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