students, but they are also free to fail and face closure if they can’t keep their numbers up.

The point here is that, under the open boundaries system, schools change what they do if they want to stay open in order to survive. No individual school – its administration, teachers, parents, students and community – is going to “go gently into that good night;” schools, as organizations, are invested in their own survival. So they examine what competing schools are doing, try to discern what parents and students might want, and actively seek out a niche. If they rely on their old ways of being and think of themselves just as neighbourhood schools that serve their geographical communities, there’s a chance they won’t make it. Or at least they’ll find themselves struggling with fewer students and less funding. And hey – who wants less funding?

In my consideration of the professions, we can think about professions in the same way I just discussed schools – as institutions that need to survive. If we return to the question of nursing, we can see that the profession as a whole involves all sorts of institutions and organizations – higher education (where nurses learn and get their degrees), unions, and professional associations. All of these entities have a stake in nurses being valued in their workplaces, so all will maneuver in response to changes that threaten the well-being and welfare of the nursing profession as a whole.

So when I talk about status seeking through more education, I want to make it clear that I’m talking about the way institutions behave – that’s institutionalism – and not, as I think some of White Coat Black Art listeners took it, about status seeking by individuals. Because nursing has historically been treated like “women’s work” and marginalized next to doctoring, it’s always had to work hard to be recognized as a profession. And now nursing is facing new threats as more care work is provided by practical nurses and aides.

I wouldn’t propose to offer any solutions to the complex business of providing the right mix of health professionals for a given setting – that one is out of my league. But I do think it is important to look at how professional organizations – and the nursing profession is just one among many – seek to ensure how their own interests are protected in the process.

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[1] I want to add a few words about “legitimacy” here. It’s an especially important concept when we are talking about professions, because members of the public come to use professional services on the basis of recognizing that the “professional” exclusively possesses skills and knowledge that not just anybody can get/use. That’s why you’re willing to pay for that person’s services, and it’s the basis for professional’s compensation (like making big bucks); you accept that the person possesses a legitimate combination of knowledge, skills, and experience that you can’t cobble together on your own.

[2] Credentialism, if it isn’t clear, refers to the growth, over time, of schooling required to be recognized as a legitimate worker in a given area. Historically, occupations have required more and more schooling for entrance. One example is school principals. It is increasingly difficult to become a school principal without a master’s degree, but this has not always been the case. Physiotherapists now require a master’s degree, not just a baccalaureate (undergrad) degree.

[3] Institutionalism is a field of study that, much as I described above, studies institutions (instead of people). It asks questions like: why do institutions behave as they do? How do institutions affect each other? What causes institutions to change (or not)? How do institutions affect the way society is organized? For further explanation, here’s the Wikipedia entry.

[4] The premise of The Corporation was that a corporation has the legal status of a “person.” The documentary systematically examines the behavior(s) of a corporation and concludes that if the corporation were in fact a person, it would be a psychopath!

[5] For an explanation of quasi-markets, see J. Kachur (1999), Privatizing Public Choice: The Rise of Charter Schooling in Alberta. In Contested Classrooms: Education, Globalization and Democracy in Alberta.

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