The plasticity of professional boundaries: a case study of collaborative care in maternity services.

ABSTRACT

A case study of twenty-nine midwives and nine obstetricians working in a regional, public sector Australian hospital demonstrates the plasticity of professional boundaries within a post-welfare state. Driven by new discourses of globalisation, marketisation, managerialism and consumerism, professional boundaries in health care are being blurred, reordered and reconstituted. Government policies that call for a new interdisciplinarity between maternity professionals may be seen as responses to the above pressures. However, there remain considerable barriers to achieving collaborative models including conflicting interpretations of risk, of women's bodies and of childbirth; the veto power of decision-making retained by obstetricians; questions of professional accountability; and diversity over appropriate styles of micro-interaction. Collaboration demands a new egalitarianism to eclipse the old vertical system of obstetric dominance and this means that midwives need to create a distinctive professional specialty, or new object of knowledge. Midwives' skill in 'emotion management' could provide this speciality in addition to their rational-technical knowledge and thus elevate midwifery to an equivalent professional status with obstetrics but as yet neither obstetrics nor midwifery have realised its professionalising potential

KEY WORDS

Sociology, childbirth, professional boundaries, 'emotion management', gendered discourses of knowledge

Globalisation, 'reflexive modernisation', a growing awareness, real or otherwise, of contextual risk and recruitment crises in some professions have prompted neo-liberal post-welfare states (e.g., Australia, Canada and the UK) to apply new mechanisms of corporate governance to the public sector (Giddens 1990, Beck 1992, Dent and Whitehead 2002). These mechanisms or discourses, known broadly as marketisation, managerialism and consumerism, have posed challenges to the existing boundaries of many professions, including the health professions, by calling for new interdisciplinary, collaborative practices. The disruption to market privileges enjoyed by elite professional groups as a result of these discourses has revealed that professional boundaries are not natural enclaves organised around a specific object of knowledge (positivist knowledge or knowledge as 'a given'). Rather, they are contested spheres of practice--cultural artefacts produced by a 'labour of division' (Fournier 2000). This paper reports on the responses of professional workers within an Australian maternity unit to the challenges of collaborative care. Boundaries are simultaneously being blurred, fortified and renegotiated around conflicting interpretations of 'risk', the veto power of decision-making retained by obstetricians, who will be professionally accountable for adverse outcomes and how best to manage micro-interactions with consumers. I argue that the exemplary skill of midwives in 'emotion management' (Bolton 2002, Hoschchild 1983) in addition to their rational-technico knowledge represents a potential to disrupt old boundaries and to facilitate realignment between midwives and obstetricians along more egalitarian lines. However, responses by midwives and providers to these opportunities remain the lynchpin to the full transformation of the old professional boundaries.

The 'cultural work' of boundary maintenance

Abbott (1988) discusses the 'cultural work' that actively maintains separate professional spheres and shores up the boundaries of the dominant group. Representing knowledge as a series of abstractions defying codification, standardisation or popularisation is a common device in this usurpation of power as are practices like claiming a public service ethos over pecuniary self-interest and labelling competitor groups as amateurs or 'snake oil merchants'. Such strategies stigmatize the 'other' and simultaneously create a sense of anxiety and fear in the public. With marketisation of public sector agencies, multidisciplinarity has become a key strategy in rationalising resources and delivering services. As the utility of old professional boundaries have been questioned, so the basis of the professions has come under fire. Rather than being seen as derived from an organic division of labour around a special skill or 'natural' object of knowledge, professions and professional boundaries are seen to be culturally created through a 'labour of division' (Fournier 2000).