Professionalization and Expertise In Care Work: The Hoarding and Discarding of Tasks in Nursing

• Published date: 01 September 2015
• Author: Sue Dopson,Ian Kessler,Paul Heron
• DOI: http://doi.org/10.1002/hrm.21695
• Date: 01 September 2015

Human Resource Management, September–October 2015, Vol. 54, No. 5, Pp. 737–752

© 2015 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com).

DOI:10.1002/hrm.21695

Correspondence to: Ian Kessler, Professor of Public Policy and Management, King’s College University of London,

150 Stamford Street, London SE1 9NH, UK, Phone: +44 (0) 207 848 3970, E-mail: ian.kessler@kcl.ac.uk

nursing, and allied health professions. Yet while

there is a well-developed organizational studies

literature on the care professions (for summary

see Muzio, Brock, & Suddaby, 2013), mainstream

HRM has devoted relatively limited attention to

this distinctive group of employees.

The relative neglect is all the more noteworthy

given recent attempts by governments in many

developed countries to reform the delivery of

It is difficult to examine approaches to human

resource management (HRM) in health and

other care services without devoting consider-

able attention to the professional component

of the workforce (Gittell, Weinberg, Bennett,

& Miller, 2008). Professionals compose a signifi-

cant proportion of care workforces, reflected not

least in the acute health care setting where a large

majority of employees is drawn from the medical,

PROFESSIONALIZATION AND

EXPERTISE IN CARE WORK:

THEHOARDING AND DISCARDING

OF TASKS IN NURSING

IAN KESSLER, PAUL HERON, AND SUE DOPSON

Although health and social care workforces are heavily professionalized, the

mainstream human resource management literature has been slow to engage

with debates in the fi eld of organizational studies on this distinctive group of

employees. This lacuna is addressed by focusing on how the search for more

fl exible working practices in care services has affected the professions and espe-

cially their relationship with their assistant coworkers. The character of this rela-

tionship is seen as contingent on the logic of professionalization, in turn based

on different notions of expertise, with implications for the allocation of tasks. The

article distinguishes between a specialist expertise, encouraging the profession

to discard routine tasks, and a holistic expertise, nurturing the hoarding of tasks.

This distinction is used to explore the nurse professional project in Britain, a criti-

cal case where the statutory regulation of the nursing workforce has remained

relatively weak. While noting shifts over the years in the British nursing profes-

sions’ adherence to these two logics, workplace data on the nurse–health care

assistant relationship reveal a fragmented pattern of nursing work consistent

with a specialist-discard logic, albeit underpinned by a residual ambiguity among

nurses about their preferred professional logic. © 2015 Wiley Periodicals, Inc.

Keywords: health care, professionalization, nursing, assistant role: Britain

738 HUMAN RESOURCE MANAGEMENT, SEPTEMBER–OCTOBER 2015

Human Resource Management DOI: 10.1002/hrm

User-centered

public services

have prompted the

search for more

flexible forms of

working, challenging

the professionals’

prerogative to

perform certain,

traditionally protected

tasks.

Smith, Vilder, & Westmarland, 2007), the essential

role of the professional in giving effect to changes

in care delivery has been acknowledged, not least

reflected in enhanced state-sponsored rewards

for involvement in the “modernization” process

(Bach & Kessler, 2012, p. 101–104). However, these

rewards often have come with a reciprocal obli-

gation on the part of the professions to adopt a

looser approach to the organization of work. User-

centered public services have prompted the search

for more flexible forms of working, challenging

the professionals’ prerogative to perform certain,

traditionally protected tasks.

This article explores how nurses in acute

health care have come to view and deal with the

recalibration of tasks between themselves and

health care assistants (HCAs), particularly in the

context of their ongoing attempts to profession-

alize. In doing so, the article focuses on Britain as

a critical case. With the distribution of nursing

tasks relatively weakly regulated, nurses in Britain

have been presented with an unusual range of

options on how to pursue their professionaliza-

tion project, raising a number of research ques-

tions: What options have British nurses chosen

in seeking to professionalize? How have these

choices affected the distribution of nursing tasks

and their views of HCAs in this context? How

have the choices affected nurses’ working lives

and particularly their engagement with HCAs at

ward level?

This article argues that nurses’ views on and

engagement with HCAs are contingent on the

underpinning rationale for or logic of profession-

alization, this logic in turn being related to differ-

ent conceptions of expertise and their implications

for task performance. In Britain, nurse uncertainty

over the choice of logic in pursuit of professional

status is seen to lead to a residual ambiguity about

how they view and relate to HCAs. In advancing

this argument, the article not only seeks to deepen

understanding of the professionalization project

among a key group care workers, nurses, but in

broader terms to sharpen analysis of similar proj-

ects across the range of care occupations, not least

in terms of clarifying the positioning of the assis-

tant role within them.

The article is divided into the following parts:

the first explores how the relationship between

the assistant and the professional has been dealt

with in the research literature; the second focuses

on the assistant role in health care and how it has

been positioned within the nurse professional

project; the third articulates the research ques-

tions and approach; the fourth presents the find-

ings; and the final sections provide a discussion

and a conclusion.

their public services, placing the status and role of

the care professional under pressure. In the 1980s

and 1990s, reforming efforts were often tied to

the principles of new public management (Hood,

1991), which in championing “customer sover-

eignty” in the public services, challenged “pro-

ducer capture,” mainly seen to reside in the power

of the professional. The marketization of public

services provided a vehicle for this challenge, cre-

ating opportunities for the exercise of user choice,

which weakened custodial forms of management

founded on professional authority and discretion

(Ackroyd, Hughes, & Soothill, 1989; Kitchener,

2000).

The prevalence of this management para-

digm was reflected in an influential prescriptive

rhetoric emanating from the Organization for

Economic Cooperation and Development (OECD,

1995), a “prominent global advo-

cate for the new public manage-

ment” (Pal, 2007). This rhetoric

belied the uneven implementation

of new public management prac-

tices (Pollitt & Bouckaert, 2011),

but countries such as Britain and

New Zealand embraced such an

approach, seeking to introduce a

range of related practices. These typ-

ically included the strengthening of

a general management cadre across

the public services, establishing a

new authoritative source of decision

making alongside the professional,

with considerable influence over

target-driven organizational perfor-

mance (Power, 1997).

Despite the assault on the profes-

sions during these years (Alaszewski

& Mathorpe, 1990), there was much

debate on its consequences for the care profes-

sions. Some argued that the professions welcomed

these public service reforms as providing them

with greater scope for entrepreneurial activity and

the opportunity to develop hybrid roles, which

combined traditional expertise with a new mana-

gerial authority (Exworthy & Halford, 1999; Ferlie

& Geraghty, 2005; Noordegraaf, 2007). Others

suggested that the care professions had fared

more unevenly, with some vulnerable to pressure

for change and less able to resist it (Kirkpatrick,

Ackroyd, & Walker, 2005).

More recently, OECD governments in further

developing their public service reform agendas

have recognized the resilience of the care profes-

sions and adopted a more nuanced approach to

their management (OECD, 2010). While continu-

ing to privilege the users’ voice (Clarke, Newman,