http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(2): 92–97 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2013.869197
SPECIAL THEMED SECTION: HISTORICAL PERSPECTIVES
Historical analysis of professionalism in western societies: implications for interprofessional education and collaborative practice Western-Fanshawe Collaborative BScN Program, School of Nursing, Faculty of Health Sciences and Human Services, Fanshawe College, London, Ontario, Canada Abstract
Keywords
Health care systems around the world are under tremendous pressure to change their models of health care delivery – from the current multiprofessional health care delivery into interprofessional collaborative care models with the ultimate goal of improving patient/client outcomes. The growing diversity of the population, the increasing number of vulnerable persons (elderly, homeless, those living with chronic health conditions), the complexity of health problems, and the shortage of health care providers have forced health policymakers to call for sweeping revisions to how health care is provided, impacting how health care program students are educated. However, in professional training emphasis is placed on uniprofessional education. Learners are socialized in isolation from those in other related professions to ensure the development of a shared professional identity. Consequently, by program completion each student will not only master the knowledge, skills and norms of his/her own profession, but will also develop a silo identity, called ‘‘uniprofessional identity’’. This isolationist identity creates a lack of understanding of others. In limiting their exposure to learning about the roles and value of other health care professionals, persistent negative stereotypical attitudes towards other professionals are reinforced. In this paper, we present the historical evolution(s) of the discourse of professionalism to assist us to develop a deeper understanding of socio-historical context within which interprofessional education (IPE) is embedded within, and collaborative personcentered practice (CPCP). With greater insight, we can (re)conceptualize the possibilities, and advance research on, interprofessional education and practice in the present.
Dual identity, historical analysis, interprofessional collaborative practice, interprofessional education, professionalism, professionalization, socialization
Introduction Health care systems around the world are under tremendous pressure to change their models of health care delivery – from the current multiprofessional health care delivery toward interprofessional collaborative care models. The ultimate goal of such a transition is improving client outcomes. Given the growing diversity of the population, the increasing number of vulnerable persons (elderly, homeless, those living with chronic health conditions), the complexity of health problems, and the shortage of health care providers, combined with patients/families’ willingness to be partner with health care teams, health policy-makers are calling for sweeping revisions to how health care is provided. In response, a re-visioning of how health professionals are educated is imperative (Gilbert, 2005; Health Force Ontario, 2007; World Health Organization, 1988, 2010). A primary objective of interprofessional practice is to replace the competition among health care professions with co-operation and partnership, and transcend existing power imbalances through a commitment to equality and collective responsibility – recognized as two main barriers against delivering collaborative
Correspondence: Prof. Hossein Khalili, Western-Fanshawe Collaborative BScN Program, School of Nursing, Faculty of Health Sciences and Human Services, Fanshawe College, London, Ontario N5Y 5R6, Canada. E-mail: [email protected]
History Received 30 June 2013 Revised 20 November 2013 Accepted 21 November 2013 Published online 2 January 2014
person-centered care (Carpenter & Dickinson, 2008; Gilbert, 2005; Khalili, Orchard, Laschinger, & Farah, 2013). In practice settings, there is a collective understanding that failures to implement collaborative practice has led to fragmentation of care, dissatisfaction for both clients and practitioners and poor quality of care (Henneman, Lee, & Cohen, 1995); however, the current literature indicates that many practitioners have problem integrating interprofessional collaborative practice within their workplace setting, leading to resistance against interprofessional collaboration (Whitehead, 2001). A lack of understanding and little knowledge of others’ professional roles and perspectives, along with ‘‘turf’’ wars and fear of ‘‘identity loss’’ have been cited as the main barriers to interprofessional collaborative practice (Carpenter, Barnes, Dickinson, & Woof, 2006; Felten, Cady, Metzner, & Burton, 1997; Frenk et al., 2010; Khalili et al., 2013; Suter et al., 2009). These barriers are deeply rooted in the way the health care professions have evolved over time, called professionalization, and as a consequence of how health care providers are socialized into their profession, called professional socialization (Arndt et al., 2009; Baker, Egan-Lee, Martimianakis, & Reeves, 2011; Cameron, 2011). Professionalization in practice, and socialization in professional education have been seen as central processes for developing professionalism among professional students/members. The discourse of professionalism has been used as a powerful tool for occupational change and social control at macro, meso and micro levels in education and practice (Evetts, 2005).
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Hossein Khalili, Jodi Hall, and Sandra DeLuca
DOI: 10.3109/13561820.2013.869197
In this paper, we present the historical evolution(s) of the discourse of professionalism from a sociological perspective to assist us to develop a deeper understanding of the socio-historical context within which interprofessional education (IPE) and collaborative person-centered practice (CPCP) are embedded. With greater insight, we can (re)conceptualize the possibility and advance research on, interprofessional education and practice in the present.
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Background Professionalization as a process serves to secure and protect exclusive areas of knowledge, skills and expertise. In practice, professionalization has contributed toward the development of professions who view one another as rivals – controlling who has access to their particular profession’s ‘‘knowledge’’ through regulated professional entry (Baker et al., 2011; Hind et al., 2003). In professional training, the emphasis is placed on uniprofessional education (Gilbert, 2005; Khalili et al., 2013). Learners are socialized in isolation from those in other related professions to ensure the development of a shared professional identity and knowledge base. Consequently, by program completion each student will not only master the knowledge, skills and norms of their own profession, but will also develop a silo identity, called ‘‘uniprofessional identity’’ (Khalili et al., 2013). This isolationist identity creates a lack of understanding of other professionals’ roles and perspectives. In limiting their exposure to learning about the roles and value of other health care professionals, persistent negative stereotypical attitudes toward other professionals are reinforced. Therefore, prevailing myths and misunderstanding about roles and contributions of others on the health care team are neither well understood nor generally appreciated (Khalili et al., 2013). When professionals enter the workplace with a uniprofessional perspective, there tends to be a lack of understanding of others in practice, and ‘‘turf’’ wars emerge where scopes of practice overlap (Carpenter & Dickinson, 2008; Chung et al., 2012). Many of these professionals consider interprofessional practice a threat to their own professional identity, and therefore resist collaboration (Baker et al., 2011; Wakefield, Boggis, & Holland, 2006). This profession-specific socialization is rooted in the concept of ‘‘professionalism’’; particularly in Western societies where each health care profession is positioned to be in competition with others as a means of improving their social status as a profession (Baker et al., 2011; Cameron, 2011; Hind et al., 2003). Each health care profession tends to create their own silos to ensure its members develop common experiences, norms, approaches to problem-solving and language for professional tools (Hall, 2005). As a result, professional education ‘‘serves to socialize prospective professionals into status cultures by drawing a line between insiders and outsiders’’ (Collins, 1979; Manza, 1992, p. 279). At the same time, the growing complexity of the health care systems has forced the evolution of some new health care professions (i.e. respiratory therapy) who join in the struggle to define their own identity, values, scope of practice and role in client care.
The discourse of professionalism: modern professionalization and socialization; a historical analysis Professionalism before 1950s – a normative value Although the discourse of professionalism is relatively new within health care, much earlier in sociology and up until the 1950s, professionalism was mainly viewed as an important and highly desirable occupational value in professional relationships, also
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called a ‘‘normative value system’’ (Evetts, 2003). Within a given profession, this normative value system was perceived to be contributing to the stability and civility of social systems (e.g. Carr-Saunders & Wilson, 1933; Evetts, 2003; Tawney, 1921). This view of professionalism was rooted in the tradition of sociological positivism (e.g. Comte, 1853; Durkheim, 1938), which espoused the belief that the social world was made up of structures or organizations that ordered individual activities (social order) (Burrell & Morgan, 1979). From the perspective of the published literature, professionalism was predominately considered at macro (societal, state and market) and meso (organizations and institutions) levels wherein individuals were positioned as passive recipients of one’s professional identity – they are shaped by his/her profession, rather than playing any significant role in shaping his/her profession. Congruent with this paradigm, is the ‘‘functionalistic approach to socialization’’ in education. Within this approach, doctors, nurses and teachers for instance, had specifiable locations within a ‘‘network of status-roles’’ or social position (status) (Sharrock, Hughes, & Martin, 2003, p. 29). These roles were not considered to be the actual behaviors of any one individual; rather they were sets of pre-determined, appropriate and expected positional behaviors passively internalized (Sharrock et al., 2003). The role expectations of a given profession included its norms, values, attitudes, knowledge and skills – in short, professional culture (Merton, Reader, & Kendall, 1957). Hence, students were thought to become a professional through a passive approach. One adopts his/her professional identity and subsequent behaviors by observing behaviors demonstrated by faculty who teach and model such behaviors, and practitioners who guide practice development (Merton et al., 1957). Students come to embody these behaviors and go on to enact the same professional ‘‘performances’’ in their own practice. Institutional education and training were considered fundamental requirements for professionals, but once achieved (and sometimes licensed), ‘‘professional competence-based’’ practice was seen as central for practitioners. Obtaining professional knowledge and expertise, and practicing based on gained competences, were assumed to put professionals into positions of authority and higher in status such that the public must place their trust in their work (Evetts, 2005; Hughes, 1958). Further, according to Freidson (1970), the development of professional autonomy was also a central part of professionalization process in which professions could differentiate themselves from nonprofessional occupations. Specific to health care, modern professionalization originated in mid- to late-nineteenth century, when medicine and nursing began legitimizing and regulating their practice (Reeves, MacMillan, & van Soeren, 2010; Waddington, 1990). The publication of the Provincial Medical and Surgical Journal – the forerunner of the British Medical Journal – in the UK in1840, the formation of the College of Physicians and Surgeons of Ontario and the Canadian Medical Association around 1850s in Canada were just a few of the several developments that indicated a growing professional consciousness among medical practitioners in the mid-nineteenth century (Reeves et al., 2010; Waddington, 1990). The major focus of professionalization in medicine was the development of medical autonomy and the authority of its members to take control over their own work and over the work of health care organization (Frankel et al., 1996, Reeves et al., 2010; Waddington, 1990). This push resulted in medical dominance and hierarchy among the health care professions within the health care system (Annandale, 1998). Nursing as a profession has evolved throughout history. From the traditional role of women, apprenticeship, humanitarian aims,
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religious ideals, to a self-regulated profession (Egenes, 2009; Helmstadter & Godden, 2011; Klainberg, 2010; McDonald, 2013). The founder of modern professional nursing is known to be Florence Nightingale, who in 1860 established a financially independent school of nursing in association with St. Thomas’s Hospital in London, England. Improving standards of nursing in both education and practice continued in the US and Canada a decade after (Klainberg, 2010). The other significant developments in nursing profession at the time were the publication of the British Journal of Nursing in 1888, the American Journal of Nursing in 1900 and the establishment of two major professional associations in 1890 in the US including: the American Society of Superintendents of Hospital Training Schools, later renamed as the National League for Nursing Education, and the Associated Alumnae of the United States, later renamed the American Nurses Association. The main focus of early professional nursing was on the ‘‘profession’s purity, discipline, and faith’’ (Connolly, 2004, p. 10). However, in the 1950s and 1960s there was a significant change in the focus when the scholarship of nursing history began to grow resulting in linking nursing to ‘‘the broader social, economic, and cultural context in which events unfolded’’ (Connolly, 2004, p. 10). Professionalism during 1970s–1980s – as an ideology With the development of new professions like Occupation Therapy during the 1970s–1980s, a general skepticism surrounding the whole idea of professionalism as a normative value emerged (Evetts, 2003). In this phase, the new service- and knowledge-based professions began to criticize professionalization as a process of market closure, and monopoly control of work and occupational dominance (Evetts, 2003; Larkin, 1983; Larson, 1977). Such dominance was underpinned by gendered, classed and racialized structural arrangements that sought to exclude those professions populated primarily by women and visible minorities from professional legitimacy (Witz, 1990). Professionalization was also criticized for its intention to promote professions’ self- interests (rather than public interest), in terms of salary, status and power (Abbott, 1988; Reeves et al., 2010; Saks, 1995). These arguments were implicitly rooted in Weber’s theory of social closure which refers to the ‘‘monopolization of opportunities’’ or the ‘‘process of subordination whereby one group monopolizes advantages by closing off opportunities to another groups’’ in order to maximize their own rewards and privileges by limiting access to others (Bourgeault & Grignon, 2013; Murphy, 1988; Parkin, 1979; Swartz, 1988). In this new era, professionalism was primarily viewed as an ‘‘ideology’’ (Evetts, 2003), welcomed by various occupational groups as a way of improving their occupations’ status and to promote their services above others (Evetts, 2005). This was labeled as the ‘‘professional project’’ movement (Larson, 1977). In general, advancing ‘‘professionalism as ideology’’ was about creating boundaries and maintaining hierarchy between health care professions. Distinct occupational groups sought a monopoly in the market for their service, status and upward mobility, which impacted on education by creating some new, exclusionary, higher educational programs (Evetts, 2005). For example, beginning in the 1960s new types of nurses including clinical nurse specialists who were specialized in intensive care units, and nurse practitioners who were trained in primary care services began to appear (Egenes, 2009; Klainberg, 2010). Hence in this era, the focus of socialization shifted from ‘‘role-taking’’ to ‘‘role-making’’ and ‘‘identity development’’. To facilitate this shift, an interactionism approach was adapted for professional socialization. Interactionism is informed by ‘‘symbolic interactionism’’ theory (Blumer, 1969; Mead,
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1934;), whose proponents argue that human actions are guided by meanings we make out of interaction with others. Symbolic interaction is grounded in interpretive processes that allow students being socialized to communicate and validate their understanding of their roles with others (deMarrais & LeCompte, 1999). Individuals adopt (or do not adopt) actions out of interactions between themselves and others. Each person therefore uses an interpretive process in determining how he or she will interact with others (Sharrock et al., 2003). Interactionists criticize funtionalism’s limitations in accounting for individual’s role learning and believe that role development can (or does) occur through active engagement in discussions between those wishing to emulate the role and those already performing the role. Interactionists believe their approach provides a milieu of possibilities, where ‘‘status quo’’ functioning of a professional can be transcended, allowing students to explore the roles, knowledge and skills of the professionals who work with them. Rather than passive recipients of their professional identity, professionals actively select role behavior and attitudes deemed by them to be most appropriate (Becker, Geer, Hughes, & Strauss, 1961; Olesen & Whittaker, 1968). Individuals socialized through interactionist approaches are more likely to actively modify his/her expectations and adopt new roles, termed ‘‘role making’’, and behaviors based on situational needs (Sharrock et al., 2003). An additional contribution of the interactionist approach to health professional socialization is the development of a ‘‘shared professional identity’’ among students, opposed to a ‘‘shared value system’’ as proposed by functionalism (Sharrock et al., 2003; Stryker & Statham, 1985). This common identity is (re)produced through occupational/professional socialization (through shared and common educational backgrounds, professional training and vocational experiences), and professional membership deemed necessary for creating a shared professional culture. In this shared professional culture, individuals come to develop a sense of common understandings and expertise, common ways of perceiving problems and possible solutions, and shared ways of perceiving and interacting with customers/ patients/clients. Interactionist professional socialization, similar to functionalist, has the tendency to isolate health students in one profession away from each other. Students develop their own professionspecific identity, called uniprofessional identity, excluding understanding of the roles, knowledge, skills and values that other health care professionals bring to practice. The dominance of uniprofessional education perpetuates this isolationist identity development. From a psychosocial perspective, by holding a uniprofessional identity, students within each professional group (termed ‘‘in-group’’) are more likely to share trusting and rewarding relationships (‘‘in-group favoritism’’), while interactions with students from other professional groups (termed ‘‘out-group’’) are hostile, and characterized by distance and information-withholding (Mitchell, Parker, & Giles, 2011; Tajfel & Turner, 1986). These in-group and out-group behaviors are theorized to be one of the main barriers towards CPCP (Khalili et al., 2013). At the same time, certain professions tried to maintain their professional integrity and dominance, resulting in ‘‘turf’’ protection behaviors across professions. All the above has led to higher competition and more isolation among students/ professionals from different health care programs/professions. Professionalism after 1980s – towards creating a balance in normative value and ideology The consequence of the ‘‘professional project’’ movement among Western societies who put unusual emphasis on certain
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DOI: 10.3109/13561820.2013.869197
occupations, such as medicine and law, was the emergence of an even more radical view of ‘‘profession’’ as powerful occupational groups in 1980s (Evetts, 2003). According to this view, certain privileged professions preserved the right to dominate and control the ‘‘professional market’’ in the interests of their own practitioners (Evetts, 2005). As a result, the dominance of medicine/ physicians in health care has been linked to the growing hierarchy within the health care system (Annandale, 1998), and to perpetual disputes among the professions regarding jurisdiction over professional boundaries (Abbott, 1988). In 1990s, the literature began to re-examine the meaning of professionalism in the context of global changes/challenges by returning to a normative value system interpretation (Evetts, 2003). In this (re)vision of professionalism, the professional selfinterest was (or should be) neither contrary to the public interest, nor to those of other related occupational/professional groups within the social order (Evetts, 2003, 2005). The critical elements of this current view of professionalism include the importance of trust in client/practitioner relations (Evetts, 2003), discretion (Hawkins, 1992), and quality of service in the best interests of both clients and health care providers (Evetts, 2003; Freidson, 1994). According to this new normative value perspective, professionalism as a disciplinary mechanism (Fournier, 1999), was seen as the government of professional practice ‘‘at a distance’’ (Evetts, 2003). This new perspective of professionalism as a unique form of occupational control of work required a new way of professionalization. Professions could now create and represent distinct professional values or moral obligations, but with restraint on interprofessional competition –interprofessional co-operation was now encouraged (Dingwall & Lewis, 1983; Evetts, 2003). From this perspective, professionalism was defended as a desirable way of providing complex, discretionary quality health service to the public (Freidson, 1994). Towards creating a balance in normative value and ideology More recently there has been a movement in the literature to create a balance between the normative and ideological control elements of professionalism (Evetts, 2003). It has been argued that professionalism for individual professional members is a more powerful motivating force of control ‘‘at a distance’’ (Burchell, Gordon, & Miller, 1991; Evetts, 2005). For professions at the system level, professionalism is more an ideology of holding an ‘‘exclusive ownership of an area of expertise, autonomy and discretion in work practices and occupational control of work’’ (Evetts, 2003, p. 406). A call for ‘‘new professionalism’’ in health care The Lancet Commission Report (Frenk et al., 2010) calls for a ‘‘new professionalism’’ for health care in the twenty-first century. Accordingly, professionalism ‘‘should promote quality, embrace teamwork, uphold a strong service ethic, and be centred around the interests of patients and populations’’ (Frenk et al., 2010, p. 43). The acknowledgment of the interdependency and complementarity of different health care programs/professions (and clients/community) in advancing the professional ‘‘self-interests’’ and the public interest (Saks, 1995) has the potential for socialization processes to help students/professionals to cultivate a sense of one’s own professional identity, while fostering a respectful and understanding disposition toward others’ professional roles within the interprofessional community – a dual identity (Khalili et al., 2013). This view of professionalism in health care, however, is overly simplistic, ignores the essential role of clients in managing their health, and perpetuates the widely held perception of clients as passive recipient and ‘‘out-groups’’, rather than
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active participants and ‘‘in-group’’ members of the interprofessional team. For this new vision for enacting professionalism to be successful in preparing the new generation of practitioners for CPCP, professional silos in education and practice need to be dismantled, while enhancing collaborative and non-hierarchical relationships across health care programs/professions. Currently, in health care education the profession-specific socialization informed predominantly by a functionalist approach, causes students to be viewed as role-taking recipient who passively and in silo internalize role expectations through observation of the behaviors demonstrated by others already functioning in the accepted roles (Merton et al., 1957; Stryker & Statham, 1985).
Conclusion Tracing the evolution of professionalism over time indicates that the meaning of professionalism is not fixed; rather the discourse of professionalism has shifted over time both in its interpretation and function. Such changes reflect the shifting socio-historical contexts this discourse has evolved within – from a positivist perspective of normative value to an interactionist view of ideology, toward a constructivist worldview of both normative value and ideology in society. In the health care system, health care professions are part of an open system in which individual professions exist interdependently. Professional boundaries should not just be seen as markers of difference, but important interfaces that enable communication across communities, facilitating interprofessional collaboration and knowledge production (Abbott, 1998; Star & Griesemer, 1989). In health care currently, the debate around collaboration has moved beyond the functionalist view that argued for better coordination of health care teams to improve quality in patient care. The question now is how to develop and deliver health professional education programing that foregrounds interprofessional collaborative partnerships in practice? Such collaborative partnership will be unattainable as long as professionals remain educated in silos and working in parallel to other health care professionals, with their own agendas for clients always at the foreground. Socializing their future professional members in isolation from other health care professions will reify a health system incapable of meeting the complexity of today’s health care challenges. Rather, health care professionals are encouraged (if not required), to develop and utilize new discourses of professionalism that can accommodate the duel task of overseeing the identity development and knowledge base of their own professionals, while fostering understanding and a deeply valuing of the different professional cultures and expertise of other professionals. Rather than uniprofessional identity, such discourses would nurture the development of dual professional and interprofessional identities which could assist professions and professionals at the individual and system levels to, on the one hand maintain their professional solidarity reducing their fear of ‘‘identity loss’’, and on the other hand to develop a sense of belonging to the interprofessional community and effectively, overcoming the negative consequences of out-group discrimination and turf wars (Khalili et al., 2013).
Acknowledgements We wish to acknowledge the contribution of Alexis Taylor, an undergraduate nursing student at Western University, who conducted some literature review and provided us with her self-reflective regarding her interprofessional experience in clinical placements as part of her research course placement with the first author. We would like to extend our sincerest thanks and appreciation to Dr. Carole Orchard, Dr. Heather Laschinger, and Dr. Randa Farah from the University of Western Ontario for their contribution to the
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conceptualization of Interprofessional Socialization in the cited Khalili et al. (2013) paper and in the first author’s (HK) dissertation (Khalili, 2013).
Declaration of interest The authors report no declarations of interest. The authors alone are responsible for the writing and content of this paper.
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Frankel G., Speechley M., & Wade T. (1996). The sociology of health and health care: A Canadian perspective. Toronto, ON: Copp Clark. Freidson, E. (1970). Profession of medicine: A study in the sociology of applied knowledge. Chicago: University of Chicago Press. Freidson, E. (1994). Professionalism reborn: Theory, prophecy and policy. Cambridge: Polity. Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., & Zurayk, H. (2010). Lancet Commission Report on Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet, 376, 1923–1958. Gilbert, J.H. (2005). Interprofessional learning and higher education structural barriers. Journal of Interprofessional Care, 19, 87–106. Hall, P. (2005). Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofessional Care, 19, 188–196. Hawkins, K. (Ed.). (1992). The uses of discretion. Oxford: Clarendon. Health Force Ontario (2007). Interprofessional Care: A Blueprint for Action in Ontario. Available from: http://www.healthforceontario.ca/ upload/en/whatishfo/ipc%20blueprint%20final.pdf. Helmstadter, C., & Godden, J. (2011). Nursing before Nightingale 1815–1899. (pp. xxi–219). Farnham: Ashgate Publishing. Henneman, E.A., Lee, J.L., & Cohen, J.I. (1995). Collaboration: A concept analysis. Journal of Advanced Nursing, 21, 103–109. Hind, M., Norman, I., Cooper, S., Gill, E., Hilton, R., Judd, P., & Jones, S.C. (2003). Interprofessional perceptions of health care students. Journal of Interprofessional Care, 17, 21–34. Hughes, E.C. (1958). Men and their work. New York: Free Press. Khalili, H. (2013). Interprofessional socialization and dual identity development amongst cross-disciplinary students. (PhD Dissertation). Retrieved from ProQuest Dissertations and Theses. (Accession Order No: ETD #3120). Khalili, H., Orchard, C., Laschinger, H.K., & Farah, R. (2013). An interprofessional socialization framework for developing an interprofessional identity among health professions students. Journal of Interprofessional Care, 27, 448–453. Klainberg, M. (2010). An historical overview of nursing. Today’s Nursing Leader: Managing, Succeeding, Excelling, 21,21–40. Larkin, G. (1983). Occupational monopoly and modern medicine. London: Tavistock. Larson, M.S. (1977). The rise of professionalism. California: University of California Press. Manza, J. (1992). Classes, status groups, and social closure: a critique of neo-Weberian social theory. Current Perspectives in Social Theory, 12, 275–302. McDonald, L. (2013). The timeless wisdom of Florence Nightingale. Canadian Nurse, 109, 36–41. Mead, G.H. ([1934] 1967). Mind, self, and society: From the standpoint of a social behaviorist. Chicago: University of Chicago Press. Merton, R.K., Reader, G.G., & Kendall, P.L. (1957). The student physician. Cambridge, MA: Harvard University. Mitchell, R.J., Parker, V., & Giles, M. (2011). When do interprofessional teams succeed? Investigating the moderating roles of team and professional identity in interprofessional effectiveness. Human Relations, 64, 1321–1343. Murphy, R. (1988). Social closure: The theory of monopolization and exclusion. Oxford: Clarendon Press. Olesen, V.L., & Whittaker, E.W. (1968). The silent dialogue: A study in the social psychology of professional socialization (p. 1968). San Francisco, CA: Jossey-Bass. Parkin F. (1979). Marxism and class theory: A bourgeois critique. London: Tavistock. Reeves, S., MacMillan, K., & Van Soeren, M. (2010). Leadership of interprofessional health and social care teams: A socio-historical analysis. Journal of Nursing Management, 18, 258–264. Saks, M. (1995). Professions and the public interest. London: Routledge. Sharrock, W., Hughes, J.A., & Martin, J. (2003). Understanding modern sociology. London: Sage Publication. Star, S.L., & Griesemer, J.R. (1989). Institutional ecology, ‘‘translations’’ and boundary objects: Amateurs and professionals in Berkeley’s Museum of Vertebrate Zoology, 1907–1939. Social Studies of Science, 19, 387–420. Stryker, S., & Stratham, A. (1985). Symbolic interaction and role theory. In G. Lindzey & E. Aronson (Eds.), Handbook of social psychology: Theory and method (Vol. 1, pp. 311–378). New York: Random House. Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective
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communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23, 41–51. Swartz, D. (1988). Social closure: The theory of monopolization and exclusion. In R. Murphy (Ed.), Social closure attempts to synthesize from the writings of Max Weber (p. 276). New York: Clarendon Press. Tajfel, H., & Turner, J.C. (1986). The social identity theory of inter-group behavior. In S. Worchel & L.W. Austin (Eds.), Psychology of intergroup relations (pp. 7–19). Chicago: Nelson-Hall. Tawney, R.H. (1921). The acquisitive society. New York: Harcourt Bruce. Waddington, I. (1990). The movement towards the professionalization of medicine. BMJ: British Medical Journal, 301, 688–690.
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Wakefield, A.B., Boggis, C.R.M., & Holland, M. (2006). Team working but no blurring thank you! Learning in Health and Social Care, 5, 142–154. Whitehead, D. (2001). A social cognitive model for health education/ health promotion practice. Journal of Advanced Nursing, 36, 417–425. Witz, A. (1990). Patriarchy and professions: The gendered politics of occupational closure. Sociology, 24, 675–690. World Health Organization. (1988). Learning together to work together. Geneva: World Health Organization. World Health Organization. (2010). Framework for action on interprofessional education & collaborative practice. Health Professions Networks. Geneva: World Health Organization.
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SPECIAL THEMED SECTION: HISTORICAL PERSPECTIVES
Historical analysis of professionalism in western societies: implications for interprofessional education and collaborative practice Western-Fanshawe Collaborative BScN Program, School of Nursing, Faculty of Health Sciences and Human Services, Fanshawe College, London, Ontario, Canada Abstract
Keywords
Health care systems around the world are under tremendous pressure to change their models of health care delivery – from the current multiprofessional health care delivery into interprofessional collaborative care models with the ultimate goal of improving patient/client outcomes. The growing diversity of the population, the increasing number of vulnerable persons (elderly, homeless, those living with chronic health conditions), the complexity of health problems, and the shortage of health care providers have forced health policymakers to call for sweeping revisions to how health care is provided, impacting how health care program students are educated. However, in professional training emphasis is placed on uniprofessional education. Learners are socialized in isolation from those in other related professions to ensure the development of a shared professional identity. Consequently, by program completion each student will not only master the knowledge, skills and norms of his/her own profession, but will also develop a silo identity, called ‘‘uniprofessional identity’’. This isolationist identity creates a lack of understanding of others. In limiting their exposure to learning about the roles and value of other health care professionals, persistent negative stereotypical attitudes towards other professionals are reinforced. In this paper, we present the historical evolution(s) of the discourse of professionalism to assist us to develop a deeper understanding of socio-historical context within which interprofessional education (IPE) is embedded within, and collaborative personcentered practice (CPCP). With greater insight, we can (re)conceptualize the possibilities, and advance research on, interprofessional education and practice in the present.
Dual identity, historical analysis, interprofessional collaborative practice, interprofessional education, professionalism, professionalization, socialization
Introduction Health care systems around the world are under tremendous pressure to change their models of health care delivery – from the current multiprofessional health care delivery toward interprofessional collaborative care models. The ultimate goal of such a transition is improving client outcomes. Given the growing diversity of the population, the increasing number of vulnerable persons (elderly, homeless, those living with chronic health conditions), the complexity of health problems, and the shortage of health care providers, combined with patients/families’ willingness to be partner with health care teams, health policy-makers are calling for sweeping revisions to how health care is provided. In response, a re-visioning of how health professionals are educated is imperative (Gilbert, 2005; Health Force Ontario, 2007; World Health Organization, 1988, 2010). A primary objective of interprofessional practice is to replace the competition among health care professions with co-operation and partnership, and transcend existing power imbalances through a commitment to equality and collective responsibility – recognized as two main barriers against delivering collaborative
Correspondence: Prof. Hossein Khalili, Western-Fanshawe Collaborative BScN Program, School of Nursing, Faculty of Health Sciences and Human Services, Fanshawe College, London, Ontario N5Y 5R6, Canada. E-mail: [email protected]
History Received 30 June 2013 Revised 20 November 2013 Accepted 21 November 2013 Published online 2 January 2014
person-centered care (Carpenter & Dickinson, 2008; Gilbert, 2005; Khalili, Orchard, Laschinger, & Farah, 2013). In practice settings, there is a collective understanding that failures to implement collaborative practice has led to fragmentation of care, dissatisfaction for both clients and practitioners and poor quality of care (Henneman, Lee, & Cohen, 1995); however, the current literature indicates that many practitioners have problem integrating interprofessional collaborative practice within their workplace setting, leading to resistance against interprofessional collaboration (Whitehead, 2001). A lack of understanding and little knowledge of others’ professional roles and perspectives, along with ‘‘turf’’ wars and fear of ‘‘identity loss’’ have been cited as the main barriers to interprofessional collaborative practice (Carpenter, Barnes, Dickinson, & Woof, 2006; Felten, Cady, Metzner, & Burton, 1997; Frenk et al., 2010; Khalili et al., 2013; Suter et al., 2009). These barriers are deeply rooted in the way the health care professions have evolved over time, called professionalization, and as a consequence of how health care providers are socialized into their profession, called professional socialization (Arndt et al., 2009; Baker, Egan-Lee, Martimianakis, & Reeves, 2011; Cameron, 2011). Professionalization in practice, and socialization in professional education have been seen as central processes for developing professionalism among professional students/members. The discourse of professionalism has been used as a powerful tool for occupational change and social control at macro, meso and micro levels in education and practice (Evetts, 2005).
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Hossein Khalili, Jodi Hall, and Sandra DeLuca
DOI: 10.3109/13561820.2013.869197
In this paper, we present the historical evolution(s) of the discourse of professionalism from a sociological perspective to assist us to develop a deeper understanding of the socio-historical context within which interprofessional education (IPE) and collaborative person-centered practice (CPCP) are embedded. With greater insight, we can (re)conceptualize the possibility and advance research on, interprofessional education and practice in the present.
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Background Professionalization as a process serves to secure and protect exclusive areas of knowledge, skills and expertise. In practice, professionalization has contributed toward the development of professions who view one another as rivals – controlling who has access to their particular profession’s ‘‘knowledge’’ through regulated professional entry (Baker et al., 2011; Hind et al., 2003). In professional training, the emphasis is placed on uniprofessional education (Gilbert, 2005; Khalili et al., 2013). Learners are socialized in isolation from those in other related professions to ensure the development of a shared professional identity and knowledge base. Consequently, by program completion each student will not only master the knowledge, skills and norms of their own profession, but will also develop a silo identity, called ‘‘uniprofessional identity’’ (Khalili et al., 2013). This isolationist identity creates a lack of understanding of other professionals’ roles and perspectives. In limiting their exposure to learning about the roles and value of other health care professionals, persistent negative stereotypical attitudes toward other professionals are reinforced. Therefore, prevailing myths and misunderstanding about roles and contributions of others on the health care team are neither well understood nor generally appreciated (Khalili et al., 2013). When professionals enter the workplace with a uniprofessional perspective, there tends to be a lack of understanding of others in practice, and ‘‘turf’’ wars emerge where scopes of practice overlap (Carpenter & Dickinson, 2008; Chung et al., 2012). Many of these professionals consider interprofessional practice a threat to their own professional identity, and therefore resist collaboration (Baker et al., 2011; Wakefield, Boggis, & Holland, 2006). This profession-specific socialization is rooted in the concept of ‘‘professionalism’’; particularly in Western societies where each health care profession is positioned to be in competition with others as a means of improving their social status as a profession (Baker et al., 2011; Cameron, 2011; Hind et al., 2003). Each health care profession tends to create their own silos to ensure its members develop common experiences, norms, approaches to problem-solving and language for professional tools (Hall, 2005). As a result, professional education ‘‘serves to socialize prospective professionals into status cultures by drawing a line between insiders and outsiders’’ (Collins, 1979; Manza, 1992, p. 279). At the same time, the growing complexity of the health care systems has forced the evolution of some new health care professions (i.e. respiratory therapy) who join in the struggle to define their own identity, values, scope of practice and role in client care.
The discourse of professionalism: modern professionalization and socialization; a historical analysis Professionalism before 1950s – a normative value Although the discourse of professionalism is relatively new within health care, much earlier in sociology and up until the 1950s, professionalism was mainly viewed as an important and highly desirable occupational value in professional relationships, also
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called a ‘‘normative value system’’ (Evetts, 2003). Within a given profession, this normative value system was perceived to be contributing to the stability and civility of social systems (e.g. Carr-Saunders & Wilson, 1933; Evetts, 2003; Tawney, 1921). This view of professionalism was rooted in the tradition of sociological positivism (e.g. Comte, 1853; Durkheim, 1938), which espoused the belief that the social world was made up of structures or organizations that ordered individual activities (social order) (Burrell & Morgan, 1979). From the perspective of the published literature, professionalism was predominately considered at macro (societal, state and market) and meso (organizations and institutions) levels wherein individuals were positioned as passive recipients of one’s professional identity – they are shaped by his/her profession, rather than playing any significant role in shaping his/her profession. Congruent with this paradigm, is the ‘‘functionalistic approach to socialization’’ in education. Within this approach, doctors, nurses and teachers for instance, had specifiable locations within a ‘‘network of status-roles’’ or social position (status) (Sharrock, Hughes, & Martin, 2003, p. 29). These roles were not considered to be the actual behaviors of any one individual; rather they were sets of pre-determined, appropriate and expected positional behaviors passively internalized (Sharrock et al., 2003). The role expectations of a given profession included its norms, values, attitudes, knowledge and skills – in short, professional culture (Merton, Reader, & Kendall, 1957). Hence, students were thought to become a professional through a passive approach. One adopts his/her professional identity and subsequent behaviors by observing behaviors demonstrated by faculty who teach and model such behaviors, and practitioners who guide practice development (Merton et al., 1957). Students come to embody these behaviors and go on to enact the same professional ‘‘performances’’ in their own practice. Institutional education and training were considered fundamental requirements for professionals, but once achieved (and sometimes licensed), ‘‘professional competence-based’’ practice was seen as central for practitioners. Obtaining professional knowledge and expertise, and practicing based on gained competences, were assumed to put professionals into positions of authority and higher in status such that the public must place their trust in their work (Evetts, 2005; Hughes, 1958). Further, according to Freidson (1970), the development of professional autonomy was also a central part of professionalization process in which professions could differentiate themselves from nonprofessional occupations. Specific to health care, modern professionalization originated in mid- to late-nineteenth century, when medicine and nursing began legitimizing and regulating their practice (Reeves, MacMillan, & van Soeren, 2010; Waddington, 1990). The publication of the Provincial Medical and Surgical Journal – the forerunner of the British Medical Journal – in the UK in1840, the formation of the College of Physicians and Surgeons of Ontario and the Canadian Medical Association around 1850s in Canada were just a few of the several developments that indicated a growing professional consciousness among medical practitioners in the mid-nineteenth century (Reeves et al., 2010; Waddington, 1990). The major focus of professionalization in medicine was the development of medical autonomy and the authority of its members to take control over their own work and over the work of health care organization (Frankel et al., 1996, Reeves et al., 2010; Waddington, 1990). This push resulted in medical dominance and hierarchy among the health care professions within the health care system (Annandale, 1998). Nursing as a profession has evolved throughout history. From the traditional role of women, apprenticeship, humanitarian aims,
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religious ideals, to a self-regulated profession (Egenes, 2009; Helmstadter & Godden, 2011; Klainberg, 2010; McDonald, 2013). The founder of modern professional nursing is known to be Florence Nightingale, who in 1860 established a financially independent school of nursing in association with St. Thomas’s Hospital in London, England. Improving standards of nursing in both education and practice continued in the US and Canada a decade after (Klainberg, 2010). The other significant developments in nursing profession at the time were the publication of the British Journal of Nursing in 1888, the American Journal of Nursing in 1900 and the establishment of two major professional associations in 1890 in the US including: the American Society of Superintendents of Hospital Training Schools, later renamed as the National League for Nursing Education, and the Associated Alumnae of the United States, later renamed the American Nurses Association. The main focus of early professional nursing was on the ‘‘profession’s purity, discipline, and faith’’ (Connolly, 2004, p. 10). However, in the 1950s and 1960s there was a significant change in the focus when the scholarship of nursing history began to grow resulting in linking nursing to ‘‘the broader social, economic, and cultural context in which events unfolded’’ (Connolly, 2004, p. 10). Professionalism during 1970s–1980s – as an ideology With the development of new professions like Occupation Therapy during the 1970s–1980s, a general skepticism surrounding the whole idea of professionalism as a normative value emerged (Evetts, 2003). In this phase, the new service- and knowledge-based professions began to criticize professionalization as a process of market closure, and monopoly control of work and occupational dominance (Evetts, 2003; Larkin, 1983; Larson, 1977). Such dominance was underpinned by gendered, classed and racialized structural arrangements that sought to exclude those professions populated primarily by women and visible minorities from professional legitimacy (Witz, 1990). Professionalization was also criticized for its intention to promote professions’ self- interests (rather than public interest), in terms of salary, status and power (Abbott, 1988; Reeves et al., 2010; Saks, 1995). These arguments were implicitly rooted in Weber’s theory of social closure which refers to the ‘‘monopolization of opportunities’’ or the ‘‘process of subordination whereby one group monopolizes advantages by closing off opportunities to another groups’’ in order to maximize their own rewards and privileges by limiting access to others (Bourgeault & Grignon, 2013; Murphy, 1988; Parkin, 1979; Swartz, 1988). In this new era, professionalism was primarily viewed as an ‘‘ideology’’ (Evetts, 2003), welcomed by various occupational groups as a way of improving their occupations’ status and to promote their services above others (Evetts, 2005). This was labeled as the ‘‘professional project’’ movement (Larson, 1977). In general, advancing ‘‘professionalism as ideology’’ was about creating boundaries and maintaining hierarchy between health care professions. Distinct occupational groups sought a monopoly in the market for their service, status and upward mobility, which impacted on education by creating some new, exclusionary, higher educational programs (Evetts, 2005). For example, beginning in the 1960s new types of nurses including clinical nurse specialists who were specialized in intensive care units, and nurse practitioners who were trained in primary care services began to appear (Egenes, 2009; Klainberg, 2010). Hence in this era, the focus of socialization shifted from ‘‘role-taking’’ to ‘‘role-making’’ and ‘‘identity development’’. To facilitate this shift, an interactionism approach was adapted for professional socialization. Interactionism is informed by ‘‘symbolic interactionism’’ theory (Blumer, 1969; Mead,
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1934;), whose proponents argue that human actions are guided by meanings we make out of interaction with others. Symbolic interaction is grounded in interpretive processes that allow students being socialized to communicate and validate their understanding of their roles with others (deMarrais & LeCompte, 1999). Individuals adopt (or do not adopt) actions out of interactions between themselves and others. Each person therefore uses an interpretive process in determining how he or she will interact with others (Sharrock et al., 2003). Interactionists criticize funtionalism’s limitations in accounting for individual’s role learning and believe that role development can (or does) occur through active engagement in discussions between those wishing to emulate the role and those already performing the role. Interactionists believe their approach provides a milieu of possibilities, where ‘‘status quo’’ functioning of a professional can be transcended, allowing students to explore the roles, knowledge and skills of the professionals who work with them. Rather than passive recipients of their professional identity, professionals actively select role behavior and attitudes deemed by them to be most appropriate (Becker, Geer, Hughes, & Strauss, 1961; Olesen & Whittaker, 1968). Individuals socialized through interactionist approaches are more likely to actively modify his/her expectations and adopt new roles, termed ‘‘role making’’, and behaviors based on situational needs (Sharrock et al., 2003). An additional contribution of the interactionist approach to health professional socialization is the development of a ‘‘shared professional identity’’ among students, opposed to a ‘‘shared value system’’ as proposed by functionalism (Sharrock et al., 2003; Stryker & Statham, 1985). This common identity is (re)produced through occupational/professional socialization (through shared and common educational backgrounds, professional training and vocational experiences), and professional membership deemed necessary for creating a shared professional culture. In this shared professional culture, individuals come to develop a sense of common understandings and expertise, common ways of perceiving problems and possible solutions, and shared ways of perceiving and interacting with customers/ patients/clients. Interactionist professional socialization, similar to functionalist, has the tendency to isolate health students in one profession away from each other. Students develop their own professionspecific identity, called uniprofessional identity, excluding understanding of the roles, knowledge, skills and values that other health care professionals bring to practice. The dominance of uniprofessional education perpetuates this isolationist identity development. From a psychosocial perspective, by holding a uniprofessional identity, students within each professional group (termed ‘‘in-group’’) are more likely to share trusting and rewarding relationships (‘‘in-group favoritism’’), while interactions with students from other professional groups (termed ‘‘out-group’’) are hostile, and characterized by distance and information-withholding (Mitchell, Parker, & Giles, 2011; Tajfel & Turner, 1986). These in-group and out-group behaviors are theorized to be one of the main barriers towards CPCP (Khalili et al., 2013). At the same time, certain professions tried to maintain their professional integrity and dominance, resulting in ‘‘turf’’ protection behaviors across professions. All the above has led to higher competition and more isolation among students/ professionals from different health care programs/professions. Professionalism after 1980s – towards creating a balance in normative value and ideology The consequence of the ‘‘professional project’’ movement among Western societies who put unusual emphasis on certain
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occupations, such as medicine and law, was the emergence of an even more radical view of ‘‘profession’’ as powerful occupational groups in 1980s (Evetts, 2003). According to this view, certain privileged professions preserved the right to dominate and control the ‘‘professional market’’ in the interests of their own practitioners (Evetts, 2005). As a result, the dominance of medicine/ physicians in health care has been linked to the growing hierarchy within the health care system (Annandale, 1998), and to perpetual disputes among the professions regarding jurisdiction over professional boundaries (Abbott, 1988). In 1990s, the literature began to re-examine the meaning of professionalism in the context of global changes/challenges by returning to a normative value system interpretation (Evetts, 2003). In this (re)vision of professionalism, the professional selfinterest was (or should be) neither contrary to the public interest, nor to those of other related occupational/professional groups within the social order (Evetts, 2003, 2005). The critical elements of this current view of professionalism include the importance of trust in client/practitioner relations (Evetts, 2003), discretion (Hawkins, 1992), and quality of service in the best interests of both clients and health care providers (Evetts, 2003; Freidson, 1994). According to this new normative value perspective, professionalism as a disciplinary mechanism (Fournier, 1999), was seen as the government of professional practice ‘‘at a distance’’ (Evetts, 2003). This new perspective of professionalism as a unique form of occupational control of work required a new way of professionalization. Professions could now create and represent distinct professional values or moral obligations, but with restraint on interprofessional competition –interprofessional co-operation was now encouraged (Dingwall & Lewis, 1983; Evetts, 2003). From this perspective, professionalism was defended as a desirable way of providing complex, discretionary quality health service to the public (Freidson, 1994). Towards creating a balance in normative value and ideology More recently there has been a movement in the literature to create a balance between the normative and ideological control elements of professionalism (Evetts, 2003). It has been argued that professionalism for individual professional members is a more powerful motivating force of control ‘‘at a distance’’ (Burchell, Gordon, & Miller, 1991; Evetts, 2005). For professions at the system level, professionalism is more an ideology of holding an ‘‘exclusive ownership of an area of expertise, autonomy and discretion in work practices and occupational control of work’’ (Evetts, 2003, p. 406). A call for ‘‘new professionalism’’ in health care The Lancet Commission Report (Frenk et al., 2010) calls for a ‘‘new professionalism’’ for health care in the twenty-first century. Accordingly, professionalism ‘‘should promote quality, embrace teamwork, uphold a strong service ethic, and be centred around the interests of patients and populations’’ (Frenk et al., 2010, p. 43). The acknowledgment of the interdependency and complementarity of different health care programs/professions (and clients/community) in advancing the professional ‘‘self-interests’’ and the public interest (Saks, 1995) has the potential for socialization processes to help students/professionals to cultivate a sense of one’s own professional identity, while fostering a respectful and understanding disposition toward others’ professional roles within the interprofessional community – a dual identity (Khalili et al., 2013). This view of professionalism in health care, however, is overly simplistic, ignores the essential role of clients in managing their health, and perpetuates the widely held perception of clients as passive recipient and ‘‘out-groups’’, rather than
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active participants and ‘‘in-group’’ members of the interprofessional team. For this new vision for enacting professionalism to be successful in preparing the new generation of practitioners for CPCP, professional silos in education and practice need to be dismantled, while enhancing collaborative and non-hierarchical relationships across health care programs/professions. Currently, in health care education the profession-specific socialization informed predominantly by a functionalist approach, causes students to be viewed as role-taking recipient who passively and in silo internalize role expectations through observation of the behaviors demonstrated by others already functioning in the accepted roles (Merton et al., 1957; Stryker & Statham, 1985).
Conclusion Tracing the evolution of professionalism over time indicates that the meaning of professionalism is not fixed; rather the discourse of professionalism has shifted over time both in its interpretation and function. Such changes reflect the shifting socio-historical contexts this discourse has evolved within – from a positivist perspective of normative value to an interactionist view of ideology, toward a constructivist worldview of both normative value and ideology in society. In the health care system, health care professions are part of an open system in which individual professions exist interdependently. Professional boundaries should not just be seen as markers of difference, but important interfaces that enable communication across communities, facilitating interprofessional collaboration and knowledge production (Abbott, 1998; Star & Griesemer, 1989). In health care currently, the debate around collaboration has moved beyond the functionalist view that argued for better coordination of health care teams to improve quality in patient care. The question now is how to develop and deliver health professional education programing that foregrounds interprofessional collaborative partnerships in practice? Such collaborative partnership will be unattainable as long as professionals remain educated in silos and working in parallel to other health care professionals, with their own agendas for clients always at the foreground. Socializing their future professional members in isolation from other health care professions will reify a health system incapable of meeting the complexity of today’s health care challenges. Rather, health care professionals are encouraged (if not required), to develop and utilize new discourses of professionalism that can accommodate the duel task of overseeing the identity development and knowledge base of their own professionals, while fostering understanding and a deeply valuing of the different professional cultures and expertise of other professionals. Rather than uniprofessional identity, such discourses would nurture the development of dual professional and interprofessional identities which could assist professions and professionals at the individual and system levels to, on the one hand maintain their professional solidarity reducing their fear of ‘‘identity loss’’, and on the other hand to develop a sense of belonging to the interprofessional community and effectively, overcoming the negative consequences of out-group discrimination and turf wars (Khalili et al., 2013).
Acknowledgements We wish to acknowledge the contribution of Alexis Taylor, an undergraduate nursing student at Western University, who conducted some literature review and provided us with her self-reflective regarding her interprofessional experience in clinical placements as part of her research course placement with the first author. We would like to extend our sincerest thanks and appreciation to Dr. Carole Orchard, Dr. Heather Laschinger, and Dr. Randa Farah from the University of Western Ontario for their contribution to the
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conceptualization of Interprofessional Socialization in the cited Khalili et al. (2013) paper and in the first author’s (HK) dissertation (Khalili, 2013).
Declaration of interest The authors report no declarations of interest. The authors alone are responsible for the writing and content of this paper.
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