Does the professionalisation of nursing and other occupational groups employed in healthcare and the expansion of their roles signal a levelling of the medical hierarchy or medicine’s continued dominance?

Does the professionalisation of nursing and other occupational groups employed in healthcare and the expansion of their roles signal a levelling of the medical hierarchy or medicine’s continued dominance?

The sociology of nursing continues to be dominated by its focus on the subordination of nursing in relation to the medical hierarchy. This is despite significant interventions through the professionalization of the nursing field and the expansion of their roles. In addition, other occupational groups employed in healthcare have also seen a shift in their roles as healthcare professionals. To assess the extent of medicines continued dominance we must first look at defining a profession and changes to nurse training with assistance from Eliot Friedson’s work (1970, 1986). This essay also makes reference to Svensson’s (1996) analysis of the negotiated order between nurses and doctors with relation to other social theorists such as Porter (1991) and Hughes (1980). Changes in gender status will also be assessed and finally conclusions will be drawn on whether or not medicine continues to dominate or whether there has been a levelling of the medical hierarchy.

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We should consider the bureaucratic nature of a hospital environment; this, according to Weber (1914) means that there must be an organisational hierarchy. Within a hospital, for example, this will be split into professional groups, between professional groups, between primary and acute care and between different medical specialities. Specialist expertise must be employed and there are an abundance of specialist workers within a hospital, both medical and technical. Impersonal rules are used and discipline enforced to maintain social order within the organisation. Salaries are often paid to their workers instead of wages, and there are definite career ladders within the hospital. The bureaucratic nature of hospitals limits freedom, autonomy and initiative (Turner & Stanley, 1995) due to the fact that those in managerial positions create policy and those in medical positions follow it.

Looking at Friedson’s (1970) work we can distinguish key characteristics that produce a profession. Firstly there must be a body of specialised knowledge and this must be produced and assessed by those who are members of that profession. Secondly, there must be a monopoly maintained through the registering of all members, the restriction of employment to those only on that register, and competence assessments made only by those in the same field. The Formation of the Royal College of Nursing in 1916 led to a state registration in 1918. There must be autonomy in decision making and reviews of professional changes as well as a code of ethics to dictate the ideology of service to be carried out by members. There is an associated social status concerning professions and there is a definite “hierarchical divide between the knowledge-authorities in the professions and a deferential citizenry”. The nursing profession has witnessed a change in the way that they become trained, now having to obtain a degree or a diploma that is recognised by the Nursing and Midwifery Council to be registered with the profession. This was through the ‘Professionalisation project’ which introduced training taken out of the working environment (Project, 2000) with a degree structure and status. There were distinctions made between basic care and clinical care and a development of a specific knowledge base. Specialist clinical roles were also introduced, and through further education nurses can become a nurse practitioner or a prescribing nurse. This has led to the nursing profession being recognised more adequately on the medical hierarchy.

The medical professions are definitely hierarchal in nature with surgeons and specialist doctors at the primary position. The “Dominance of doctors was supported at various levels: over the content of their own work (characterised as autonomy), over the work of other health care occupations (authority) and as institutionalised experts in all matters relating to health in the wider society (sovereignty)” (Willis, 2006:42). Their training is longer and significantly more taxing then that of lay therapists and occupational workers, meaning that they receive higher salaries and acquire status for their chosen professions. Nurses are seen further down the organizational hierarchy, however the professionalisation of the nursing occupation has meant that there has been a leveling of the chain of command. Now there is a ladder within the nursing profession, from nursing specialists, to staff nurses and then unqualified nursing support in the form of healthc…………………………….