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In Tension - Let the Doc give an example

Chapter · January 2007

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Carola Aili Lars-Erik Nilsson

Lund University Kristianstad University
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 APA Reference
Aili, C., & Nilsson, L. E. (2007). Tensions: let
the doctor give an example., in Aili, C (Ed) In
tension between organization and profession:
professionals in Nordic public service. Nordic
Academic Press.between 207, p 7-13 .

In tension: -
let the doc
give an
example

Authors’ right to dissemination of the

article
This text is the final draft, post-
refereeing.

Communication
Carola Aili
Lund University
carola.aili@soc.lu.se
 [First Authors Last Name] Page 1

“Introduction: The individual in tension…”

Carola Aili

Lars-Erik Nilsson

Kristianstad University

This book is about what it is like to be a professional in today’s public sector organisations

where higher sick leave, burnout, decreasing resources, increasing demands for professional

development, rapid changes in organizations, new forms of leadership, and client- oriented

practices are part of the professional’s working life. Our prime focus is the individual

professional and the challenges these tensions personally represent. We aim to contribute to the

understanding of tensions professionals need to handle, thereby promoting a dialogue on issues

such as ‘What conditions do new professional tasks require?’ ‘Which new competences are

needed?’ What impact does the implementation of new technology have on professionals?

Professions in Nordic countries

The chapters of this book focus on professions that have developed parallel to the

expansion of the welfare state (Bertilsson 1990). This expansion has placed new demands on

public services, leading to the restructuring of public sector organisations, the development of

new professions expected to carry out political reforms, the division of labour through

jurisdiction, and to the forming of more specific professional identities (Macdonald 1995).

Professionals in a welfare state have a problematic relation to the ideal definition of a profession,

as Freidson puts it, ‘a set of institutions which permit the members of an occupation to make a

living while controlling their own work’ (Freidson 2001:17). Since the welfare state is governed

politically, the work and the education of the professionals is a political question or takes is form

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in compromises between the state and the professionals at different levels” (c fx Svensson

2002:30). Professional corporations form an important group in the society, and the state has

legitimized them through delegating control and self-regulation to the professional bodies.

Professionals need to be aware of their responsibilities and duties in order to be able to perform

their work; they must know about political governance and political goals as well as professional

knowledge and mission.

The symbiosis of the professional groups and the state (Government) works its way down

to street level, to the local workplace. Changes at the governmental level are mediated to the

local organisations not only via the government, but also via the professional groups themselves

through government-regulated education and research (Macdonald 1995). Sometimes

government and the professions are not in step, thereby producing tensions and challenges for

the individual professional. This kind of situation can be illustrated by the implications of the

idea of citizenship conceptualized in liberal gloss about the individual’s fundamental right to

express a personal opinion (Harré m.fl 2002) leading to clients claiming “their rights”.

Professionals have to consider these claims, even at times when they are unable to fulfil them for

lack of resources, or at times when they conflict with professional judgement. Thus,

professionals have to work in tension between professional and organisational demands, while at

the same time considering issues of client empowerment.

The changes we describe are typical of a system of ideas, influenced by Anglo-Saxon

new liberalism, called New Public Management (NPM), which has spread through the western

world during recent decades (Hood 1995). Efficacy and effectiveness are central notions of

NPM. Public sector organisations should be managed by budget and quality control. A guiding

principle is that social progress can be achieved by enhanced productivity (jmf Agevall 2005).
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Productivity should increase as a result of creating independent production units. The quality of

the services produced, such as education, health and social care, are to a high extent left to the

professionals, clients and/or parents regarded as critical consumers. As an outcome, local

political decisions to a large extent move from the level of politicians to the civil servant level

(Montin 2002). According to Agevall (2005), a founding postulate of NPM is the ‘notion that

people cannot be trusted’ (p. 97). Consequently the client cannot trust the professional, who

might act out of self-interest, while the professional cannot trust the client, who might take

advantage of the situation. This state of affairs can also be applied to the relation between

politicians and professionals.

The concept of tension

When we set out to write this book, we were initially concerned by the alarming reports

we have mentioned. We regarded tensions primarily as a result of the pressure that public sector

organisations put on professionals, who try to protect professional interests and autonomy while

carrying out discretionary work. This way of conceptualising the relation between the state and

professionals as a source of conflict has been a typical approach in research (Freidson 1970,

Sarfatti-Larson 1977, Abbott 1988, Brint 1994, Svensson 2002).

As our work on the book progressed, other conceptions of tension emerged. It seemed

likely that tensions, mediated by both professional and organizational interests, constitute a

dynamic framework within which individual professionals renegotiate their individual rights,

duties and obligations. In these processes they have to take into account demands from

colleagues, clients, families and significant others, by trying to assess whether these new

demands can be encompassed by their profession and by themselves personally, and then by
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deciding which demands to prioritise. A desire to control work in the name of effectiveness and

quality is typical both for professionals and the institutions of the state, but often in different

ways. At the same time, both parties advocate autonomy for professionals in the name of

responsibility and individualisation.

The theory of professions also brings focus to the tensions between what is considered to

be optional for the profession, the public and/or the client (Freidson 2001:127). A

conceptualisation of tensions as conflicting interests, inter- and intra-professional disputes, and

general dissonance has proved to be helpful, enabling some of the authors to illuminate

important issues in a productive way. Other authors conceptualise tensions more as a field of

uncertainty exacting consideration or as new strategies where tensions even create opportunities

for the individual to act in new and better ways,. even providing new career paths.

The word ‘tension’ encompasses the ideas of dissonance or competing requirements as

well as boundary work and border crossings. Lipsky (1980) claims that politics comes into being

through the professionals’ meetings with their ‘clients’, e.g., in the hospital ward or in the

classroom. This process is not trouble-free, however, since the professionals frequently are faced

with dilemmas that are difficult to make sense of and to handle, thereby leading to different

kinds of ‘politics’ than intended.

Professionals’ intension fields – a historical perspective

Are these the worst of times for professionals or just other times? At least tensions are not

new phenomena. This can be demonstrated with a glimpse at the history of the medical

profession as a doctor describes what it meant to be working in the rural areas of Sweden during

the first part of the nineteenth century:

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‘It will not hold up in the long run that, as it is now, provincial doctors at the same time
need to manage health care and the new and increasingly more demanding social care. It is,
as we know, totally new principles presently being worked out and applied in health care.
Until now one has focused on how to cure deceases, now one begins to understand that this
is not enough, there is a need for earnest attempts to work to prevent them. And it is this
part of the problem that increasingly falls on the provincial doctor. But as his work is now
laid out he does not have the time for this new activity in a real efficient manner.’

‘Can the doctor give an example?’

‘Yes, many. I’ll satisfy myself with one. There was a question about the housing of an
agricultural labourer receiving allowance in kind under the vicarage in my district. The
house was being renovated, and I had made a specific request that it should be furnished
with a heating system. Fine! So I am away on a journey on official business, and the Dean
calls a meeting and makes the meeting decide not to install the heating system.’

‘Why?’

‘Why? He regarded it as not suitable that his labourers should have a heating system when
he did not.
(Nordström, 1938 [Lortsverige (1938)/§ 1. Prosten och stataren]) 1

Nordström’s dialogue illustrates that the welfare state, despite its often positive

connotations, may well be a locus of tension and gives nourishment to professionals reasoning

1
These paragraphs have been extracted from Lubbe Nordström’s book Lortsverige. The publication of Nordström’s
book coincided with the growth of the welfare state in the Nordic countries. Through his writings, overcrowded
living conditions, sanitary inconveniences and health problems were vividly depicted as conditions shared by large
parts of the population. These descriptions informed contemporary society about the life of ‘ordinary’ people and
contributed to a critical debate about common responsibilities for the welfare of all citizens. Nordström’s texts and
radio broadcasts became part of the debate on what has metaphorically been called the “people’s home”. In
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about moral values, redistribution of goods, rationales for action, professional responsibilities,

division of labour, forms of control and so forth. These are issues that trouble the individual

professional. What it means to be a doctor is in some respects still the same. Doctors are

concerned with the health of their patients, with diagnosis, what medicines to prescribe and

similar issues. In other respects, what it means to be a doctor has radically changed. The scenario

illustrates an emerging political will to make better living conditions. The doctor presents it as a

result of advances in medical science, saying that there is a connection between health and

housing. He pinpoints changes in technology that he considers to be important to public health.

He demonstrates that a social factor such as distribution of wealth and social status influences

how he can perform his work.

Finally, he forewarns of a particular division of labour between doctors and social

workers. Change produces professional difficulties that need to be dealt with; he cannot easily

work out how he can manage with the resources at his disposal. The Nordström scenario also

illustrates issues of occupational identity. Whether the provincial physician should be a health

worker or more of a social worker is a dilemma that he needs to handle. Identity is often

regarded as a product of social structures. Abbott (1980) suggests that for professions whose

jurisdiction is a product of laws, rules and acceptances formed in different arenas, these laws,

rules and acceptances may be sources of identity. Changes in jurisdiction thus challenge that

identity.

hindsight they can be seen as foretelling the building of what is more commonly referred to as the welfare state in
most countries.
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Continuous change in public sector organisations

Change is a ubiquitous phenomenon (Braudel 1972, Freeman & Perez 1988) and

metaphors such as post-industrial, information society, postmodern, risk society or knowledge

society are used to describe the changes. The implementation of New Public Management has

brought about far-reaching reforms and changes in Scandinavian public sector organisations,

processes often implemented to increase efficiency and to promote service quality. Street-level

bureaucrats often connect these changes with increased workload and demands for efficacy

(Larson-Sarfatti 1977). Individuals and groups are often required to take the initiative and engage

in the development of quality and work processes. Their initial creative and responsible efforts to

enhance quality are often squandered by impediments and limitations that put job satisfaction in

jeopardy. Job satisfaction, defined as attitudes based on judgement of relevant aspects of work

and work situation is strongly related to well-being and health (Karsten, Koning & Van Schooten

2007).

We propose that the conflicting aspects we have described relate to ideas of what it

means to perform professional work and to be a professional. Vermeulen (1997) shows that

tensions between these ideas and actual work conditions affect motivation. Furthermore, the

professionals in non-profit sector organisations often experience deficient working conditions

(Light, 2002) such as poor technological equipment and support and few opportunities for

professional development. Additional complications are indistinct forms of recognition, since

unclear standards of performance make it difficult both to encourage those who do a good job

and to reprove those who perform inadequately. The latter can be dealt with internally, by

professions with a strong jurisdiction (Abbott, 1988). However in countries where the expansion

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of professional organisations has been fundamental to the development of the public sector, this

is seldom carried out to its full extent.

In organisational settings, changes are often expected to take place at organisational level,

team level and at individual level. The authors of this book discuss the likely effects of these

changes by (1) adding the professional level and the professional body and (2) exploring which

tensions these processes bring about among the different organisational levels.

In the following chapters we use various perspectives to exemplify the kind of tensions

that these change processes bring about for the professionals of our time. We propose that there

are change processes that are harmful to the professional, even at times when professionals

themselves come to grips with them and sometimes act as driving forces in the process. There

are reasons to investigate these tensions and what makes them injurious. Under which

circumstances can the will to do a good job be harmful? When does new knowledge, other ways

to think or new technology become a burden instead of a resource in professional work? Under

what circumstances will professional life turn into dystopia? What does the future have in store

for the heirs of ‘the good doctor’?

This book reports and discusses research projects in Norway, Denmark and Sweden. All

chapters have been discussed in workshops, and all authors have taken active part as referees and

discussants for several chapters. Carola Aili and Lars-Erik Nilsson have been first referees for all

chapters and have operated as general editors. The final referees have been Lennart Svensson

and Pam Denicolo.

We are thankful to Kristianstad University for financial support.

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References

Since the references of all book chapters are gathered at the end of the book, we have to

direct you to the edited book.

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