Broken Professions and How to Mend Them
Professions are out of place in today’s society. They are a throwback to the industrial-manufacturing days of the United States. Professions have functioned largely autonomously within a social expectation of keeping faith with the public and the production of the social good for which they were specifically authorized by their social contract. Yet, society has found professions in breach of that social contract and out of faith with the public. This is in part a consequence of the changes in the social context of professions, and of the vicissitudes of the emergence of what has been called the new economy. Professions need repair through a course correction. By reclaiming their tradition of civic professionalism, professions will once again move public service, the welfare of the public, and the professional-public partnership, to the heart of their involvement with society. For medicine and nursing, doing so will further the realization of social goods such as health, solidarity, equality, equity, and dignity.
Professions and the New Economy
In today’s society, professions are anachronistic. They are inconsistent with developing patterns of occupational labor that flex, morph, and transmute in the alchemy of the marketplace economy that has emerged over the past 30 years. But to understand why professions are odd in today’s context, it is important to understand something about the new economy.
Historically there have been three economic sectors, each referring to a different category of economic activity (or “process of production”). In the U.S. Census Bureau’s North American Industry Classification System (NAICS), the three major sectors are:1
Primary: Associated with agriculture, forestry, fishing, hunting, mining (277 subsectors)2
Secondary: Associated with manufacturing, including food, grain, textiles, clothing, wood, paper, printing, petroleum and its products, chemicals, rubber, pesticides, soap, plastic, clay, glass, concrete, iron, steel, machinery, and more (652 subsectors)3
Tertiary: Associated with service; also called the service sector (1280 subsectors)
The Service Sector
The attribute of the service sector is that it offers a range of services, that is, activities, not products. The service sector includes banking, entertainment, health care, information technology, professional services such as counseling or accounting, spectator sports, mass media, architecture, and more. Each of these produces a service, an intangible good, for a company (corporation) or for an individual. Health care and nursing are part of the service sector and, in the NAICS, Health Care and Social Assistance section of classification, are sector 62, with 92 subsectors. The healthcare sector includes a cluster of healthcare-related sectors: health system, healthcare industry, healthcare research, healthcare financing, healthcare administration, and regulation and health information technology. What is important to note here is the comparative number of subsectors in each category. Service sector occupations now greatly outnumber those of the manufacturing sector by almost 2:1.
The industrial-manufacturing (secondary) sector has waned and the service sector has grown. The NAICS Economic Classification Policy Committee notes several reasons for this:
Service industries have become much more important than they were. …Services have not just grown in importance; radical changes have taken place in the nature of services produced in the economy. Some of the changes affecting services include the following:
Technological changes, particularly in terms of computers, information, and communication services;
Changes in intangible inputs, such as education, training and the growth of knowledge, which have increasingly become the basis for services transactions;
Changes in government policy, such as decreased regulation of transportation and financial services;
Contracting out of services (especially manufacturing);
Changes in demographics, such as aging, and the consequent demand for health care, and;
Changing consumption patterns and living standards, more consumption of entertainment, recreational and travel services, and so forth.4
Many of the changes that have given rise to the service sector over manufacturing are evident in our own lives as, for example, we have moved from corded to cordless phones, then to mobile phones, then to mobile phones connected to desktop computers, then connected to tablet computers, from which we can now watch television programs, movies, read books, or access library resources. Remembering, not imagining, is all that we need to see how we ourselves have witnessed the rise of the service and technology sector. Nurses who graduated in the 1960s and are now transitioning into retirement remember when intensive care units (ICUs) did not exist except as experimental units. They will remember when ICUs (primitive by today’s standards) moved into non-teaching hospitals. In those days, one might see medical and surgical patients, adult and pediatric patients, and gynecologic and cardiac patients all in the same “intensive care unit.” Soon thereafter nursing specializations would explode. Today, the ANA has standards of practice and professional performance for 22 nursing specialties; it will not stop there!5 Nursing’s Social Policy Statement notes that
the Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership. Registered nurses are accountable [in all roles and venues] for their professional actions to themselves, their patients, their peers, and ultimately to society.6
That society has changed profoundly. It has moved from an agrarian to a manufacturing to a service society, and from a largely rural to a largely urban population. The Industrial Revolution moved the United States from hand-made production to manufacturing. In the United States, the Industrial Revolution begins in the founding of the Slater textile mill in the 1790s. Textiles moved from home and crafts production to industrial production. The United States moved from horse power (real horses!) to water power to steam power and eventually to coal power. The first phase of the Industrial Revolution continued to about 1850. It got a second wind in 1855 with the patenting of the Bessemer process for steel production. Though the dates are contested, the Industrial Revolution ends with World War I. We are now a post-industrial society in which the economy has, in great measure, shifted
from a manufacturing to a service economy. Modern nursing emerged during the Civil War, during the end of the first portion of the Industrial Revolution and the beginning of the second. The reader is encouraged to look at the fascinating period of nursing history between the Civil War and World War I when nursing moves both into private duty nursing in the home, and into society as advocates for public health. Today’s social context of nursing is not that of our forbearers: it is a service and technological economy and society in which nursing has grown into increasingly complex and advanced roles.
from a manufacturing to a service economy. Modern nursing emerged during the Civil War, during the end of the first portion of the Industrial Revolution and the beginning of the second. The reader is encouraged to look at the fascinating period of nursing history between the Civil War and World War I when nursing moves both into private duty nursing in the home, and into society as advocates for public health. Today’s social context of nursing is not that of our forbearers: it is a service and technological economy and society in which nursing has grown into increasingly complex and advanced roles.
The New Economy
The new economy refers to the shift that has taken place in the economy as the United States has transitioned from an industrial/manufacturing economy to one based on service and information technology. The manufacturing economy brought with it job security, a life-long employer, regular wages, a rising income scale, health benefits, pension systems, career ladders, job stability, and more. The new economy, on the other hand, is much more volatile and much less secure occupationally. It is characterized by entrepreneurship, rapid change, distributed management, continuous innovation, skill flexibility, teamwork, continuous learning, risk, networking, contingency, and more. Williams and colleagues describe this environment: “In the so-called new economy, work is increasingly characterized by job insecurity, teamwork, career maps and networking.”7
Professions do not have a good fit with the new economy and the new workplace. Sullivan writes that
the traditional structures of professional life, such as corporate membership [professional associations], controlled markets for professional services, and monopolistic practices in training, recruitment and the control of standards, seem quaint and even antithetical to some of the most touted new patterns of work. The question is: “Where do the professions fit in the future depicted as a globalizing march toward a frictionless capitalism that is based upon information and communications technology?” The fluid morphing of one occupational identity for another and the migration of disparate domains of activity celebrated as a new economy are antithetical at a number of points with key elements of professionalism. Today’s enthusiasm for untrammeled flexibility in workers is not a good match with the professions’ demand for deep training in a complex under-determined field that requires professional judgment and integrity. Professions, unlike businesses, are pledged to protect those in vulnerable situations.8
Issues emerge here that are not our immediate concern but need to be mentioned, such as the demand for nurses to work (float) disparate domains of clinical activity, or the pressure for more rapid production or graduation of nurses, and the pressure to reduce educational requirements for nursing in the direction of manualism. The present concern, however, is for the place and future of professions in the context of radical socioeconomic change. Despite their anachronistic status, professions persist in society, even in the new economy, though, as Sullivan notes, professions are broken and in need of repair.
Professions: Breaking Faith with the Public and in Breach of Contract
In addition to being an anachronism, Sullivan reproaches the professions for their part in breakdowns of “core sectors in the emerging new economy,” much of the “breakdown of public oversight,” and destructive deregulation. He cites the “US financial bubble burst” and the Enron scandal that directly implicates professionals in law, accounting, and banking. He writes that, “quite correctly, both officials and the public saw the leading lawyers and accountants of those organizations as guilty of an insolent repudiation of public trust.”9 He notes a public “suspicion that professionals have broken faith with the public” more generally.10
Breaking Faith
The Enron and banking crises are not the only examples of professions breaking faith with the public and breaching the social contract. There are examples across many professions, many of which have claimed mass media attention.
Both Beecher and Pappworth have noted ethical violations in medical research in the United States and the United Kingdom, respectively.11
Both Beecher and Pappworth have noted ethical violations in medical research in the United States and the United Kingdom, respectively.11
THINKING ABOUT THE START OF THE NEW ECONOMY…
In her book Animal, Vegetable, Miracle: A Year of Food Life, Barbara Kingsolver writes of her experience of taking her family into dietary near self-sufficiency. For a year her family ate only what they could grow themselves on a farm in Southern Appalachia or could obtain locally. They learned sowing and growing and harvesting plants and animals, canning foods, the vicissitudes of raising turkeys, how to make cheese, and on and on. They ate only what was in season, and swapped with local residents for things they did not grow. So: no strawberries in January and no avocados at all. Only if they had canned it could they eat it out of season. They became locavores. Except for flour and cooking oil, which they could neither produce themselves nor obtain locally.
That was the glitch in their self-sufficiency. Even for those of us who have dabbled in hobbies of soap making, candle making, furniture making, spinning, weaving, sewing, leather tanning, basket making, foraging, cooking over fire, and who had neighbors who engaged in other useful hobbies, we still do not achieve self-sufficiency. But that’s okay. It can be ordered. On the Internet. From Germany. As economies have become increasingly intertwined and interdependent, so have individuals, families, communities, nations, none of which are self-sufficient. Neither are professions.
In 1966, Henry Beecher’s landmark paper on ethics in human research was published.12 Beecher, an anesthesiologist, identifies 22 medical research projects that were conducted by prestigious universities, published in respected medical journals, and were deeply ethically questionable. The paper makes for very disturbing, even frightening, reading. In addition to the 22 experiments that Beecher identifies in the paper (and many others that were not in the paper), there were a number of studies that became well-known and roused public ire. Four such studies included the Willowbrook experiment, the Tuskegee experiment, the Tearoom Trade experiment, and the Milgram obedience experiment.13
Two additional examples are the Ford Pinto gas tank explosions, and the Challenger Shuttle O-ring failure. In the case of the Ford Pinto car there was a design flaw in the placement of the gas tank as well as economizing measures in its construction and mount that proved dangerous. In rear collisions over 25 miles per hour, a bolt would puncture the gas tank and cause fuel leakage that could spark, cause the gas tank to enflame and the passengers to suffer severe burn injuries or burn deaths. The flaw was discovered during testing, but in Ford’s risk-benefit analysis the decision was made that it would cost more to re-tool and correct the flaw than to compensate victims for burn injuries or death.14 It was criticized that in Ford’s profit-based risk-benefit equation, human life was accorded insufficient value.
The second example took place in 1986 when the space shuttle Challenger disintegrated shortly after launch, killing all seven crew members aboard. An O-ring seal (made by Morton Thiakol) in the right rocket booster had failed, ultimately causing a structural failure that lead aerodynamic forces to break the shuttle apart. The launch, and subsequent disaster, had been widely covered by the media and was witnessed by millions of Americans on television. An investigating commission found that the flaws in the O-ring seals (which would fail under a certain ambient temperature level) were known, that the disaster could have been avoided, and that it was largely a consequence of NASA organizational culture and decision-making processes that ignored warnings and did not adequately communicate engineering-technical concerns.15
Reclaiming a Moral Force
Sullivan’s analysis of the failures on the part of professionals is much broader than simple avarice and dereliction. Much like Durkheim, he characterizes professions as a moral force for good in society, a force that needs to be reclaimed. His starting point in that reclamation is the belief that professions offer something of moral value to society:
I argue that a democratic society also draws heavily on the skills and moral sources of the professions. Particularly within a society like ours, in which the pull of utility and instrumental thinking—as in today’s ascendant business model for institutions—is so strong, the professions are vital reminders that human welfare ultimately depends upon cultivation of values such as care and responsibility, which cannot be produced by self-interest alone. By focusing on the quality of their craft and the inventiveness of their practice, professionals provide an alternative model of what work can be: a contribution to public value, as well as a source of motivation and deep personal satisfaction.16
The privileged position of professions in society is based on a social contract from which a number of expectations arise. Those include establishing standards of practice and education, ethical behavior, competence, a degree of altruism, responsibility and accountability, self-policing, and the like as discussed in earlier chapters. As NSPS notes, “the professions are expected to act responsibly, always mindful of the public trust.”17 Sullivan writes, “professionals are often engaged in generating or applying new ideas and advanced processes, and so are doing ‘creative’ work, that are all directly pledged to an ethic of public service.”18 According to Sullivan, professions are to engage in a partnership with society where the profession is accountable and responsible and the public is actively engaged and concerned: “These are the stakeholders of the various professional enterprises in health, justice, education and the rest. [This]…ideal of social reciprocity is called civic professionalism.”19 (The issue of stakeholders will become important for Chapter 4.) He cites Brint’s work that points to “a long-term movement away from an earlier conception of professionalism as ‘social trusteeship.’ The drift is toward embracing a notion of the professional as a purveyor of expert services. …The term technical professionalism is employed to refer to this tendency.”20
Sullivan’s claim is that “the narrowing of professional claims toward the purely cognitive or technical in recent decades has contributed to the weakening of professionalism,”21 resulting in a decline in professional civic engagement, a loss of concern for the welfare of society, a decline in altruism and professional ethics, and the reconceptualization of the recipient as consumer of a commodity. He calls for several changes to move professionals away from technical and into civic professionalism.
Restoring a Sense of Calling
One such change is the restoration of a sense of calling or vocation among professionals, to strengthen a professional culture of altruism and commitment to the public good.22 Here, vocation as calling must be distinguished from
vocationalism, a skills-based technicalism, with no roots in calling. In reclaiming the concept of vocation, the profession becomes a part of the person’s identity, the work meaningful as “love of craft,” and the occupation more than just a job. Sullivan’s claim is that “it is ‘affection for the subject matter,’ the particular domain of professional activity that motivates and consolidates love of craft into ‘a standing disposition’ to serve.”23 This is the nurse who loves nursing and who finds satisfaction, if not joy, in service. Vocation is not only essential to civic professionalism, it also removes the possibility of runaway self-interest on the part of the professional.
vocationalism, a skills-based technicalism, with no roots in calling. In reclaiming the concept of vocation, the profession becomes a part of the person’s identity, the work meaningful as “love of craft,” and the occupation more than just a job. Sullivan’s claim is that “it is ‘affection for the subject matter,’ the particular domain of professional activity that motivates and consolidates love of craft into ‘a standing disposition’ to serve.”23 This is the nurse who loves nursing and who finds satisfaction, if not joy, in service. Vocation is not only essential to civic professionalism, it also removes the possibility of runaway self-interest on the part of the professional.
There is more that is needed for professional reform. The outcome of the professional’s work must “contribute to the public value for which the profession stands.”24 For its part, the public, in this profession-public partnership, must take leadership in resolving issues of abuse of privilege and the professions’ refusal of public accountability.25 He calls upon physicians not to recast “patients as consumers” or to “narrow professional roles to fit short-term encounters.”26 He goes further in this project of reform by tackling professional education, calling upon it to recover the formative dimension of professional culture, character, and values.27 He identifies three sets of values: “Values of the academy, the values of professional practice, and the ethical-social values of professional identity.”28 Sullivan particularly emphasizes the last. He writes that
this third set of values emphasizes the professional’s integrity, sense of direction, and ability to assume responsibility for the quality of his or her own work and the standards associated with the field of practice. These values ground professional education in a broader conception of the purpose of the profession and the ideals to which it aspires, connecting training directly with the field’s social contract.29
Sullivan’s summative argument is that
professionalism has proven an ambiguous good. The ambiguity stems in large measure from professionalism’s loss of direction. This in turn has been due to weakening connections between the professions and the culture of civic democracy. …The professional life can and needs to be restructured in ways that suffuse technical competence with civic awareness and purpose.30
Citizenship in Nursing
Nursing has a long history of a call to civic awareness and participation and to fulfilling the duties of citizenship. While early discussions of the duties of citizenship presumed actual legal citizenship, they also understood citizenship as a
larger construct referring to civitas, the body of all contributing members of the society, irrespective of legal status. For the purposes of this work, citizenship should be understood as the latter, and as having no reference to immigration status. It is beyond the compass of this chapter to present a detailed account of nursing’s concern for civic participation, which can be found extensively in the nursing literature (both books and journal articles) from the late 1800s to the present. However, a few examples taken from the various revisions of the Code will give evidence of nursing’s concern for participatory citizenship by nurses, specifically as nurse-citizens.
larger construct referring to civitas, the body of all contributing members of the society, irrespective of legal status. For the purposes of this work, citizenship should be understood as the latter, and as having no reference to immigration status. It is beyond the compass of this chapter to present a detailed account of nursing’s concern for civic participation, which can be found extensively in the nursing literature (both books and journal articles) from the late 1800s to the present. However, a few examples taken from the various revisions of the Code will give evidence of nursing’s concern for participatory citizenship by nurses, specifically as nurse-citizens.
Citizenship and the Code of Ethics for Nurses
The Suggested Code of 1926 details five relational categories of moral duties of the nurse. They are: nurse to patient, nurse to the medical profession, nurse to allied professions, nurse to nurse, and nurse to her (exclusively) profession. However, the preamble of the Suggested Code sets all five of these relationships of moral obligation within the larger umbrella context of nursing’s relationship to society. It states:
Nursing emerges as a profession from its historic setting in an attempt to meet the present demands of society. The most precious possession of this profession is the ideal of service extending even to the sacrifice of life itself, in its incessant effort to meet the need of the world. …The nurse is primarily a citizen. The fundamental basis of ethics is the same for every profession. The obligation of each individual is to serve society as well as possible by contributing that for which he is best fitted. The obligation of society is to see that the individual has the opportunity to develop and to realize the fullest health and happiness possible without interfering with others.31
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