Australian Occupational Therapy Journal (2014) 61, 168–176
Living tensions: Reconstructing notions of professionalism in occupational therapy Hazel Mackey1,2 1
Staffordshire and Stoke on Trent Partnership NHS Trust, Haywood Hospital, Stoke on Trent, and 2School of Health and Rehabilitation, Keele University, Keele, UK
Background/aim: Reform of health organisations has brought significant changes to healthcare systems with attendant consequences for the definition and practice of professionalism. Occupational therapists must continually strive to provide excellent patient care, delivering positive patient outcomes whilst responding effectively to increasing fiscal constraint and changing organisational paradigms. This paper explores the experiences of occupational therapists as they reconstruct professionalism as a consequence of health care reform in England. Method: Fourteen occupational therapists were interviewed over 12 months across five National Health Service organisations in England. Each participant was interviewed three times and was asked to keep a monthly diary of critical incidents. A process of narrative analysis was developed to analyse these data. Results: Findings suggest that changes have occurred in the National Health Service which affects notions of professional values, expertise, status and accountability. However, far from seeing themselves as mere responders to stimuli, occupational therapists tell of mediating policies, of responding, experimenting and redefining choices whilst struggling to reconstruct professionalism. Conclusions: It is suggested that professionalism can be conceived as a reflexive ethical concept in that it is through the process of reflecting on the discursive and behavioural options and values available that occupational therapists come to understand, and define their professional selves. KEY WORDS culture, management and professional issues, organisational behaviour.
Hazel Mackey PhD; Research Lead, Honorary Lecturer. Correspondence: Dr Hazel Mackey, Staffordshire and Stoke on Trent Partnership NHS Trust, Haywood Hospital, Ground Floor, Barker Unit, High Lane, Stoke on Trent ST6 7AG, UK. Email: [email protected]
Accepted for publication 7 October 2013. © 2013 Occupational Therapy Australia
Introduction The occupational therapy workforce is influenced both by changes to the way direct care is delivered, and by new approaches to the organisation of the health service. Occupational therapists must continually strive to provide excellent patient care, delivering positive patient outcomes whilst responding effectively to increasing fiscal constraint and changing organisational paradigms. It is within this context that allied health professionals within the United Kingdom (UK) have been encouraged by the Chief Health Professions Officer at the Department of Health, Karen Middleton, to engage in a conversation on what it means to be ‘professional’ and ‘to create a culture whereby professional behaviour is as discussed as clinical competence and expertise’ (Fairbrother, 2012, p. 37). This paper aims to contribute to this conversation by exploring the experience and practice of occupational therapists as their view of professionalism is constructed and challenged in changing healthcare environments.
Literature review According to Colley, James and Diment (2007) there are two main paradigms to the construction of professionalism. One approach takes the ‘list’ form. In this approach, notions of healthcare professionalism rest on indeterminate terms of professional characteristics and behaviours (Abbott, 1988; Friedson, 2001; Hugman, 1991). Using this ideology, health care professionals are perceived to be well trained, knowledgeable, and vocational, have existing collegial communities with varying levels of freedom of judgement and discretion in performance. Ideal notions of professionalism differ from other ways of organising the control of work, namely consumerism, which celebrates competition and cost, and managerialism which celebrates efficiency through standardisation and the minimisation of discretion. The other paradigm is less concerned with what the professional does but more with who they are. This ‘Inside Out’ approach (Stronach, Corbin, McNamara, Stark & Warne, 2002) argues that professional accounts
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of themselves incorporate shards of uncertainty, and disparate and conflicting identities. The essence of this approach rests in revealing inner tensions and moral dilemmas and examining how these forces link with the creative responses professionals make to changes in their environments. There is an emerging discourse within occupational therapy on the definition, development and sustainability of professionalism which draws on the different conceptualisations of professionalism (Aguilar, Stupans, Scutter & King, 2013; Ashby, Ryan, Gray & James, 2013; Whitcombe, 2013). Located within the ‘list’ paradigm, Aguilar et al. argue that the term professionalism relates to the application of the values of the profession and the demonstration of essential behaviours and attitudes. In this study of Australian occupational therapists, the use of a Delphi technique identified consensus around 61 professional values and seven professional behaviours which could help set occupational therapists apart from other occupations. Located within the ‘Inside out’ paradigm, Ashby et al. were concerned with the sustainability of notions of professionalism through the concept of resilience strategies. In this study of nine Australian occupational therapists working in the field of mental health, supervision, supportive networks, and a match between valued knowledge and practice sustained and enhanced a strong professional identity. Germov (2005), in an Australian study incorporating occupational therapists, found that the expansion of professional practice, the defence of professional domains, and the protection of people’s jobs featured highly among the reasons participants gave for supporting self-imposed work standardisation in line with changing managerial and organisational requirements. Cooper (2012), in the Muriel Driver lecture, advises that because professionalization is a dynamic and continuous process, occupational therapists need to examine the influences on their situations at regular intervals. She argues that to date, Canadian occupational therapists have looked inwards and are focussed on the internal dynamics of professionalization, such as drivers to raise status, control of educational requirements and the protection of the knowledge base. She stresses the need for occupational therapists in Canada to consider the external dynamics, such as power relations within society, changes in technology and organisations, changes in management principles and the significance of tasks to society. Acknowledging the highly contestable nature of the meaning of professionalism, Evetts (2003) advocates analysing the appeal of the discourses of ‘professionalism’ as a means of motivating and facilitating occupational change. Referring to McClelland (1990) categorisation of professionalism ‘from within’ (the professional market) and ‘from above’ (dominant external forces), Evetts describes how the values of professionalism are imposed ‘from above’ by employers and managers in their pursuit
of highly trained and credentialised workforce; and ‘from within’ by professional groups accepting those values and grasping on to them as a means of increasing status and rewards. Thus, the disciplinary discourse of professionalism can be analysed as a powerful instrument in bringing about occupational change and managerial control (Fournier, 1999). The view endorsed within this paper sees professionalism as a dynamic, complex process which requires flexibility in adaptation and interpretation. Thus attention needs to be paid to the power of discourse (Foucault, 1988) and the processes of professional construction and reconstruction; to examine the ways occupational therapists continually work on their professional selves. As such the term professional requires the adoption of a learning orientation that demands constant attention and skills in order to address the various and complex tensions surrounding its practice (Mackey, 2007).
Aims of study This paper presents one element of a larger study that sought to understand the construction of professional identities within occupational therapists. This paper aims to contribute to the understanding of the evolving concepts of professionalism within occupational therapy, as ideas of professionalism are transformed, sustained and reproduced within reforming health care socio-cultural contexts. The research explored the meaning and construction of these ideas of professionalism as occupational therapists were asked to tell their own stories of organisational redesign, changing work identities and new roles. The research questions were: ● How do occupational therapists define, experience and practice their work during a period of health service reform? ● How are the professional identities of occupational therapists working in the NHS challenged by organisational reform? By defining and operationalizing the words used in the research questions, the focus and theoretical approaches taken by the study become explicit. The word ‘How’ displays the exploratory nature of the study. The term ‘professional identities’ reflects the way that occupational therapists, both as individuals and as a collective, establish and position themselves in relation to the structural environment and other people. Thus, the construction of professional identities is seen as a social construction (Clouston & Whitcombe, 2008). The words ‘define’, ‘experience’ and ‘practice’ refer to the process of how participants construct, make sense of and react to the specific changes within their own locality and guide the methodological choice of using verbal interviews and written reflective diaries. © 2013 Occupational Therapy Australia
The context Since 1997, successive UK Governments have attempted to modernise the NHS. As a consequence, professionalism in healthcare has begun to be redefined in terms of systems of care, with professionalism directly connecting to optimising outcomes of care and reducing adverse events. Reform has sought to regulate the work of health care professionals as part of a strategy to re professionalize public sector workers away from notions of expertise, vocationalism and community centeredness, towards managerial notions of flexibility, loyalty to the employer and adherence with good practice standards. This necessitates more corporate, carefully managed and measured NHS professionals, and the creation of more harmonious structures in which health care professionals coexist and develop each other. The changing concepts of professionalism require major cultural change in the NHS and naturally health care professionals have struggled with these issues, experiencing reductions in their security, freedoms and job satisfaction.
Methods This study is located within a qualitative research paradigm, using social constructivist epistemology and narrative based designs. This study adhered to the Research Governance Framework (Department of Health, 2005) and to the research ethics embedded into the College of Occupational Therapists Code of Conduct (College of Occupational Therapists, 2010). Full ethical approval was obtained through the National Research Ethics Service. The empirical research was conducted over 12 months across five NHS organisations in England. Participants were selected using a purposive sampling frame. A call for participants was placed through the local Allied Health Professions network. Potential participants received a written information leaflet and were invited to attend an information giving discussion. There were 14 occupational therapists recruited. Each participant was interviewed three times and was asked to keep a monthly diary of critical incidents. The working areas of these participants and the level of engagement in the study can be found in Table 1. One participant withdrew from the study after the first interview, due to a change in family circumstances, but consented to the continued use of her data. Adherence to the requests for monthly diaries was patchy and will be considered in a further paper arising from the study. Interviews typically lasted between 60 and 90 minutes. The interviews were discovery orientated: that is, they attempted to reveal experiences and meanings attached to the world they explored. Hollway and Jefferson (2000) highlight that the question and answer method of interviewing has a tendency to suppress respondents stories.
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TABLE 1: Participants
Area of work
Monthly diaries of critical incidents
Forensic unit Older people mental health/ Prison in-reach Community mental health Accident and emergency Acute Services Manager Acute – Short stay Orthopaedics Older people Hand therapy Medicine and surgery Stroke rehabilitation Acute rehabilitation Forensic unit Community paediatrics
3 3 3 1 3
8 9 9 0 4
3 3 3 3
3 7 11 10
SARAH AMANDA NANCY LAURA SANDRA JANET COLETTE JANICE SOPHIE ABIGAIL KATIE GWEN
However, the narrative interview format does not guarantee systematic coverage of issues across participants. For this reason, an open but focussed narrative interview (Mischler, 1986) was designed. The initial interviews focussed on eliciting the work life stories of the participants and, whilst retaining workforce change as the spine of the interview, looked at key events, significant people, current roles and responsibilities, conflicts and unresolved issues and periods of stress. The second and third interviews focussed on particular aspects of workforce change and how these have affected the participants. Specifically, interview two was concerned with inter-professional practice, pay review, quality and governance and notions of professionalism and ethical practice. Interview three covered areas such as consumerism, structural professional bodies, the values and beliefs of the occupational therapy profession and the participants’ future aspirations. Interviewing is an interactive, social experience and is influenced by the perceptions of its participants. In the focussed but unstructured approach taken, the interview became a conversation around the broad topic areas identified earlier. Conversation is what Schon (1990) refers to as knowing in action, a concept which embodies the knowledge people have to do
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things, a knowledge that does not always extend to being able to explain what they do. Interviews were taped, fully transcribed and coded. Analysis was informed by a number of readings in the area of narrative research and analysis (Crossley, 2002; Emerson & Frosh, 2004; Lieblich, Tuval-Mashiach & Zilber, 1998; McAdams, 1993; Riessman, 1993). Narrative analysis was applied to the first level of vertical analysis. Vertical analysis refers to the concentration on the individual’s perceptions of professionalism and working life through analysis of each participant’s interview transcripts and reflective diaries. Each participant’s data were analysed in order to understand critical incidents and experiences as well as recurring themes and topics. This resulted in a working life narrative for each of the 14 participants. This was followed with a horizontal analysis of the working life narratives of all the participants specifically looking at issues of professional identities, and professionalism. This horizontal analysis was necessary to build from individual stories to a more general sense of how occupational therapists as a professional group narrated and practiced their professional identities. This study took a relativist approach which emphasised the multiplicity of voices within the occupational therapy profession and the likelihood of diverse interpretations. Since a work life narrative will change through retelling, Mattingly (1998) contends that in the context of narrative, validity has no single truth but multiple ones. Consequently, the narratives as presented in this study are the subjective truths of the narrator rather than the actual or factual truth of events. All names have been changed to ensure the anonymity of the participants.
Findings: Living tensions and the challenge of rethinking professionalism Despite the different areas of practice, the occupational therapists described similar issues and concerns as they struggled with questions surrounding the occupational therapists role in shifting health care environments. The occupational therapists expressed doubts about the status of the profession and areas of expertise; and struggled with tensions between their agentic and professional values amidst strict systems of accountability and assurance. It was in the process of negotiating or balancing these forces that these occupational therapists contributed to a new understanding of professionalism, seeing professionalism as a process rather than static concept.
Living tension – “Who is the client?” The participants frequently referred to the belief that occupational therapists were very much concerned with patient well being. Information about patients and their
relationships with the occupational therapists were spread throughout the interviews and diaries. These relationships valued interpersonal skills and the need to communicate respect and understanding, and were based on a full focus on the individual client, emphasis on engagement and participation rather than illness and disability, and an understanding of the importance of environmental factors to health and well being. As Kate identified, Occupational Therapists are very much strong advocates for the patients, quite often we push for things or voice things that, for whatever reasons, other multi-disciplinary team members are happy to overlook or not deal with or don’t feel are important, but the patient thinks they are extremely important.
Yet there were many examples of where the occupational therapists claimed that these professional values of client centred interventions were compromised by the high pressured environment in which they worked. Business orientated health service managers kept the attention on the ‘product’ and ‘process’ of healthcare. Amanda reported that the focus of her accident and emergency work was to prevent admissions and that discussion of quality had been reduced to quantifiable indicators, checklists and targets that made process effectiveness visible yet hid patient experience. She told of feeling overwhelmed with the day to day struggle of managing waiting lists, meeting discharge targets and working to criteria. you have got this constant (voice) ‘you need to get them out’… it is almost like there is somebody sitting on your shoulder all the time saying to you ‘you have got to get that person home’ and it is a really uncomfortable place to be:
A shift in perception as to who the service was being provided for was evident with the wishes of managers and service commissioners framing the time and service allocated to patients. Gwen was in her mid-fifties and had had a long career in occupational therapy. She was based in a community setting working with children across a rural area. This role put her at the crossroads of many organisational, professional and personal boundaries, and as such was the site of competing expectations and power struggles. Gwen frequently had dealings with representatives from other health organisations, education, housing and social care sectors. She regularly found herself in contact with solicitors and legal representatives as she became involved in compensation or educational tribunal cases. She worked closely with family carers, or learning support assistants, advising on therapeutic approaches. She worked in the child’s home, at school or in local clinics. Gwen often
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found herself in the middle of complex relationships, unsure as to where her main priorities should lie. This lead Gwen to ask. “who is the client?”.
Living tension – “You can only do so much” Many occupational therapists spoke of new restrictions on the amount of contact they had with service users. Demand for detailed and extensive record keeping, time limited services and the delegation of much face to face work to support workers, had altered the occupational therapists rapport with the client. When the occupational therapists expressed concerns about quality of care, using the multiple and varied discourses of holistic practice, management discourses of necessary care and the need to set priority within budgets overruled concerns. When the occupational therapists complained that their workload was too heavy, they were met with the argument that they had taken on excessive responsibility for patients and gave too much care. Nancy, in her role as manager, identified this issue: I think sometimes it really just understands where our role starts and stops because I also find …. especially the newly qualified therapists that have this rose-tinted version of what occupational therapy is really like in real life, they feel that they have to resolve every problem the patient has and they will spend hours and hours with one patient and I’m constantly saying ‘you can only do so much.
Nancy was a service manager in an acute general hospital. In her early 30’s she has been in post a little over twelve months when the data collection period started. For Nancy, her qualification in occupational therapy and her membership of the occupational therapy profession was a safety net on which she could depend. This security offered her the opportunity to explore other fields and options which extended her skills and practice. Nancy was aware that this managerial role took her away from conventional occupational therapy practice and also put her in an environment in which she did not adhere to her core professional values and beliefs. She explained her managerial role was to comply with organisational demands and through compliance, the occupational therapy department would be safe from further scrutiny and the fear of service cuts, service redesign and ultimate redundancy. Nancy told of her struggle to retain her commitment to occupational therapy values, at the same time as meeting the organisations business needs. but it is very difficult … because it is not a business to be Occupational Therapists and it is not a busi-
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ness to the patients. It is about quality and care and as a manager, trying to balance that between my staff and their patients and allowing them time and the resources to provide that quality service, but also keeping the Trust satisfied that their demands are being met and their targets are being met and trying to juggle the two is difficult.
Consequently, holistic care, an important concept for the occupational therapy profession, was sidelined. Thus, the occupational therapists ethics of care struggled against management’s calculation of necessary care and the effective use of resources, leading the occupational therapists to reflect on specialist skills, and an increasing desire to break free of perceived oppressions.
Living tension – Getting “amongst the action” The occupational therapists felt they needed to be active and strategic in affecting the strategic direction of their services and engaging with the agenda of health care managers and commissioners. The occupational therapists made use of professional discourses that placed the needs of the client at the centre of their interventions and through the adoption of this approach the occupational therapists positioned themselves as the guarantors and protectors of quality. Katie provides expert clinical advice for mentally disordered criminal offenders within a medium secure forensic unit. Katie described the difficulty managers and commissioners had in viewing the everyday activities that occupational therapists engage in as areas of expert practice. everything we are working on with our patients they (the managers and commissioners) can do, they take it for granted, they have relationships, they have a job, they go home and they can cook, they can make choices, they can budget, they have friends, they have hobbies, they go on holidays, so sometimes I think they struggle to see it through the patient’s eyes.
For Kate the belief that ‘anyone can do (Occupational Therapy)’, undervalued this type of work and attacked occupational therapists claims for professional status. Katie acknowledged that those occupational therapists that mastered the discourses of ‘new’ managerial inspired professionalism and performed in ways the organisation defined as trustworthy and desirable were rewarded with greater service developments, with career promotion and status. She saw her role as to inspire, encourage and model change. This strategy offered occupational therapists a way to break free from their traditional professional anxiety of being misunderstood, instead replacing it with an enthusiasm for ‘reform’ and the opportunity to construct themselves as
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acknowledged expert health care workers who could make a difference. Katie attempted to be: always amongst the action, I think not always leading, but always contributing somehow;
She talked of feeling excited, being prepared to be flexible by identifying a common agenda with others. She felt certain that occupational therapy could develop in this new healthcare environment. In this way, Katie felt a sense of achievement by learning how to be business aware and business responsible, thus becoming the cost effective occupational therapist who could prioritise and who gave attention to the resolution of immediate concerns. One of Janet’s reflective diaries detailed how she felt she needed to show how she could help her organisation meet its targets by engaging in interdisciplinary and skill mix initiatives in order to feel safe and secure in her employment. Here Janet pondered on the benefits of generic working across the health professions: I actually think just for us all to become more generic is something I’d probably welcome in the future, I think it almost, I get quite frustrated at times at having to stay within our little box of occupation.
Occupational therapists, such as Janet, knew what was expected of them in order to be seen as good professionals in the eyes of their managers, and so all communication with the managers deployed ‘managerial’ terms. Instead of using client centred terms they talked of saving bed days and reducing waiting times. They worked out the mutual benefits of professional and managerial values and had managed to arrive at a fairly stable pattern of accommodating managerialism whilst remaining rewarded by professional roles and values.
Living tensions – Balancing responsibilities For the occupational therapists in the sample, accountability was as much a matter of ethics as it was a legal issue. They lived with dilemmas brought about by their triple accountability involving responsibilities towards their employers, their clients and their professional bodies. Conflicts arose when the clients challenged for services the employing organisation did not want to supply. Gwen told of how she used the issue of professional accountability to pressurise a manager in another organisation to take a client centred approach to equipment provision rather than reissue unsuitable stock; Sarah told how occupational therapists were asked to account for the number of hours they spend in direct patient contact and time spent away from this activity was increasingly scrutinised by managers. She spoke of the tensions she felt when the national professional body expected involvement in occupational therapy professional matters but local work pressures did not
allow for the necessary time commitment. Many occupational therapists felt their uni professional needs were hidden or overlooked within their own organisation. The occupational therapists reported that in a tight financial climate, training budgets had been affected and little training had been undertaken. Jane says, I haven’t had one study day away and that’s down to lack of funds and lack of courses. I’ve actually applied for two courses that have then been cancelled because of lack of funding in other Trusts and lack of applicants.
Also on the job learning was being restricted by time pressures and the reduction in the number of senior therapists. As Sophie identifies, I see how much more knowledge my senior has than I do and with them eliminating more senior level posts, you know, they’re really trying to whittle them down so that you have one senior member of staff, … and then lots of lesser grades, but how do you ever get your knowledge to that level if your contact with that person is so minimal?
This necessitated occupational therapists looking further afield for support and learning opportunities, and often resulted in the adoption of new relationships with service users and colleagues from other professional groups. As Nancy and Laura wrote in their diaries, attendance at service conferences and user events helped occupational therapists to reconnect with their professional values and expertise. Many of the occupational therapists spoke of the stressful nature of occupational therapy work during this time of workforce ‘modernisation’. One aspect of these discussions was on the ability (or otherwise) of themselves as individuals to cope with the stresses associated with the transformation of workplaces and differing work practices. In this discourse the obligation not to be overly stressed or to burn out is essential for maintaining the enthusiasm, clarity and energy required to develop good client – therapist relationships. Both Janice and Sarah were working mothers. Both worked part time; Janice as a senior therapist in a medicine and surgery unit within a rural acute hospital; and Sarah as team leader of a mental health community resource centre, in which she had responsibility for staff across a number of professional groups. Sarah resisted stress through reducing her involvement in work related events, Janice by distancing herself from the unrelenting demands of the modernising health care agenda. I don’t take on any more than I absolutely have to so I don’t tend to think out of the box. If it’s not an issue that concerns me or worries me I don’t take it on board unnecessarily…I’m in work, I deal with
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what’s relevant and then I leave it. When I leave work I tend to leave work at work, I don’t take my worries home with me.
Abigail had been through years of considerable selfexamination and self-exploration, leading her to review many of her working patterns and experiences and reconsider the ways in which she related to occupational therapy. For Abigail, the central purpose of her witness through engagement with this study was to manage stress and avoid burnout. This arose from her direct experience of an emotional breakdown, severe stress and anxiety several years ago. Abigail described herself as being in a passenger phase, in which she was happy to let others do the forging ahead, whilst she consolidated her position. This afforded a new story of professionalism, one that embraced multi faceted and variable selves rather than repressed them with a deterministic vocational professional discourse.
Discussion: The concept of the reflexive ethical professional This study builds on previous studies which have explored the challenges faced by occupational therapists in defining professionalism (Aguilar et al., 2013; Whitcombe, 2013). The occupational therapists voices in this story provided not only a rich and interesting case, but clearly suggested the problematic nature of remaking long standing notions of professionalism. Occupational therapists in the sample were trying to negotiate a difficult balance between investing in new professionalism, focussed on inter professional practice, standardised and managed care, the sharing of expert knowledge and acknowledgement of the complexities of relationships of power, whilst holding on to an organised self that retained a focus on professional values, acknowledges professional expertise, status and accountability. The Occupational Therapists recognised the need to transform if they want to succeed but the transition entailed confusions and ambiguities about the sort of self they were seeking. Tensions existed within and between managerial and professional discourses. Whilst the professional value of client centred practice remained strong, powerful managerial voices and systems of control lead to changes in behaviour. This may explain Hammell’s (2007) perception that occupational therapists are accountable to their employers rather than their clients. This tension is illustrated clearly in Nancy’s role as both occupational therapist and manager and in Janet’s interdisciplinary role in elderly care. However, both Nancy and Janet illustrate a new generation of professional security and confidence which facilitates a more collaborative ethos. From this view point, to be focused on occupational therapy in isolation was to be trapped within a uni-professional discourse that put at risk the ability to commu© 2013 Occupational Therapy Australia
nicate across other health and social care professions. This challenges the occupational therapist to present in a way that is seen as assisting both the patient and other team members in achieving overarching aims, at the same time as maintaining and growing the specialist knowledge and practices that sustain the occupational therapy profession. This establishes the possibility for the emergence of new concepts of professionalism, a field of possibilities that did not exist so long as occupational therapists were kept isolated as specialist workers in their self-contained departments. This study challenges the assumptions about both the permanence of professionalism once attained, and the unidirectionality of movement from novice to expert. Abigail, Sarah and Janice have moved from full membership and belonging in their professional community to a state of peripheral participation. To understand these dynamics, it is necessary to consider occupational therapists as human beings living wider lives and to explore the possibilities that occupational therapists knowledge and practices are produced and reproduced with reference to a wider set of influences other than professional and organisational discourses. Neither structure nor agent had total control over the other, thus the concept of professional autonomy was challenged and was rewritten on a daily basis. Individual occupational therapists were neither totally free to exercise their individual will nor were they totally constrained by the structure and policy diktats within the broad organisation. Consequently, any idea of creating a single, central, permanent notion of professionalism is rejected. Instead the emphasis is on the importance of the reflexive ethical professional, in the way individual occupational therapists construct the changes associated with the structural reform of the NHS, in situated and localised circumstances. It is through the reflexive ethical professional that these strategies emerge, build and reinvent a multiplicity of professional roles and identities. The reflexive ethical professional results in a more individualised professional who acknowledges that it is not always desirable to have a consistent approach to practice because of the tensions contained within and surrounding relationships with collaborating partners. In this way being an occupational therapist entails looking beyond rules and routines in order to deliver a good service. Thus, professional relationships become ethical ones, based on knowledge and capabilities rather than boundary settings. The resulting multidirectionality of professional involvement encompasses full participation in a professional community and strong professional identity, to peripheral participation and fragmented identity and even ‘unbecoming’ professionalism where the ties to the professional community and identity are severed. Such movement anticipates a professional reorientation which requires of its practitioners a willingness to reconceive and radically adjust its relationships.
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Scientific evaluation: Demonstrating quality The approach taken towards evaluating the quality of this research was to argue for (rather than prove) integrity by systematically justifying claims. The demonstration of the comprehensiveness and coherence of evidence included providing examples of behaviour and direct quotes to back up interpretations sufficiently to enable others to confirm the plausibility of the analysis. The findings were shared with the participants and testimonial validity gained. Communicative validation involved the testing of the validity of knowledge claims in a dialogue. In addition to member checking, the results were presented to other occupational therapists and allied health professionals at both a local and national level with the aim of checking whether interpretations resonated with a similar audience, and in light of comments, to broaden the interpretive range, to look at the data anew in order to produce a richer interpretive account. This was a successful form of demonstrating quality with many comments suggesting occupational therapists could identify with the findings.
means in a modernising health care environment. They grappled consciously with a realisation of the constraints imposed by culturally constructed meanings, and recognise the fluidity of definitions. They adopted a number of sophisticated strategies which impact on the implementation of change and which differ from hierarchical control. The crucial point is that changes to the workplace are not imposed rather they are negotiated. As such, notions of professionalism are constructed through living and making sense of the tensions that exist in everyday practice (Stronach et al., 2002). In this process of redefining concepts of professionalism, occupational therapists are neither totally free to exercise their individual will nor are they totally constrained by organisational control. Notions of professionalism are based on a relationship of reflexivity made present through ethical decision making and the professional conversation. Defining reflexive ethical professionalism in this complex and dialogical way facilitates searching for ways to interact with others through careful consideration of the self, of experiences and of the ongoing discourses within society.
Future research and limitations The exploration of occupational therapists work life narratives in this study has indicated questions for further investigation. These questions include: ● What conditions will encourage occupational therapists to become reflexive ethical practitioners? ● Where, and how is it useful to talk about occupational therapists as a single collective category? Where, and how is it useful to focus on the differences between occupational therapists? The environment in which occupational therapists work and the dynamics that affect practice, are in a constant state of flux. Therefore, the depiction of the profession in this paper is but a snap shot in time. By locating this study in one country with a small sample size of 14 occupational therapists, the findings are particular to the specific nuances and design of health care provision in that country. Therefore, this subject requires further research to evaluate its applicability to the wider community of occupational therapists.
Conclusion This study contributes towards the developing knowledge of professionalism within occupational therapy. This paper focuses upon the social relations, techniques and forms of practice through which individuals constructed and reconstructed their notion of professionalism. The study raised questions about how far occupational therapists are coerced or constrained, and how far they can determine their own actions, shape their own agendas, and identify and pursue their own interests. The occupational therapists in this study struggled with the question of what professionalism
Acknowledgements The author would like to thank the participants who volunteered in this study. This study was partly funded through the NHS West Midlands “Bridging the Gap” award.
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