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].


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.


[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.


All About Bedpans: How Credentials Stratify Work

In a September episode of White Coat, Black Art,  host Dr. Brian Goldman attributes burnout among some young nurses to a gap between expectations established in pre-professional training, and the realities of the job. His guest, an early career ICU nurse, described this:

“Nurses really still seem to be in a secondary role to doctors, and I was surprised by the lack of respect that I felt as a nurse, and the stuff I was expected to do as a nurse that I didn’t get taught in nursing school.” The stuff she was expected to do included cleaning up bodily fluids (as the cleaning staff were not allowed to do this), cleaning bedpans, and answering the phone. “I feel like a glorified secretary sometimes,” she said.

This nurse, who at the time of the interview was considering a career change, also described having a great deal of responsibility, but little autonomy in the performance of her work. This is an issue well worth discussing on its own. But I’d like here to focus on what her comments suggest both about how our career expectations are shaped, and about, again, the question of status in the professions1.

First, consider the question of expectations. The nurse interviewed by Goldman recalled the idealism she developed through her nursing education: she described, briefly, feminist influences, and the idea that nursing profession was evolving professionally into realms of greater power and responsibility. Her work experience was rather far removed from what, through her education, she had been taught to expect.2

As college and university degrees are increasingly marketed in terms of “careers,” you have to wonder whether unmet, “great expectations” are also becoming more pervasive. Lots of unis and colleges are developing co-op programs to help bridge learning and practice, but I remain skeptical. It seems to me that once we start marketing education – a phenomenon that has really intensified in Canada in recent years – there can be a nasty, dark underbelly in terms of exploiting students’ (often uninformed and under-researched) aspirations. Does this contribute to unrealistic career expectations? I wouldn’t argue this as an absolute, but I do think it’s a question worth asking.

The second point I’d like to consider is a question that I’d love to put to health professionals. Does the increasing stratification of health care entrench, in some unhealthy and unexamined ways, a form of credentialed elitism? Perhaps I was tweaked to consider this by the nurse’s comments about cleaning bedpans. I couldn’t help but compare this to the stoically cheerful comments by my daughter’s stepmom, a long-practicing nurse, about shifts spent “wiping butts.” Have these two nurses – one newer, one with twenty years on the job – simply learned to think differently about the meaning of their work? Has our younger nurse been trained in an environment where it is expected that the lower status aspects of care will be “downloaded” onto LPNs and nursing assistants?3

It’s not a frivolous question. What I’m thinking about here is something akin to an unrecognized caste system, which is entrenched both through professionalization and, in many cases, unionization. Basically, the more thoroughly we are able to describe work – name positions and place boundaries around the nature of tasks that will and will not be performed – the more opportunity there is to segregate “good work” from “not so good work.”

Feminist accounts of work and learning (which have expanded, appropriately, to consider questions of race), point to the ways in which care of children (education, early childhood education and daycares/dayhomes), and care of the ill and infirmed (hospital and long-term care), are disproportionately assigned to society’s most disadvantaged (on average) members: women, immigrants, and visible minorities.

So as we continue to define increasingly specific forms of work through training and credentialing (dayhome providers, homecare providers, nursing assistants, etc.), some real problems emerge. One is that university degrees may “overqualify” those who, once in the workplace, find themselves changing bedpans, answering phones, or undertaking similar “low status” and low skill work. A second, more serious problem is captured through a feminist take on care work: As a society, we can all too easily perpetuate its low status through education paths. College and training credentials specific to care work ensure that it is always “someone else’s job.”

For me, this last question raises lots more ethical and economic questions about “good” work, “bad” work, and how it ought to be distributed in society. Someone has to clean the bedpans. Who should it be and why? Food for thought, and fodder for another blog. In the meantime, I have to go wash some sheet (a job for which I am grossly overqualified).


1See my blog from last week about Physicians’ Assistants.

2The problem of being “rudely awakened” in practice is one shared by teachers. In our own Faculty of Education at the University of Alberta, present reform efforts in teacher preparation are in part spurred by a recognition that classroom learning and work-based learning (through practicums) needs to be better integrated. The culture shock of shifting from “ideal” to “real” is just intense.

3I want to emphasize that I’m not personally criticizing the nurse in question here. I’m more interested in whether her perceptions of her work are representative of some broader assumptions. The nurse’s comments do deserve to be heard in their context: The White Coat Black Art episode about burnout in the health professions was broadcast September 2, 2009, and is available for download. And WCBA is a terrific show by the way! Check it out.

So You Want To Be a Professional? The Case of Physician Assistants in Health Care

These are certainly interesting times if you are a health care provider trying to figure out where you stand in the “pecking order” of professional designations. We have a health care system fraught with chronic shortages of physicians. Other health care providers are subject to boom and bust cycles in demand for their services.1 These conditions, along with the pressing need to improve the efficiency of health care delivery, are encouraging innovation in human resources: re-allocations of labour, team care models, and new specialization areas. A recent episode of CBC’s The Current  discussed the emergence of one such innovation: the introduction of the Physician Assistant position in Ontario health care settings.

What’s a Physician Assistant? Great question. Add it to the growing list of specializations and sub-specializations that fall under the umbrella of health care providers. The Physician Assistant or “PA” position has been a staple in the military for several decades, but has only very recently been given a place in civilian health care in Canada. According to CAPA, the PAs’ professional organization, a PA works as a “physician extender.” Typical tasks include taking medical histories, ordering and interpreting diagnostic tests, prescribing medications, and assisting in surgery. CAPA President Ian Jones, who was interviewed by The Current, states that the introduction of PAs is a sensible strategy for delivering healthcare more efficiently, and reducing patient wait times.

So what’s the problem here? Doris Grinspun, Executive Director of the Registered Nurses’ Association of Ontario, also appeared on the Current episode, arguing that PAs are inconsistently trained, less trained than RNs, and may potentially compromise care quality.3 In fact both guests define the issue in terms of patient care and patient interests. Regulation of professions, via self-regulation, the state, or some combination of these, is indeed important for protecting public interests in areas that significantly affect their wellbeing. Think, for example, of concerns voiced by some around the unregulated nature of alternative medicine.

The patient-interests based arguments of The Current’s guests are thus not without relevance or merit. However, they obscure the fascinating dynamics of power struggles among established professional groups and “up and comers” competing for legitimacy within a given field. Perspectives that examine conflict, competition and self-interest within and among professions are sometimes designated “neo-Weberian” because they pick up on and extend the work of turn-of-the-century (that’s 20th century) sociologist Max Weber.4 Among his many historical and sociological explorations, Weber took an strong interest in how specialized knowledge brought power and status to the emerging professional class. In other words, he recognized that the idea of “the professional” has what we might call cultural or symbolic worth beyond their defining educational and technical criteria. Professionals have social status; people defer to their authority. This has some cachet, no?

So if we apply this kind of thinking to the discussion on the Physician Assistant accreditation, the opposition expressed by nurses takes on a new dimension. Registered Nurses have historically specialized in similar capacities, so a PA is essentially a new kid on their block, competing with nurses for “ownership” over the bodies of knowledge required to support physicians in various settings. The rarity and breadth of knowledge involved (“expertise”), along with the overall necessity of the services offered, impacts the demand for the work, and the compensation for the work. Simply put here, PAs and RNs may be competing for the same jobs, and they do so by trying to persuade others (including the public) of the legitimacy, importance, and usefulness of what they know.

Turf Wars: Implications for Career Planning

I find these conflicts among professional bodies fascinating in their own right,5 but they can have important consequences for students attempting to establish career paths. Professional turf struggles can translate into competing accreditations, designations, and programs of study that can be bewildering for students entering the field. As provinces and provincial level bodies tend to regulate and license forms of education and work, standards and designations can differ from one end of the country to another, making it difficult for students to move to other provinces with assurance that their credentials will be recognized. In the case of PAs, for example, it’s a graduate-level degree in Manitoba,6 whereas in Ontario a student may enter a PA program after two years in any undergraduate degree program.

Fields in the process of professionalizing – fitness trainers and massage therapists come to mind – can be fraught with risk for those entering them. Credentials with weak or questionable recognition value can make it tough to find work in the chosen field, and the road to such recognition is often long. (Midwifery is a great example of an uphill battle to achieve professional status and recognition.) Emerging fields often can’t promise the same compensation as established fields. Being a “professional” is no guarantee of income or job security.

So if you or someone you know is thinking about career routes, it’s not a bad thing to recognize that a “professional” designation isn’t always a straightforward thing. Some professions like RN, LLB, or CGA (among many others) are well established and well recognized. Where newer and less recognized fields are laying claim to professional status, it is a good idea to do some investigation and determine which programs of study are recognized where. Professionalization generally serves public interests, but it’s important to recognize and remember that professional organizations and professionalizing areas have a stake in selling the public on their legitimacy and credibility.


1 Health Canada (2004). Health human resources: Balancing supply and demand. Health Research Bulletin, 8.

2 Health care provider designations include registered nurses, doctors, licensed practical nurses, registered psychiatric nurses, nursing assistants, nurse practitioners, lab techs, radiation techs, respiratory therapists, psychologists, physiotherapists, and occupational therapists… among others! See Health Canada (2004), above. Also Salhani & Coulter, 2009, The politics of interprofessional working and the struggle for professional autonomy in nursing.

3 More detail on the OARN’s position on PAs is available here.

4 Neo-Weberian or critical accounts of professionals and professionalism take the perspective that many aspects of professional organization and professional regulation are self-serving because they bar entry by competitors. The status of the profession is upheld when its exclusiveness is maintained. Weber didn’t talk about this stuff directly himself, but his work serves as a foundation for it. Weber is best known for his work “The Protestant Ethic and the Spirit of Capitalism,” which looked at (like the title suggests) the historical conditions that led to capitalism being more successful in some places than others (i.e. England and North America). The work famously cites Ben Franklin as an exemplary early capitalist, emphasizing frugality, hard work, and self-control. For a quick and dirty overview, here’s the Wikipedia entry.

5Competition for legitimacy can occur in any professional field. For an interesting account of…well, accountants, see Macdonald, L. & Richardson, A. (2004). Identity, appropriateness and the construction of regulatory space: the formation of the Public Accountant’s Council of Ontario. Accounting, Organizations and Society, 29(5-6), 489-524. It’s a historical overview of competing professional accreditation bodies. And hey, who knew there was a field of academic study called “Critical Accounting?”

6Nurses oppose the Ontario government’s physician assistant role…