Radcliffe Medical Press, Oxford, England: 2004, pp 228,
ISBN 1 85775 818 8
This interesting book never mentions Integrated Care as such, even so it is always relevant for readers of IJIC and sometimes both enlightening and entertaining.
‘Values in professional practice’ is the product of three years’ discussion by a multidisciplinary group of researchers from three British universities linked with several professions. These include nursing, social work, and health service management as well as academic theology, philosophy and anthropology. Additional professionals contributed to a symposium held at the end of 2002 to summarise the work. So this is a multi-author work, but the two editors, a theologian and a social scientist, coordinate it well by introducing each of the five main sections as well as starting and concluding the book.
In a thought provoking introduction the editors explain how values make up a many faceted concept, understood in a variety of ways (‘my values—your assumptions’!). Values are usefully seen as ‘normal’, that is conservative and often unspoken, or as ‘aspirational’, that is sought after and often written down in mission statements. They also discuss the nature of professions and professionalism starting from the traditional three (Divinity, Law and Medicine) and spreading to today's wide range, many of which wish to emulate the older three in status and influence. They show us how, while an explicit set of values is a key feature of a profession, this is often an incomplete indication of how members of a profession actually carry out their day-to-day work. Values can be studied both from a sociological stance—how society works—and a philosophical one—how society should work.
To give us a wider historical perspective, Part I then examines two widely contrasting examples of professions—18th century artists in England (who aspired to professional status through education in order to gain new markets in the growing middle classes) and the clergy, one of the original ‘big three’, who are currently experiencing a marked decline in professional status in Western Europe.
The core of the book lies in Part II. This looks at value conflicts and professional identity. Again the message is built upon concrete examples. An experienced health service manager sees some arguments in favour of professional status for his group but concludes that this is not desirable. Managers certainly need their values steer a course between the conflicting demands of government, the institution and the public. His arguments do not convince me—I feel that a strong professional body could be vitally supportive—but they certainly illustrate the underlying concepts.
A leisure professional explains how his group works in a rapidly evolving set of societal attitudes. Originally his mission was “rational recreation to divert the masses from licentious proclivities” whereas nowadays we have a more tolerant and wide ranging view of leisure, with consequent changes in professional values.
Closer to integrated healthcare, a social worker then describes a professional group that is often attacked and which has become increasingly circumscribed by the law in the UK. This follows a series of difficult and embarrassing deaths of children in care and other widely publicised and dramatic social problems which may defy solution but where social workers can be blamed. Here it becomes clear that in a complex world with a limited evidence base there is often no one correct answer—professionals have to make the best decisions they can. These are based on their experience and expertise, but also, crucially on the support and on the enacted value systems of their own group of professional colleagues.
Part III naturally follows on with a closer, critical look at explicit codes of practice. These may appear to offer a solution to the challenge of laying down how professionals may act for the best. But careful inspection reveals that such codes contain both contradictions (a manager must serve his employer at all times but also must always put patient safety first) and omissions (how does one respect the client's autonomy and their best interests, simultaneously?—it's not in the code!). A chapter from a professional engineer defends professional codes but in terms that further reveal their inadequacy for helping professionals resolve the inevitable conflict between the certainties of a code and the complexities of problems involving real people.
Part IV is about values in education and training. This happens to be the most provocative and entertaining section. In an outstanding chapter Eileen Fegan, an academic lawyer, challenges traditional legal education by pointing out how apparent certainties in the nature and definition of the law, its capability, its limits and its application are deeply rooted in a particular tradition of values and thus wide open to challenge. She feels that a university based education should do this but shows how this sets up conflict with the actual practice of a profession which has made a virtue of its professionalism. This is really helpful in liberating the reader to examine his or her own set of values in healthcare.
The following chapter on the role of town planners is less dramatic but nearly as effective at showing how a value system is vital in supporting members of a professioal group in their day-to-day work—assaulted on one side by the public who want approval for their building projects and on the other by the elected local government councillors who have a much wider political agenda. In the absence of evidence procedure is all important. The adversarial nature of legal appeal processes encourages a male pattern behaviour. This is arguably sexist and itself another form of procedure informed by an implicit value system.
Part V, on values in research, is also topical, though perhaps containing less that is new for readers working in research themselves, who may already be aware of the conflicts between increasing competition in research work and professional academic values. This is manifest by the simultaneous rise in awareness of research fraud. A chapter on academic nursing research rehearses arguments between qualitative and quantitative researchers.
After so much to stimulate and interest the integrated healthcare professional, the conclusion is pithy and succinct. I liked the editors’ quote on the life cycle of the mission statement—“from dynamic discussion to death by lamination” (and subsequent filing at the back of ones cabinet).
So I repeat that this book has much to offer any IJIC reader who is wondering why it is often so difficult to integrate healthcare in real practice. The wide scope of professions included is a particular strength. Though it is not international (being entirely confined to the United Kingdom) nor directly examining problems of sharing care between professions, I find it so good at making me think in new ways about the challenges in working in partnership with both professionals and patients that I can recommend it very strongly.
Yes, read this book and become a wiser and more humble professional!