present day under.docx
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presentdayunder
AQuietRevolution?
ParaprofessionalDevelopmentandLearninginHealthandSocialCare.
ChrisKubiak
FacultyofHealthandSocialCare,
TheOpenUniversity,UnitedKingdom
September,2008
Correspondenceto:
FacultyofHealthandSocialCare
TheOpenUniversity
WaltonHall
MiltonKeynes
MK76AA
UnitedKingdom
c.d.kubiak@open.ac.uk
Thisisaworkinprogress–pleasedonotcitewithoutpermission.
ThelasttwodecadesoftheUKHealthandSocialCaresectorhasbeenoneofnearconstantchange.WhileNewLabourhadnotreturnedtothelongstandingmodelofcentralisedcommandandcontrolwhichhadbeendismantledundertheConservativegovernment,theygovernedaneraofrelentless,almosthyperactiveinterventionandredesign(ApplebyandCoote,2002).Groundedinneoliberalideology,thewelfaresectorhasbeenrevisedandrevisionedalonganumberofrecurringthemes.MooneyandLaw(2007)presentathoroughanalysisdescribinganincreasingconcernwithefficiencyandeffectivenessinbothadministrationandclinicalpracticecouplingadriveforcashsavingswithincreasinglevelsofinterventionintoprofessionalpractice.Serviceusershavebeenreconceptualisedascustomersandservicesreconfiguredaroundtheirneedsbringingwithitincreasedmonitoring,reviewandauditaswellasaconsiderableblurringthetraditionaloccupationalandprofessionalboundaries.
Theneoliberalturnwithitscontinualpursuitofanevermoreefficient,value-for-moneyservicehasalsobroughtitwiththeuseofTayloristtechniques(Bolton2004)whichprovidedthespaceforaredistributionofthedivisionoflabour.Thisreformhasbeencharacterisedbyareshapingofoccupationalrolesaswellascomplexsystemsofregradingandreclassification(MooneyandLaw2007).Staffarecalledupontobemoreflexibleaboutroledefinitionwithdrivestoshiftoutoftraditionalboundaries(Dawsonet.al.,2007;DH2001;DHSSPS2008).
Inthispaper,workinglifeinsuchliquidtimesisanalysedintermsoflearningandidentity.Therequirementforworkerstomovewithvariouswavesofchangehaslongbeenassociatedwithdrivesforlifelonglearningandreskilling,anagendaofsomeambivalence.Theneedforflexibilitydefinesalearningagendacouplingthecreationofmalleablehumancapital,capableofadaptingtothecurrentagendawithonefocusedonachievingselfactualizationorbuildinghumanpotential.Moreover,theneedtomovewithcentrallydeterminedbestpractice,asisoftenthecaseunderclinicalgovernanceforexample,issetagainsthardwonexperience,knowledgeandskill(Jacobs2004).Movingwiththetimesintroducestensionsaroundwhatitmeanstobecompetentortohaveavocation.
Suchconditionsalsohaveimplicationsforidentity.Thedecadeofchangeinthewelfareservicehasbeenboundupwithaprocessinwhichinstitutionsarederidedasinefficientstaffedbypeoplewhocouldnotmakeintheprivatesector(Sennett2007).Theseareinstitutionsinwhichallmustchange–domore,dobetter,bemoreresponsive(LawandMooney2007).TheimplicationsofthepushforconstantchangewascapturedbySennett(1998)inhiscompassionateanalysisofthecorrosionofcharacterinwhichhearguedthattheworkingconditionsofflexiblecapitalismcorrodetheindividual’sattemptstodevelopanarrativeofidentityandlifehistory.Hisconcernisthatpractitionersdonotstrivetobejustanotherpairoflabouringhandsbutdesiretodevelopcareers,professionalidentitiesortheskillsofcraftwork.Thisisaquestionofhowdohumanbeingsmaintaintheirvocationanddevelopanarrativeofidentityinsuchfluidtimes?
Thisquestionleadsmetoconsiderhowindividualsareshapedbysuchtimesbutalsothewayinwhichtheyagenticallyshapetheircircumstancesinordertoearnadecentsalary,doagoodjoborearnesteemandstatusfromtheircolleagues.Inthischapterthisconcernistakenupinrelationtoagroupcollectivelyreferredtoassupportworkersinhealthandsocialcare.Exploringthewayinwhichtheroleandskilldemandsmadeofthisgrouphavebeenchangingsignificantlyinrecenttimes,thispaperconsiderstheconsiderableambivalencesurroundingtheirdevelopment.
Reshapingtheparaprofessionalworkforce
OneaspectofthereshapingofHSChasinvolvedchangesintheroleoftheHSCparaprofessional–theAssistanttonursesoralliedhealthprofessionals,theCareWorkerforthosewithmentalhealthproblemsorlearningdisabilities–agroupreferredtohereasthesupportworker.Thedevelopmentofthisgrouphasbeenpresentedasacosteffectivemethodtoaddresstheproblemofunderresourced,oversubscribedservices(seeforexample,Keeneyet.al2005).Thereshapingoftherolehastakendifferentforms.Insomequarters,newparaprofessionalroleshavebeencreatedsuchasSupport,TimeandRecoveryworkersinmentalhealth.Othershavebeensubjecttosameoccupationalboundaryblurringthathasbeenrunningacrosstheworkforceasawhole.Forexample,insomequarterstheuni-professionalpractitionerhasbecomeamulti-professionalgenericrehabilitationworkerwithskillsfromnursing,occupationalandphysiotherapy(Knightetal.,2004;Rolfeetal.,1999).
Mostcontroversially,supportworkersareperformingrolespreviouslyheldbyprofessionals(Ashbyetal.,2003;Atwaletal.,2006;DepartmentforEducationandSkills,2006;DepartmentofHealth,2006;Mackey,2004;Rainbirdetal.,1999;SpilsburyandMeyer,2004;Suttonetal.,2004).Italsomarksashiftinthedivisionoflabourinwhichtheregisteredprofessionalincreasinglywithdrawsfromclientengagementintopaperwork,reportsandaudits(seeforexample,KennedyandKennedy2007)leavinganothertrancheofstaff,theparaprofessionalorsupportworker,todothebasicfrontlinework.
Inotherpartsofthesector,thedemandsmadeofsupportworkershavehadadifferentemphasis.Policydrivesemphasisingcareinthecommunitydemandsnewrolesandservices.User’sneedsareseenasincreasinglycomplex(FlemingandTaylor,2007;Rainbirdetal.,1999).Serviceusersareseenindiversifiedterms,conceptualisedasactiveandcompetentsubjectswithservicesincreasinglycommodifiedwithdirectdeliverytofamiliesandchildren.(CameronandMoss,2007).Moreover,policyemphasisesgoalsofautonomy,empowermentandchoice(seeforexample,TheNHSandCommunityCareAct1990).Serviceusersthemselvesarenolongerseenaspassiverecipientsofcarebutactivecitizenscallingintheirrightsforqualityandpersonalisation(CameronandBoddy2006).
Consequently,lowlevelsofskillsarenotlongersufficient.Forexample,theprioritygiventoholisticcaremeansthatthediscretetasksofcaring(e.g.washingorfeeding)arenotmerelyinstrumentaltaskstobedelegatedtotheunqualifiedbutarepartofdevelopinganddeepeningtherelationshipwiththeclientcreatingopportunitiesforsupportingthatperson’sdevelopment,theirautonomyandempowerment(Mossetal.,2006b).Inaddition,theHSClandscapehasbecomeonemarkedbyhighpublicexpectations,akeenerfocusonprofessionalstandards,socialwelfarelegislationandalitigiousculturedampenedwithriskmanagementprocedures(FlemingandTaylor,2007).Similarly,thereareplansforsupportworkerregistrationacrossHSC(DepartmentofHealth,2006;GeneralSocialCareCouncil,2007).
Paraprofessionallearning–acontestedprocess
Therecognitionthatfrontlinecarerequirescomplexskillsandknowledgefocusesattentionontheneedforongoingtraininganddevelopment.Whilethedevelopmentofsupportstaffmaybenecessaryorevensupportedinpolicystatements,theremaybeconsiderableambivalenceconstrainingtheirgrowth.TheseambivalencesconnecttoBillett’s(2004)notionofco-participation.Workingfromasocio-culturalperspective,Billettpresentsaffordancesforlearningasaproductofboththeopportunitiesandactivitiesavailableintheworkplaceandtheindividual’scapacitytoconstrueandtakesuchopportunities.
Soatthemostbasiclevelofanalysis,HSC’sresourcedifficultiesprovideasourceofambivalencearoundtheservicevisionandactualopportunitiesfordevelopment.Forexample,theNHS’commitmenttolifelonglearningisparadoxicallyunderminedbytheinabilityofhumanresourcemanagerstoplanforanythinglongerthanayear(McBrideetal2005).Onthe‘shopfloor’,heavyworkload,lackofresourcesforchangeandlackofmanagementback-upcaninhibitchangestopracticefollowingstudy(Forrester-JonesandHatzidimitriadou,2006).Accessandinteractionwithskilledothersisasignificantsourceoflearning,thoughsupportworkersmayfindthatsupervisionorsupportislackingduetoprofessionalcolleagues’workloads(Coffrey2004),lackoftraininginsupervision(Coffrey2004;EllisandConnell2001)orsimplyinadequatestaffinglevels(StokesandWalden2004).Moreover,supportworkersmaybereluctanttoengageintrainingbecauseofthelackoffinancialrewardattheendofit(EllisandConnell2001;Hancock2005;Rolfe1997).
Affordancesforlearningarealsoassociatedwithworkplacenorms,valuesandpracticeswhichnotonlystructureactivitybutareoftenconcernedwiththecontinuityandreproductionofpractice(Billett2001).Assuch,makingchangesinpracticecanmeanthatlearningisacontestedprocess.Thus,opportunitiestoparticipateinactivities,accesssupportandguidancemaybeunevenlydistributedacrossparticipantsonthebasisoffactorssuchasrace,gender,workeroremploymentstatusorperceivedvalue(Billett,2004).Careworkerscanoccupyamarginalizedpositionintheworkplace(Miersetal.2005)andissuesofstatusorhierarchymaychallengedevelopmentoppor