Carers’ agency: Power, professionalization & decommodification (part III of V)

Summary

This essay is about how care work might come to be professionalized, and how such a process of professionalization might fits with a wider process of social and economic progress in the current UK political context.

Part I was a personal ‘testimony’, written back in the first phase of pandemic, about what it’s like to work in care, and what motivates care workers, along with some early reflections, also written at that time, about what professionalism actually is, the professionalism latent in care work and the barriers faced by care workers when it comes to such a process of professionalization.

Part II delved further into concepts of power and powerlessness as it relates to careworkers, using the seminal work of radical psychologist as guide, before moving towards the core argument of the essay: that a way to resolve the powerlessness wrought by decommodification in the care ‘industry’ is to initiate a conscious, reflexive project of professionalization. The argument is underpinned by the insights from a recent Novara Media podcast, in which careworker testimony is balanced with analysis of what decommodification means.

This Part III takes a step back, and looks back at the rise and partial fall of nursing as a profession. The central claim here is that, while a nursing elite professionalized quickly in favourable conditions, this professionalization was underpinned by the racial and class prejudices of the time which, because they were not challenged, have led to lack of solidarity within the profession under the more recent managerial assaults, although more recent moves from Nurses United offer promise of a brighter future. The experience of nursing, it is suggested, should inform the development of an inclusive and reflective caring profession.

Part IV grapples with the tasks of professionalization. Seeking to rise to the challenge of the RSA’s Anthony Painter & Joanne Choukier on the need to instil a “sense of agency” for the building of a new convivial future, I set out how ‘progressives’ might help facilitate the agency of careworkers, such that the latter are in a position to carry forward their own professional emancipation. Then, following a ‘pan out’ to review the challenges and opportunities offered by a new phase of Conservatism, in which a new ‘dual polity’ now offers more scope than widely envisaged for the building of alternatives to a commodified economy, I focus in on how careworkers as a profession can lead the development and embedding of new models of care.

Finally, a shorter Part V offers some reflection on how a process of professionalization and decommodification in care might act as a model for wider attempts to develop post-capitalist economy structure and convivial modes of living even within the interstices of the body capital, before a final afterword on my own agency, with the suggestion of a moral imperative to personal activism on the part of those who would have others deploy their agency for the wider good.

Part III Professionalization, precedent, prejudice

Nursing vs care

So is it possible to create, as conscious political act and within a reasonable timescale, a new profession?

Well, as I said back in May, I’m hopeful.

First, there is at least some precedent to follow: nursing. I will make the case in part IV for care as a separate profession from nursing on the basis that it is, with some overlap, quite simply a different thing. Here, though, I want to trace the development of nursing as profession, and draw out the successes and failures, such as they might act as a useful guide for careworkers.

The rise and fall of the nursing profession

Space here does not permit a very detailed history of the rise of nursing from role as doctor’s handmaiden to established professional status across most of the world, but it is worth noting the main social conditions in which it took place (in the UK), and the main instrument of its growth as a discipline identifiably different from medicine; this will act as a guide to both why professional status came quickly when it did come, as well as why its status has declined in recent years.

Nursing in Britain came of professional age in the 1960s and 1970s through the determined agency of people like Nancy Roper, who developed and soon gained widespread acceptance of her ‘model of nursing’, based on the idea of 13 activities of daily living and the idea of a continuum between total dependence and total independence.

At the heart of the implementation of the model was the ‘care plan’, drafted by nurses on admission of patient to a ward (with a later spread to community settings), in autonomy from, but with reference, to any medical intervention plan. The ‘care plan’ quickly became the symbol of nursing autonomy, and was embedded in all nurse training from the 1970s onwards (other models imported from the US were also available, but Roper’s was dominant at that time).

The spread of this autonomy was also aided by the conditions of the time. At a societal level, it was becoming more possible for (mostly female) nurses to assert themselves on the ward, as post-war recognition of women in the workplace shifted towards at least some valuing of what those women brought, and at the same time an NHS with a growing budget was still ‘decommodified’ enough to allow the emergent new profession to make the demands it needed for additional staffing, such that the model could be implemented and nursing outcomes become better (this was a time when hospital stays were becoming greatly reduced for many reasons, but nursing autonomy was one of them).

That’s the upside of the development of the nursing profession in the 20th century: a story of female agency focused on setting standards and creating regulatory institutions for their maintenance, and making the most of the opportunities afforded in a fast-changing world.

But there’s also a downside that it’s important to recognize, as we try to trace a path for the professionalization of caring. The downside is that, while nursing is validly seen as a profession reasonably straightforward for anyone to enter, the professionalization process itself depended to a significant extent on race and class exclusions, and these exclusionary beginnings have created a damaging legacy from which carers seeking to develop their own autonomy, through solidarity, would do well to learn.

I trained as a Registered General Nurse (RGN) in London in the late 1980s. Astonishing though it may now seem, there was not a single black student in my cohort of around 30 student nurses. Indeed, I’m pretty sure the only interaction I did have with a black nurse student on RGN training was with one in a cohort after mine whom I represented, as a young union steward, in a grievance procedure against a nurse tutor who was discriminating against her.

That does not mean there were no black nurses in this big teaching hospital. There were plenty, but almost all of them had Enrolled Nurse status, because the recruitment system had militated against them entering the higher level training (this was just before the start of nursing degrees linked to universities).

While perhaps most obvious in a big teaching hospital which drew in white, middle-class applicants from around the country, this racial (and class) segregation was pretty generalized across the country, and was rooted not just in the broad racial discrimination of the time, but also in the fact that the nursing profession had not broken down class and race barriers even as it developed its own autonomy. This was a time, even into the early 80s, where doctor-nurse romance and marriage were still part of the norm, and where registered nurses still tended to come from ‘respectable’ families for whom nursing was an appropriate career move for a ‘girl’ in a world still short of opportunities in other professions.

The shift of nurse education into universities, and the expansion of higher education itself, did change these dynamics rapidly in the 1990s and 2000s but not before a deep split in the overall workforce, represented by the fact that middle-class nurses tended to join the Royal College of Nursing while the rest opted for the nitty-gritty union support offered by the NUPE or COHSE (later amalgamated as UNSON).

To my mind at least, the nursing profession never recovered from that split.

Come the managerialism and associated de-professionalization trends of the 1990s and 2000s, nurses emerging from universities into the workforce were met with conditions of work that I could nenvee have imagined in the 1980s, as the autonomies once gained were stripped away, and in many cases nurses were reduced to the role of proficient technician, while a lot of the actual nursing work as I had known fell to the undertaken by healthcare assistants who endure a status and powerlessness lower than that of the Enrolled Nurses that they effectively replaced.

This flow through into lower standards of care, with individualized care plans and implementation replaced by a return to the routines of ‘rounds’; this change was ‘sexed up’ under the very direct orders of one David Cameron as ‘intentional rounding’, but in reality a return to the conveyor belt-style task orientation of the 1950s and 1960s.

Ultimately, the reason this de-professionalization process has been allowed to happen is that the initial process of professionalization was conducted by an elite, for an elite, and this brought with it a lack of willingness or capacity on the part of otherwise forceful agents of change to develop a holistic view of what nursing actually was, and who nurses were. Thus, while there was some trickle down of benefits to the rest of us, it has turned out be short-lived; come the managerial assault on professional standards nurses were not in a position to resist, because the necessary bonds of solidarity did not exist across the workforce.

Care vs nursing

I am not sure where nursing will go from here.

Ideally, the new militancy evident in the formation and rapid growth of Nurses United, which may or may not swiftly overtake both the RCN and UNISON as the go-to organization for nurses who want to see their professional autonomy restored as well as the value of their pay, will also take in a re-appraisal of the profession’s post-war history, and perhaps even do so through the lens of David Smail’s conceptions of proximal and distal power (see part II).

In this version of nursing history, the new profession’s agents of change did effectively challenge more proximal powers as it shifted care from a medical model to a more patient-centred one, but did so largely in concert with the more ‘distal’ powers of structural racism and class inequality, in a way which has not served it well in the long run.

The fact that Nurses United has been fostered by the New Economy Organizers’ Network (NEON), which has a well-developed approach to the anti-oppression agenda, which can help nurses, ‘unlearn’ their own history, suggests that this may happen, though there is little concrete evidence of it yet, with the main focus still understandably on using the pandemic response to secure a reasonable pay rise.

But while I am not sure where nursing might go in any ‘unlearning’ process, I am certain that its flawed development to date does offer useful lessons for an emergent care profession around the missteps it will need to avoid if it to develop the solidarities it needs, in a less propitious period for such than that enjoyed by nursing and, conversely, the kind of behaviours it will need to encourage and embed early on.

In Part IV, I move on to examine ways in which civil society and left activists interested in supporting care workers to create their own profession, and in so doing I make an assumption that effective support for this will come from those people and groups who have a range or resources to offer. Such support should of course be provided respectfully, for the ‘power’ reasons; I have referred to, but such respect need not impede acts of critical friendship as long as those acts are themselves implemented with reflexivity and consciousness of historic power imbalances.

In such circumstances, I think it quite reasonable for those on the resource-offering side of the new professionalization team to develop and agree conditions that ensure inclusivity and reflexivity about the downsides of newly won power over the long term; this should be not just in relation to those working in and around the care sector who might be inadvertently excluded in the way that Enrolled Nurses were, but also — crucially — in relation to those on the receiving end of care.

Carers should learn from what (some) nurses got wrong, and it is better, if the emancipatory range of professionalization is to maximized, to do this earlier than to regret it later, in the way that (all) nurses now should be doing, perhaps en route to putting it right.

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Paul Cotterill

Paul Cotterill

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Secretary General, Habermasian Labour (UK). Indefatigably focused on the promotion of ethical discourse in the public sphere, except when there's cricket.