Professional Work

Knowledge, Power and Social Inequalities

Elizabeth Gorman, Steven.P Vallas, Elizabeth Gorman, Steven.P Vallas

• Publisher: Emerald Publishing Limited
• Year: 2020
• ISBN:
  9781800432123
• Topic: Business
• Subtopic: Workplace Culture
• Index: Business

The professions have undergone massive changes in recent decades, as globalization, information technology, bureaucratization and market competition have begun to envelop even the most prestigious occupations in contemporary societies. Ironically, at a time when expert knowledge has grown increasingly important, the 'golden age' of the professions has receded into the past. Professional autonomy, authority, and ethics are all under siege, and even their claims to exclusive control of knowledge face challenges on multiple fronts.Volume 34 of Research in the Sociology of Work explores how the professions are faring in this changed world, shedding new light on a field that has long been at the center of social science thinking about the economy, the state, and social order. Chapters in this volume explore a series of questions that are vital to modern life, such as:

• How has increased control by employers and clients altered the experience of work for professionals?
• What are the new bases of professional status?
• How are underrepresented groups faring within the professions?
• How do professionals respond to precarity and unemployment?

PART I

THEMATIC CHAPTERS

CHAPTER 1

PROFESSIONAL ENGAGEMENT IN ARTICULATION WORK: IMPLICATIONS FOR EXPERIENCES OF CLINICAL AND WORKPLACE AUTONOMY

Jane S. VanHeuvelen

ABSTRACT

Autonomy has long been established as a critical component of professional work. Traditionally, autonomy has been examined as the extent to which an individual or a professional group controls the decisions and knowledge used in their work. Yet, this framework does not capture the additional work activities that professionals are increasingly expected to perform. Therefore, this chapter argues for theoretically expanding our understanding of professional autonomy by bringing in the concept of articulation work. Using the case of healthcare organisational change, this study assesses how shifts in work practices impact autonomy. Data come from longitudinal ethnographic fieldwork and in-depth interviews conducted at a Neonatal Intensive Care Unit as it underwent significant structural changes. Findings show that professionals were forced to change articulation work strategies in response to new organisational structures. This included changes in the way professionals monitored, assessed, coordinated and collaborated around patient care. Furthermore, these shifts in articulation work held important implications for both workplace and professional autonomy, as professionals responded to changes in their work conditions.

Keywords: Autonomy; articulation work; healthcare providers; collaboration; organisational change; coordination

A foundational topic in sociology has been the role of professions in society (Gorman & Sandefur, 2011). Many of the studies responsible for our theoretical understanding of contemporary professionals have focused on the changes in status and authority of medical professionals (Hafferty & Castellani, 2011; Light, 2004; Mckinlay & Marceau, 2004; Mechanic, 2004; Pescosolido & Martin, 2004; Starr, 1982). Within these studies, scholars have highlighted the importance of autonomy as a key characteristic that serves to secure professional status (Gorman & Sandefur, 2011). Drawing from the work of Freidson (1970), professional autonomy refers to control over the technical knowledge used when making decisions. Yet, since this original definition was established, the landscape in which physicians and other professional groups work has significantly shifted to include increased interactions with organisations, external pressures, and new client expectations (Gorman & Sandefur, 2011). In response, scholars have examined how such changes affect the autonomous practice of medical professionals (see Armstrong, 2002; Timmermans & Kolker, 2004 for an overview). Disagreement emerged regarding whether these changes resulted in a loss of professional autonomy, as well as the broader implications for the overall status and power of professionals (Prechel & Gupman, 1995). More recent research moves past broad debates about professional dominance, exploring instead the relationship between autonomy and specific policies, such as the introduction of evidence-based medicine (Armstrong, 2002; Timmermans & Kolker, 2004) or how professionals navigate and adapt to working in various organisational contexts (Hoff, 2003; Hoff & McCaffrey, 1996; Leicht & Fennell, 1997; Lin, 2014).

Yet, even as studies have sought to expand and update our understanding of professional autonomy, they have continued to exclusively focus on control over knowledge and decision making (Armstrong, 2002; Leicht & Fennell, 1997; Lin, 2014; Timmermans & Kolker, 2004). This framework provides a narrow lens for assessing the way professionals experience control, or a lack thereof. Specifically, studies of professional autonomy have largely ignored the actual work of professionals and the numerous tasks they are expected to perform. For example, healthcare professionals¹ are increasingly expected to collaborate and work in interdisciplinary teams. The promotion of teamwork is in part due to the Institute of Medicine’s report, which called for improving coordination and communication between providers as a critical component for the reduction of medical errors (Institute of Medicine (U.S.), Committee on Quality of Health Care in America, 2001). In addition, many providers are encouraged to practice patient-centered care, a philosophy that promotes a “physician–patient partnership” in which the views of the patient are considered (Ishikawa, Hashimoto, & Kiuchi, 2013, p. 147). In light of these changes, physicians face a potentially contradictory set of institutional logics: they must maintain their professional autonomy of decision making inside a healthcare environment in which they are increasingly expected to coordinate work activities with a larger number of individuals, groups, and organisations. Responding to these new institutional logics, many healthcare facilities are enacting organisational reforms that directly impact and alter the daily tasks and coordination activities, or what can be categorized as the articulation work, of medical providers (Mikesell & Bromley, 2012; Strauss, 1985; Strauss, Fagerhaugh, Suczek, & Weiner, 1985; VanHeuvelen, 2019).

Yet, despite major shifts in the daily work of professionals and research that finds non-decision making tasks account for an increasing amount of professional work (Postma, Oldenhof, & Putters, 2015; Tai-Seale et al. 2017), studies have not yet assessed what these work activities mean for professional experiences of autonomy. The answer to this question is central for scholarly understanding of the relationship of modern professionals to society, and reflects organisational actors attempting to maintain control in an era of shifting professional authority. Therefore, the current study seeks to address this question by using a case of healthcare organisational restructuring to examine the impact of changes in articulation work on health care professionals’ autonomy. To do so, this study uses data gathered at a Neonatal Intensive Care Unit (NICU) as it underwent structural changes. These include a physical transformation from an open-bay setting to a unit comprised entirely of private rooms, as well as, the adoption of new technology systems. The data for the study come from 13 months of ethnographic observations prior to, during and after the transition to single-patient rooms. It also includes analysis of 35 in-depth interviews conducted with providers across a range of medical professions and occupations. The data analyzed capture a time of organisational restructuring and thus present a unique opportunity to examine the relationship between autonomy and shifts in articulation work that occur as a result of organisational changes.

Overall, this study makes three main contributions. First, practically, it contributes to our understanding of professional autonomy by considering the real, daily tasks that professionals are expected to perform in the modern organisational context. Second, this study theoretically advances the concept of articulation work. Analysis of the data suggests that collaboration operates as a distinct aspect of articulation work that is not captured by the often referred to process of coordination. For providers in this study, collaboration is a critical and valued aspect of professional articulation work that was altered due to organisational restructuring. Third, this study calls for greater attention to the way organisational changes alter articulation work, which holds important implications for autonomy. As this study indicates, when organisations implement reforms, they may unintentionally alter the articulation work professionals have established. This, in turn, impacts the amount of control providers experience regarding how and when they complete tasks, as well as how they interact and communicate with their colleagues. Shifts in articulation work may be a necessary part of any transition process. However, policymakers and healthcare administrators should consider the implications of these shifts for the work practices of providers, finding ways of recognising these activities.

EXAMINING THE “CONTENT” OF WORK: PROFESSIONAL ENGAGEMENT IN ARTICULATION WORK

In this chapter, I argue that the way articulation work is accomplished is often an unintended consequence of organisational arrangement, however, the nature of articulation work on the ground is critical for influencing the degree and type of autonomy experienced by healthcare professionals. I begin by briefly describing the theoretical development of articulation work and professional autonomy, with specific attention to medical professionals. I then move on to discuss how these concepts can be applied to the specific case of change examined in this study.

Articulation work offers a useful frame for capturing the realities of work by examining how a final project is accomplished. Originally conceptualized by Strauss (1985), articulation work is a “supra-type” of work that involves:

First, the meshing of the often numerous tasks, clusters of tasks, and segments of the total arc. Second, the meshing of efforts of various unit-workers (individuals, departments, etc.). Third, the meshing of actors with their various types of work and implicated tasks. (Strauss, 1985, p. 8)

Therefore, articulation work focuses specifically on the interactions and communication between workers, which offers a critical counterbalance to research in the sociology of work that has traditionally focused on the division of labor, occupational roles, power and status, all of which risks neglecting an examination of work itself (Strauss, 1985; Strauss et al., 1985).

Articulation work occurs at multiple and often overlapping levels, from the creation of the overall outline of a project or in the case of a hospital the development of a patient treatment plan, to the organising, monitoring and actual tasks involved in accomplishing and carrying out a final project goal (Strauss et al., 1985). According to Strauss, higher status workers are often viewed as engaging in “first-level” articulation work, which involves developing an overall plan for a project or outlining the “arc of work” (Strauss et al., 1985), while lower status workers are often responsible for second- and third-level articulation work, which involves carrying out and arranging the tasks that have been ordered or are necessary to complete the final project (Strauss et al., 1985; Timmermans & Freidin, 2007). At these lower levels, articulation work activities may be less formalized and not as highly rewarded as more formal activities (Mikesell & Bromley, 2012).²

While many forms of work exist, articulation work is distinguished by its attention to the coordination work that is necessary to bring together the tasks and efforts of different actors across types of work (Postma et al., 2015). Because articulation work encompasses such a wide-range of work activities, studies of articulation work often focus on categories or types of articulation work including: lay activities (Postma et al., 2015; Timmermans & Freidin, 2007), inter and intraprofesssional work (Postma et al., 2015), routine and non-routine work and visible versus invisible work (Hampson & Junor, 2005; Mikesell & Bromley, 2012). Empirically, studies of articulation work have tended to focus on second- and third-level articulation work, examining the supportive tasks associated lower status work and workers (Mikesell & Bromley, 2012; Timmermans & Freidin, 2007). However, other scholars have called attention to the way that all workers and professionals engage in some form of articulation work and are frequently dependent upon the work of others to complete the final task (Strauss, 1988). Others have taken this view further arguing that articulation work is “an int...