ABSTRACT
It is by no means self-evident that these, and other developments, should be considered ‘challenges to medicine’. There is no prima facie reason to expect that gains in professional autonomy within nursing will reduce or encroach upon the professional powers of medicine in any simple or straightforward way. We will argue instead that developments in nursing have been harnessed to the new public management agenda currently driving reform in the NHS. This agenda is concerned as much, if not more, with economic efficiency as it is with the professional autonomy of medicine or nursing. Indeed, the achievement of economy efficiency is predicated on unsettling the health care division of labour to meet local workforce demands. As the health care division of labour is increasingly fragmented, contestation is likely to be between individuals as much, if not more, than between doctors or nurses as groups. This suggests that, while it remains important to consider the corporate bodies of medicine and
nursing since they are integral to an understanding of health politics, now more than ever we need to also appreciate the multiple divisions within each occupational group and to be alert to the influence of local contexts upon any challenges that nursing might pose to medicine (and vice versa).
Historical continuities as well as discontinuities are evident in nurses’ long-standing ‘professional project’, which has taken the form of an occupational strategy of dual closure (Witz 1990, 1992). This is a double-edged occupational strategy which has its roots in the nineteenth century and has sought not only to challenge medical definitions and control over what nurses know and do (this is its usurpationary dimension), but also to create mechanisms of occupational closure that will clearly distinguish who and who might not practice as a nurse (this is its exclusionary dimension). In addition, the defining feature of a profession is generally considered to be its distinctive body of knowledge, based on credentials gained through advanced training (Annandale and Field 2003). So credentialism will be a central plank of any professional project. Demarcationary strategies which shape the content of and boundaries between different occupations engaged in the delivery of health care have historically also been central to the professional projects of health care occupations (Witz 1990, 1992; Sandall 1999). To what extent, then, are strategies of closure and demarcation, once so central in shaping the occupational jurisdictions of health care occupations, still relevant to an analysis of the health care division of labour today, and particularly to the relation between nurses and doctors?
