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CURRENT CONTROVERSIES IN CRITICAL CARE |
Anoteworthy book has been written by William Sullivan, PhD, titled Work and Integrity: The Crisis and Promise of Professionalism in America.1 The book presents a sobering indictment and visionary challenge to all professions. It provides an incisive critique of the current failures and challenges to professionalism. Sullivan presents a compelling vision for renewing the social contract for the professions. If moved from vision to action, this work could transform the current crisis of cynicism about the professions into renewal and confidence. All professionals would do well to take this book seriously. To that end, this issue’s column is devoted to an interview with Dr Sullivan.
Benner: In some ways, this book seems to be a continued conversation that you and your colleagues began in the 2 influential books Habits of the Heart2 and The Good Society.3 What connection do you see between those works?
Sullivan: Both books dealt with the cultural and moral resources within American society for justice, community, and greater social solidarity amid pluralism. In Work and Integrity, I argue that a democratic society also draws heavily on the skills and moral sources of the professions. Particularly within a society like ours, in which the pull of utility and instrumental thinking—as in today’s ascendant business model for institutions—is so strong, the professions are vital reminders that human welfare ultimately depends upon cultivation of values such as care and responsibility, which cannot be produced by self-interest alone. By focusing on the quality of their craft and the inventiveness of their practice, professionals provide an alternative model of what work can be: a contribution to public value, as well as a source of motivation and deep personal satisfaction.
Benner: Could you explain what you mean by the social contract between the professions and society?
Sullivan: Nursing and medicine have enjoyed positions of honor based on their social contract with the public that they serve. In exchange for bearing social responsibility for safe conduct with those who rely on their services, nurses and physicians (and indeed all professionals) within the bounds of their legal regulations have authority to control who enters their profession, how they are educated, and key aspects of how they conduct their work.
Benner: What do you see as the major threats to professionalism today?
Sullivan: There is little doubt that the professions are central to the successful development of high technology necessary for the global economy. They are also heavily involved in developing productive and educated citizens. Professionals such as engineers, academics, nurses, doctors, scientists, and lawyers are major contributors to the prosperity and high level of technical development in all advanced societies. However, the traditional structures of professional life, such as corporate membership, controlled markets for professional services, and monopolistic practices in training, recruitment and the control of standards, seem quaint and even antithetical to some of the most touted new patterns of work. The question is: "Where do the professions fit in a future depicted as a globalizing march toward a frictionless capitalism that is based upon information and communications technology?" The fluid morphing of one occupational identity for another and the migration among disparate domains of activity celebrated as a new economy are antithetical at a number of points with key elements of professionalism. Today’s enthusiasm for untrammeled flexibility in workers is not a good match with the professions’ demand for deep training in a complex under-determined field that requires professional judgment and integrity. Professions, unlike businesses, are pledged to protect those in vulnerable situations.
Benner: What do you think are the specific threats to medical and nursing professionalism?
Sullivan: Medicine is struggling in an uphill battle to control a major evolving reorganization, largely in reaction to changes in its regulatory, reimbursement, and organizational context. Medicine and nursing as professional practices are increasingly managed and controlled by complex industries and institutions such as insurance companies, health maintenance organizations, and complex medical centers. All of these trends require more training, more individual integrity, and more responsibility. Unfortunately, they also erode aspects of professional autonomy and control. On the other hand, the confidence that healthcare is a business enterprise best controlled by the market is breaking down. Failures in healthcare access and continually rising costs have clarified the limits of the market as a good control mechanism for healthcare. What to do next has become a decisive political issue for the immediate future. Medicine and nursing could be far more active and important players in how this gets decided. To do that, they would have to engage the public more directly by becoming visible, collective advocates for public protection amid the bewildering changes racking the healthcare world.
Benner: Given these threats and challenges, what can we do as professionals and citizens?
Sullivan: In Work and Integrity, I try to suggest ways in which the professions can reinvent their civic dimensions by becoming public advocates for policies that clearly benefit the common welfare. This is a moment at which various professions could rediscover their civic missions, especially since, at least for the moment, failures in a key number of economic sectors ranging from telecommunications, energy and electricity industries, and accounting and financial services have shaken many people’s faith in the ability of markets to self-correct. Consequently, the question of how healthcare professionals can function as prudent managers in the public interest, as well as engaged, autonomous professionals, takes on salience in this new environment.
Benner: As a nurse educator, I was particularly drawn to your chapter on the renewal of professional education. What do you consider to be the most important mandates for change in professional education today?
Sullivan: The university and college settings that prepare professionals have been far more adept at educating professionals’ analytical and scientific capacities, and far less successful in teaching skillful practice and wise judgment in complex practice settings outside the university classrooms. Academic theory aims at pure academic disciplines and is less focused on experiential learning from and through practice. While there are advantages for innovations in the academic setting’s reflective, removed space, its disadvantage is that it fails to address the public’s need and the social contract of the professional in the context of practice. This lack of integration between cognitive training and the practice skills is compounded by weak abilities to think responsibly about the larger social and political significance of their practice, which really constitutes the major challenge. Renewal depends heavily upon getting these vital elements of professional preparation properly aligned with public mission.
Benner: Yes, and here a succinct quote from your book is helpful.
The strengths of the academic model are efficiency in systematic transmission of ideas and information, along with at least some guarantee that the knowledge communicated to students is reputable and up-to-date. Its weaknesses lie in relative abstraction from actual application of knowledge to practice, along with general avoidance of the embedded knowledge of practice itself. The crucial aspect of apprenticeship—initiation into the wisdom of practice—remains on the margin of academic training.1
As a nurse, I worry when I hear the word apprenticeship, because in nursing apprenticeships were notoriously geared first to the hospital’s needs and only secondarily to the educational mission. It was liberating when nursing finally entered educational settings where work demands and educational demands were kept relatively separate. I suspect you want to call attention to the positive sides of what is learned from thinking in practice situations. Many nurse educators still remember the frustration experienced by nurses under the old apprenticeship training in hospital-owned schools of nursing. Even the most enlightened directors of nursing were not able to make the educational and safety needs of the students take priority over the hospital’s staffing demands. Similarly, physicians have just wrenched themselves away from the old apprenticeship of working in excess of 80 hours per week during their residencies with little or no pay. Those are clearly the weaknesses and excesses of apprenticeship education, but this is not the apprenticeship model that you outline. Can you describe the role of apprenticeship you have in mind for professional education?
Sullivan: Your point is well taken. The professional must learn, as Eliot Freidson4 pointed out in his description of the aim of medical education, to form a clinical habit of mind for "consultants who must intervene [with specialized, esoteric knowledge] in everyday practical affairs."
Benner: As a professional, I have to admit that I was not familiar with your notion of civic professionalism. Can you explain what you mean by that term and also the links between citizenship in society and professionalism?
Sullivan: Professionals are central to performing in the public’s interest. For example, a good health-care system and a functional legal system are essential public goods. They provide services and uphold values that benefit the entire public. They depend upon cooperation, yet no particular market has a strong incentive to cooperate and to provide services along the needed continuum of care. These public goods require a civic professionalism that entails social reciprocity, responsibility on the part of the professions, and active participation and public concern on the part of citizens served by the professions. Civic professionalism can be contrasted to technical professionalism, which is defined by a narrow focus on the possession and control of a highly specialized form of knowledge. Throughout the 20th century, professions have tried to establish their position in society by emphasizing their peculiar expertise. However, at its extreme, this has led to the all-too-familiar deformation of the professional as simply the expert for hire, or another mercenary on the make. The ascendancy of the technical model of professionalism has also weakened the connection between professionalism and care for others. For example, since the clergy lack a clear scientific knowledge base—though historically the clergy were the central intellectuals in Western societies, including staffing the universities—they cannot claim professional status on the technical model. That thinking is at least controversial once again. This allows an opening for a more engaged model of professionalism and a more pluralistic vision of knowledge.
Benner: Given the recent market preoccupation in healthcare, this book comes at a time when the move to civic professional is crucial to self-correction within healthcare organizations and professionals. This column focuses on ethics, and I particularly like your understanding and articulation of work integrity related to civic professionalism. Could you lay out a few of the aspects of work integrity that you see as central to the renewal of the professions?
Sullivan: The key point, which I’ve tried to develop at some length in Work and Integrity, is that professional work is, at least in part, an alternative to the familiar business model of work and also to the way public or private bureaucratic organizations organize work. Like businesses, professions sell their services in the marketplace. Like bureaucratic organizations, they also need regulations and standards. However, professions are essentially communities of living craft-knowledge that have become self-reflective about their practice (this is one of the key functions of the professional school as a center of research and scholarship). This knowledge is their collective possession, but it is also a social asset of which the organized profession is the collective steward. Within their social contract, professionals aim at quality of performance in complex situations in which outcomes are uncertain. Therefore, they must be able to judge situations well—that is the great objective of all professional training. To function well, they need room for discretion in how they apply their knowledge and craft. This is the basis of collective professional self-regulation. To enter a profession is to assume a certain kind of social identity, as a person of valuable knowledge and skill, a recognized contributor to valuable public goods, but also as a trustee of the knowledge and skill that define the professional domain.
Benner: So you see the importance of renewal within the professions and also in the institutions that support the professions? Is there a role for professionals that you see as central to democracy and to a good society?
Sullivan: I think that universities need to continue with their strong program of analytic training, but they need to enhance their pedagogies for practical narrative rationality. Physicians and nurses must develop their practical reasoning ability that is guided by concern for human well-being, and that is situated in actual healthcare delivery settings. This aspect must not be considered applied and thus not as demanding as analytical training.
Benner: Work and Integrity has provided a major theoretical anchor for the ongoing study of the professions at the Carnegie Foundation for the Advancement of Teaching. I am privileged to codirect the Nursing Education Study with Dr Molly Sutphen. Can you explain how Work and Integrity relates to the larger Carnegie Foundation study of the Professions?
Sullivan: The Preparation for the Professions Program entails the integrated, comparative study of education for professional understanding, integrity, and practice in 5 professional fields: clergy, engineering, law, nursing, medicine (3 in Phase I and 2 more in Phase II). All professional educational programs grapple with questions of how to teach the profession’s scientific or scholarly knowledge in ways that will best guide and inform professional practice. We are examining how to educate for integrity as well as competence, how to impart the fundamentals of good professional judgment, and how to teach complex skills so that students not only master the technical craft of the profession, but also develop analytical skills and learn generalizable principles that make possible creative adaptations to new situations. We are seeking to bring a comparative perspective to teaching, learning, assessment, and curriculum in these fields. Medicine and nursing will be studied in relationship with each other because both professions are so intertwined.
Benner: I am excited to be a part of this cross-profession comparative study and look forward to learning from other professional disciplines as we come to better understand nursing and medical education. Thank you for bringing this dialogue to the attention of critical care nurses and physicians.
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