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How does professional dominance in healthcare organizations support and / or hinder organizational learning?

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  • Save Public Health Research 2018, 8(5): 101-105 DOI: 10.5923/j.phr.20180805.01 How Does the Dominance of Professions in Health Care Organisations Support and/or Obstruct Organisational Learning? Mohammed Khaled Al-Hanawi Department of Health Services and Hospitals Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia Abstract In recent years, many organizations have heavily invested in organizational learning to improve the quality and efficiency of their workforce. While the benefits of implementing a learning organization are well documented, the ability to cultivate such learning is a highly complex process that varies considerably from one occupation and organization to the next. Review of the literature regarding health care sector operations made evident the unique challenges that need to be addressed for there to be the development of an organizational culture which will embrace new and positive learning cycles, simply due to the nature of the professionalism inherent to the occupations. Traditionally there has been a large gap with regards to gender as well as perceived “professionalism”, with most doctors being male and most nurses being female and nursing being viewed as a “semi-professional” occupation. Additionally, there is a considerable dichotomy between the efforts of health care managers, which seek to facilitate knowledge sharing across professional and organizational levels, and the medical experts that want to maintain professional “boundaries” and keep management involvement to a minimum. Thus, there are numerous inherent factors that need to be overcome in order for truly effective organizational learning in the health care sector. Keywords Organizational learning, Health care quality, Health care sector operations, Professionalism 1. Introduction There is no doubt that the issue of the extent to which the domination of professions in health care organisations weather support or obstruct organisational learning is one that open to debate. This article aims to consider the problem of professionalism in health care, looking in particular at the extent to which the domination of professions within the health care sector can be understood as either a barrier to or a facilitator of organisational learning. This, quite clearly, represents an especially complex problem to attempt to tackle, one that requires an understanding of the underlying dichotomy between organisations and professions as they appear in the health care sector. [1] As a consequence, it is prudent to divide this article up into distinctive subsections, considering, firstly, the relevant academic theory relating to professions and professionalism before, secondly, turning attention towards examining the fundamental concepts * Corresponding author: (Mohammed Khaled Al-Hanawi) Published online at Copyright © 2018 The Author(s). Published by Scientific & Academic Publishing This work is licensed under the Creative Commons Attribution International License (CC BY). behind organisational learning. In the aftermath of considering the key ideas on professions and organisational learning, it will be necessary to marry the two paradigms together under the aegis of health care. In this way, the article will seek to provide an answer to the question of whether the dominance of professions in health care organisations support or obstruct the ideal of organisational learning. 2. Professions and Professionalism The rise of professions and professionalism has its roots in the evolution of modern western capitalist societies over the course of the nineteenth and the twentieth century’s. Where, prior to the advent of the modern era, occupations were assigned exclusively according to social and economic status, with the achievement of industrialisation and the rise of the middle classes in the modern era professions became increasingly organised according to education, skill and expert knowledge. [2] Professions are thus synonymous with the organisation and division of middle class labour in post-industrial western societies. [3] The growth in the core professions of law and medicine demonstrates the shift away from standardised occupations to specialised professions grounded in the “use of a circumcised body of knowledge and skills thought to gain particular productive ends”. [2] 102 Mohammed Khaled Al-Hanawi: How Does the Dominance of Professions in Health Care Organisations Support and/or Obstruct Organisational Learning? The rise and the growth of professions during the modern era have necessarily incorporated a rise and a growth in the ideal of professionalism. According to Eliot Freidman, professionalism can be defined in terms of self-governing institutions that allow the members of an occupation “to make a living while controlling their own work”. [2] These professional institutions ensure that professionalism is understood in terms of an exclusivist conception of occupation with the levels of expertise required to perform the role being so specialised as to exclude those people who do not conform to the standards expected of the professional institutions. [2] Thus, as MacDonald underlines, the process of professional formation needs to be framed in terms of social mobility, closure and the translation of expert knowledge into social and economic rewards. [4] As a result, it is prudent to observe the inherently exclusive nature of the institutional concept of professionalism. [3] In undertaking a critical analysis of the impact of professions and professionalism (both upon the occupation in question as well as upon society in general) it is important to consider the problem from two key sociological perspectives. Firstly, in considering the impact of professions and professionalism, one can adopt a functionalist approach. [5] This, in turn, reveals the importance played by professions in the maintenance of the moral order of capitalist societies. As MacDonald attests, professions have traditionally been understood in terms of entities that characterise certain social, political and economic traits. [5] In this way, professions and professionalism serve to establish a key link between the individual and the state. [6] Secondly, one can also consider professions and professionalism from the perspective of power. [5] When, for instance, one considers the way in which professionalism enables a group of people to monopolize certain highly sought after and well-remunerated positions and, moreover, the way in which professional experts exercise power over state policy, one can better understand the co-dependent nature of the relationship between professional status and power. [3] As a result, it is important to acknowledge two key points. On the hand, it is important to consider the way in which professions and professionalism represent an important link between the state and society. [5] Understood in this way, it can be argued that professionalism entails a vital social service that sets the profession apart from other occupations. [7] On the other hand, it is also imperative to recall the intrinsic nature of the relationship between professions/professionalism and power. Organisational structure and power are inevitably linked. 3. Organisational Learning In order to improve efficiency, reduce costs and enhance competiveness, organisational learning has become an essential means of improving the quality of the workforce in the contemporary era. [8] Yet while the link between organisational learning and improved quality of the workforce cannot be in doubt, the size of the task of implementing organisational learning remains very much open to question. [9] This is because the paradigm of organisational learning is about change. As Savolainen attests, at a fundamental conceptual level, organisational learning involves transplanting old, negative learning cycles with new, positive learning cycles. [8] In this way, increased levels of communication, greater involvement of team members, an emphasis upon commitment and a concerted effort to overcome resistance can become part of the organisational structure of the workforce. [8] However, although instilling a commitment to organisational learning can have a positive impact upon individual members of the workforce it is difficult to instill a commitment to change throughout the organisation. This is because organisations have their own distinctive values, concepts and principles that are best understood in terms of a collective ‘organisational culture’. [10] Therefore, it should be noted that creating a learning organisation is, due to the abstract nature of learning in addition to the pervasive nature of organisational culture, a highly complex process. [9] This is particularly true with regards to health care organisations where problems pertaining to the distinctive, professional capacity of the workforce impacted upon by an external environment influenced by multiple stakeholders. [11] Furthermore, as Waring and Currie attest, health care professionals are, because of the unique characteristics of the occupation, inherently autonomous in their working roles. [12] In critical situations, medical experts need to be able to rely on their own judgments in order to make quick decisions based upon the insights afforded via their professional opinion with the cost of poor decision-making framed in terms of life and death. [13] Therefore, it is apparent that, in seeking to create a learning organisation it is imperative in the first instance to instill a commitment to shared values, concepts and principles. [8] This, in turn, serves to give the concept of organisational learning a sense of meaning that can subsequently be managed and measured so as to maintain positive organisational change. [9] In this way, managerial practice can help to bridge the divide between the rhetoric of organisational learning and the reality of organisational change. 4. Professions and Professionalism in Health Care: An Organisational Paradox? As has been established, the learning organisation involves an adherence to the principles of meaning, management and measurement. [9] In terms of the health care sector, this has incorporated a move towards the concept of managerialism and quality management. [8] This, however, immediately presents an organisational dichotomy between the prerogatives of managerialism and the ideals upon which the concept of professionalism has traditionally Public Health Research 2018, 8(5): 101-105 103 been built. [14] For instance, where managerialism underscores the need to instigate organisational change, professions seek to uphold the values of their occupation and, moreover, to reaffirm the specialization that inform the unique skills and knowledge of their profession. [2] As a result, the problem of ‘knowledge management’ must be interpreted as a key barrier standing in the way of organisational learning in the health care sector. [12, 13] Knowledge management influences every feature of the organisational structure of health care institutions. This is because knowledge management incorporates “the systematic process of identifying, capturing and transferring information and knowledge people can use to create, compete and improve”. [13] Viewed from this perspective, it is apparent that the withholding of knowledge can serve to negatively impact upon creativity, competitiveness and the broader effort to improve the efficiency of the workforce. Moreover, as Halliday details, the epistemological bases of professional knowledge which, in terms of the health care sector, are constructed upon scientific cognitive foundations, serve to distort the organisational properties of work-based associations. [6] As a consequence, it is imperative to consider the ways in which issues relating to ‘knowledge management’ impact upon organisational learning in health care organisations. [13] As far as this is concerned, it is imperative to consider the way in which the exclusivist scientific discourses that have been used by medical professionals serve as a means of sustaining the power that is attached to the status of doctors and physicians in health care organisations. [1] This, in turn, creates structural barrier to organisational learning, separating those whose knowledge is rooted in a professional context from those whose knowledge has been acquired through performing their roles in the health care sector. For instance, as Finn highlights, when examined within the context of a medical team working in an operating theatre, the uniquely professional language used by the medical experts (i.e. the surgeons and anaesthetists) is markedly different to the discourse employed by the nurses and assistants working alongside the experts. [15] This serves as a pervasive controlling mechanism within the health care organisation with the privileged position of professional experts being maintained via exclusivist medical discourse. [15] In this way, the language of teamwork, in addition to the closed nature of the expert knowledge that underpins the medical profession, serves to divide employees working in the health care sector according to professional status. [15] As a consequence, it is evident that the unequal distribution of information in health care organisations represents a significant problem for the concept of ‘knowledge management’. Ultimately, this is due to the underlying dichotomy between management and professionals in public services. [16] Where health care managers seek to facilitate a process of collaboration across organisational and professional boundaries, medical experts seek to reinforce the rigid nature of professional boundaries within the workplace in order to fend off the advances of managerial and organisational change. [13] Thus, while, in theory, the ideal of organisational learning might emphasize the need to spread information and knowledge evenly throughout the organisation, in reality it is exceedingly difficult to implement knowledge sharing in the health care sector, which is characterized by the structural nature of organisational divisions. [11] This, in the final analysis, is due to the perpetuation of deep-rooted social, epistemological and professional boundaries. [13] In addition to adversely affecting knowledge management, it is apparent that, in seeking to reinforce professional boundaries, the professional nature of health care acts as a barrier standing in the way of implementing effective evidence based management. [14] The problems inherent in incorporating evidence based management, which entails a paradigm shift away from medical practice based upon expertise and experience towards medical practice based upon a systematic analysis of the most relevant critical scientific evidence, exemplifies the way in which the dominance of professions in health care organisations obstructs organisational learning. For instance, as Dopson et al underscore, evidence based management is “about creating a culture where practitioners automatically think in an ‘evidence’-based way every time they see a new case”. [14] However, because evidence based management threatens the exclusive foundations of professionalism (for example, by making doctors subject to managerial control, by enabling patients to challenge decision-making and by increasing litigation), medical professionals are prone to undermine the shift towards evidence-based practice. [14] Understood in this way, it can be argued that the gap between evidence based research and practice is in many ways sustained not by the inadequate spreading of information and knowledge within the health care organisation but, rather, by the organisational and behavioral obstacles that exist at a local level. [14] Therefore, it is apparent that the dominance of a professional within the health care sector acts as a barrier preventing the successful realization of the ideal of the learning organisation. [16] In addition to observing the primacy of the underlying dichotomy between managerialism and professionalism as it appears in the context of health care organisations, mention must also be made of the deep-rooted gender-based divisions that prevent the expansion of organisational learning. As research undertaken by Witz has demonstrated, patriarchal practices in the labour market have helped to ensure the dominance of male-based professions. [17] The gender-based division of labour is particularly pronounced in health care where the traditional divide between male doctors and female nurses has been aided by the interpretation of nursing as a semi-professional (as opposed to a professional) occupation. [18] Although the New Labour government sought to redress the gender-based imbalance of the health care organisation, most notably by advocating the ideal of the nurse as an entrepreneur, one must, again, note that there is a significant difference between rhetoric and reality in complex organisations such as the NHS. [19] Thus, 104 Mohammed Khaled Al-Hanawi: How Does the Dominance of Professions in Health Care Organisations Support and/or Obstruct Organisational Learning? it is important to acknowledge that the spread of knowledge, which is so crucial to the construction of a learning organisation, is further exacerbated by the gender and profession-based boundaries prevalent in health care organisations. Of course, while it is prudent to outline the ways in which the dominance of professionalism in health care has contributed to a flawed conception of organisational learning it is also important to consider the problems inherent in the concept of organisational learning as a contemporary managerial paradigm. In the final analysis, it is apparent that the transference of knowledge that is such a crucial factor of learning is negatively affected not just by professional dominance but, rather, by debilitating processes of bureaucracy and managerialisation. [20] In particular, it should be noted that implementing change in large, complex organisations depends less upon the actions of the professionals that reside at the very top of the hierarchy and more upon the strategic functions of the workforce operating at the ‘middle management’ tier of the organisation. [21] Thus, it would be incorrect to assume that the dominance of professions in health care is the sole barrier to organisational learning. Rather, it would be more circumspect to acknowledge the way in which organisational learning is dependent upon the prior existence of well-functioning clinical networks that are able to facilitate the smooth transmutation of information and knowledge in the workplace. [21] overcome simply by recourse to concepts relating to organisational learning and rhetoric relating to change management. For instance, understood from a functionalist perspective, it is evident that the medical profession is understood as a social service that sets it apart from other occupations. [7] This, in turn, has ensured that medical experts look to reinforce traditional professional boundaries, particularly during times of profound organisational change. [13] Likewise, the underlying spectre of power, which is such a crucial feature of the sociology of professions, ensures that the health care organisation is constructed along decidedly unequal lines. As Waring and Currie detail, professional knowledge demands a certain level of power and autonomy in the workplace. [12] Thus, it is very difficult to manage professionals working in health care organisations where decisions derived from professional expertise can make the difference between life and death. [13] As a result, there can be little doubt that there is a deep-seated conflict of interest inherent in those policies that seek to merge the oppositional roles of the medical professional and the managerial technocrat within the context of the highly complex health care organisation. [22] For this reason, it can be argued that the dominance of professions in health care organisations presents what is in many ways an inevitable structural barrier to the successful implementation of organisational learning. 5. Conclusions This article considered theory on the professions and professionalization and discussed the concept of ‘organisational learning’. Having set out these concepts, the article used evidence from the literature, in relation to health care organisations, and examined how the dominance of professions in health care organisations support and/or obstruct organisational learning. Health care organizations are beset by the systematic and structural division of occupations. These divisions are primarily rooted in the epistemological bases of professional knowledge which, in terms of the health care sector, are derived from scientific foundations of expertise. [1] When, for instance, one considers the manner in which expert knowledge is framed in an exclusivist, scientific dialogue, it is apparent that knowledge in the health care organisation is closed according to professional status. [15] If, as should be the case, knowledge is to be understood as the cornerstone upon which learning is based, then there can be little doubt that the problems pertaining to knowledge management in the health care sector constitute the most obvious means of demonstrating the way in which the dominance of professions in medicine acts as a barrier to organisational learning. [13] However, the issues relating to expert knowledge are so important to the medical profession that they cannot be REFERENCES [1] Francis B. Humphreys J. Professional education as a structural barrier to lifelong learning in the NHS. Journal of Education Policy. 2000; 15(3): 281-292. [2] Freidson E. Professionalism, the third logic: On the practice of knowledge. 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