Sociological theories of the professions have highlighted the key role of knowledge, especially if it is connected to abstract and formal rules of science. Knowledge has been interpreted as a basic condition to perform highly specialized work, since its application assures the rationalization of tasks and solutions to solve complex problems. Training in scientific knowledge and its legitimacy through formal credentials by higher education institutions have been the main route used by professional groups to promote professionalization based on a strategy of social closure (Johnson, 1972; Freidson, 1994, 2001; Larson, 2013). Within the knowledge society, the social prominence of knowledge is even more evident, with work activities and the division of work becoming more complex and increasingly based on a more qualified workforce. In this context, new and more diversified professional groups emerge, the number of professionals increases, and, at the same time, it is expected that professions will acquire more status and prestige in societies.
The term knowledge society has been used with different meanings, although most are interrelated. It expresses the most relevant changes within the so-called post-modern and post-industrial society. Bell (1973) was, along with others such as Drucker (1993), one of the prominent authors who referred to post-modern society as knowledge society. Drucker (1959, p. 114) was also the first author to coin the terms ‘knowledge work’ and ‘knowledge workers’ to refer to highly qualified work and people, assuming that these would have a key role in the development of societies.
In assuming knowledge as an important means of wealth production, the knowledge society is also increasingly seen as a knowledge economy. Olssen and Peters (2005) argue that traditional industrial capitalism as a solution to enhance economic development is giving way to a new knowledge-based capitalism. According to these authors, the knowledge economy can be interpreted as a meta-idea legitimating and serving national interests in the face of the globalization of the competitive arena.
Other sociological perspectives present a different view. The way knowledge has become incomparably more spread through contemporary societies, and how it becomes publicly available, allows the existence of increased reflexivity mediated by expert systems (Giddens, 1990). People think and act under the influence of information produced by experts, meaning that daily interactions are based on information produced by specialists that social actors reinterpret in their actions (Giddens, 1990).
Taking these different perspectives, one can say that the terms knowledge society/knowledge economy are used as metaphors to express not only the increasing production and flow of knowledge in globalized economies but also the way knowledge cultures spread and are now embedded in society (Knorr-Cetina, 1997, 2000).
This emphasis on knowledge presents some challenges to professionals and professionalism. First, expert knowledge is increasingly contested by different social actors (Jensen et al., 2012). Second, with the democratization of higher education, new professional groups have institutionalized codified knowledge as central devices of their professional project and formal rules of science may become less distinctive to support a professional project. Third, the association of knowledge production and dissemination with markets and new public management (NPM) devices and external pressures to make organizations and professionals more accountable and manageable challenges professional autonomy. The development of rational and formal knowledge to sustain professional practices legitimates the discretionary decision-making in situations of uncertainty but, at the same time, it is this type of knowledge that allows the standardization of professional practice, which is said to constrain professional autonomy.
This chapter intends to discuss the way knowledge has been interpreted in theories in the sociology of professions and, within this framework, how nurses’ professionalization can provide pertinent elements to improve reflection on the relationship between knowledge and professionalism. The analysis of the nurses’ case may allow us to increase our knowledge of how a certain variety of alternatives, flowing from the interplay between different types of knowledge, can support the construction of a given professional epistemology serving a strategy of social closure. The chapter draws on empirical studies of nurses in Portugal and investigates how professional knowledge can be interpreted and what role tacit and practical knowledge and scientific knowledge may have in the professional project.
Knowledge and professional development
In the first studies of the sociology of professions, researchers identified the following four main attributes that fundamentally defined a group as a profession: (i) a body of formal and abstract knowledge, obtained through higher education training, formally attested to by a diploma, (ii) an orientation to perform service to others, (iii) self-control over the work, and (iv) high incomes and social status (Wilensky, 1964; Parsons, 1972). The acquisition of academic knowledge was the most relevant of these four basic attributes. It was perceived as serving not only societal development but also, through its application, the progress of professional practices working toward the resolution of complex social and human problems.
Advancing the application of specialized science and technology toward an increased rationalization and intellectualization of the social division of work (Brint, 1994; Freidson, 2001; Larson, 2013) has contributed substantially to the recognition of abstract and formal knowledge as a basic element of professions. Moreover, this recognition has allowed professional groups to claim an exclusive access to the professional market, even if one has to add to it the role of other institutions – such as professional associations and the state – in defining and legitimating the credentials system (Freidson, 1986).
The professions’ control over labour markets was translated into social, cultural and economic power and privileges to the professions (Larson, 2013), and higher education was important in legitimating this process. At least until the 1970s, higher education institutions not only had a monopoly on abstract and formal knowledge production, but also a monopoly on training, which is the basis for the institutionalization of the cognitive support of professions – the standardization and codification of professional knowledge (Larson, 2013). From the end of World War II until the 1970s, the traditional professions enjoyed a golden age (Gorman & Sandefur, 2011).
Critical insights into the functionalism version of the sociology of professions
From the 1970s onwards, professions faced many changes, and new perspectives emerged in the sociology of professions (Freidson, 1970, 1986; Johnson, 1982; Brint, 1994, 2006; Larson, 2013), questioning the previous idealistic vision of professions and professional groups. However, the relevance attributed to the acquisition of formal, abstract and specialized knowledge has been maintained. For instance, through interpreting the sociological literature, Larson (2013) argues that, implicitly or explicitly, most of this literature takes on the idea that ‘the advance of science and cognitive rationality and the related rationalisation and growing differentiation in the division of labour [are the] most significant “modern” dimensions’ (p. xvi) of professions.
In his first critical insights on professions, Freidson (1970) maintained that the possession of formal and abstract knowledge by professionals protects their autonomy, exercises social dominance, and secures self-interest. To Freidson, the main source of professional power is the professional monopoly over knowledge, since it controls tasks and thus allows technical autonomy. In turn, this autonomy enables both professional self-regulation and control over important information and resources in the organizational context. In this sense, Freidson (1970) identified control over the acquisition of resources and interpersonal relationships with the client as sources of professional power.
Freidson later moved away from his criticism of two decades before (Brint, 2006) and engaged in a strong defence of professionalism, which he defined fundamentally as the occupational control of work (Freidson, 2001). In some aspects, this defence recovered one of the main elements identified by functionalists to define a professional – the normative orientation to the service of others. It seems that Freidson returned to the substantive functionalist logic underpinning professionalism through reconnecting it to the ethical value and moral code of ‘doing the right thing’ (Ward, 2012, p. 66). When outlining the fifth element of his ideal type of professionalism, Freidson asserts: ‘an ideology serving some transcendent value and asserting greater devotion to doing good work than to economic reward’ (2001, p. 180).
In a wider sense, professionalism as a third logic can be interpreted as a theoretical response to the challenges that the sociology of professions started to face in the 1970s and 1980s, which include, among other things, the increased influence of neo-liberalism, the market and NPM in knowledge production, dissemination and use. Some of these challenges are linked to the increasing domination by large organizations and the imposition of external controls. Within this context, professionalism refers to an ideological principle for organizing society, since it is based on a set of axiomatic assumptions and principles that distinguishes it from market and bureaucracy logic. The major distinction here is the social need of recognizing the monopoly of professionals ‘over the practice of a defined body of intellectualized knowledge and skill, a discipline’ (Freidson, 2001, p. 198).
This emphasis led Freidson (2001) to try to clarify the meaning of bodies of knowledge for professionalism through discussing the status and scope of the epistemological authority of professional knowledge. Freidson made a distinction between three forms of knowledge: (i) the descriptive forms, covering both science and scholarship and to which technical authority corresponded; (ii) the prescriptive forms, which were linked to social norms attached to secular and sacred forms of knowledge (as in, for instance, law, religion and ethics) and claims for moral authority; and, finally, (iii) the artistic forms, ‘which deal with aesthetic norms and claim normative aesthetic authority’ (Freidson, 2001, p. 158).
Elements such as a specific body of knowledge, self-control over work, and an ideal of ‘service to others’ formed the basis of the functionalist concept of professions; the control over the market and the technical content of the work also became important research subjects in the 1970s. Johnson (1972) and Larson (2013) rather emphasized, respectively, the professions’ relations with the political and economic elite and the state and also their relations with the market and social classes.
Knowledge, social distance and social closure
The analysis of the professions by Johnson (1972) is based on a reflection over the social division of labour. Furthermore, developments in professionals’ social power and domination over consumers relativized the idea of service to others portrayed by the early sociological theorizations. For Johnson (1972), the emergence of specialized occupational knowledge induces relations of socio-economic dependence and, simultaneously, relations of social distance between professionals. This social distance creates a structure of uncertainty, or indeterminacy, in the relationship between production and consumption, which results in a potential exploitation of customers by professionals. The degree of uncertainty emerges from expert knowledge and from a certain mystification produced by professionals to increase their control and autonomy over professional activities.
That uncertainty, however, may be reduced, with consequences for the professions and for consumers, a reduction which varies depending on the social context and power relations generated. To Johnson (1972), professionalism can be seen as a particular type of occupational control. It occurs when an occupation controls its work activities, but this control is only effective if the activities correspond to the fulfilment of the global functions of capital, meaning the functions of control, survival, and reproduction of labour relations.
Larson (2013) also believes that professions are an element of delimitation of the labour market. The main factor that characterizes a profession is its ability to promote its monopoly in the market for professional services, which results in controlling access to the profession (control of the education system) and market protection (licensing system). As others have proposed before, Larson’s analysis focuses both on knowledge and power. Taking the medical profession as an illustrative case, Larson considers that ‘the negotiation of cognitive exclusiveness was inseparable from the production and progress of (medical) knowledge’ (Larson, 2013, p. 24), thus sustaining the process of ‘production of professional producers’ (Larson, 2013, p. 34) by higher education institutions.
Starting from a different perspective – namely, the organization and the conflicts between professional groups for the control of the jurisdictional boundaries of work – Abbott (1988) reinforces the importance of academic or scientific knowledge. According to Abbott (1988, p. 40), professional judgements in the sphere of work disputes are concentrated in the jurisdictional claims for what he named the ‘three acts of professional practice’. These are (i) diagnosis (to classify a problem), (ii) inference (to reason about a problem), and (iii) treatment (to take action over the problem). Inference, the middle game of the process, also became an important issue in the determination of the professional work exclusions (or not) for other groups, particularly ‘when the connection between diagnosis and treatment is obscure’ (Abbott, 1988, p. 49). However, Abbott emphasized that, in most professions, the professional power over diagnosis, inference and treatment depends on linkages to a system of formal and abstract knowledge and expert skills based on academic knowledge.
More recent approaches claim that control over jurisdictional boundaries must be analysed at a global level. Faulconbridge and Muzio (2012, p. 137) call for a transnational sociology of professions since regulations, norms and cultures are being institutionalized through ‘transnational professional projects tied to imperatives of neoliberal capitalism’. Taking this assumption, Seabrooke (2014, p. 50) argues that it is in the international realm that ‘professionals are being professionalized to organize across jurisdictions and where professionals are mobilized to generate demand for their skills and knowledge’. In these processes professionals are more important than their associations. Using epistemic arbitrage, professionals exploit differences in professional knowledge and position some particular forms as the most appropriate to deal with some problems.
The concept of epistemic arbitrage emphasizes professional knowledge that comes from different sources of training and learning. Even if there is a relevant tradition in the analysis of knowledge related with working practices, it has only recently been incorporated into the sociology of professions.
Professional work and professional knowledge
Donald Schön (1983) reflects on knowledge related to working practices, maintaining that there are relevant differences between scientific and practical knowledge. Schön assumes professionals are reflective practitioners, meaning that they develop a learning process within the workplace in which they analyse their working experiences to learn from them. Schön (1983) and Argyris and Schön (1974) maintain that a gap is always present in professional work due to the existing discrepancy between theory and practice and between university curricula and training and professional action in the field.
This gap also generates tacit knowledge (Polanyi, 1967), based on spontaneous identifications and judgements, arising at some stages in the development of working processes. Tacit knowledge can be incorporated into professional abilities and norms and, potentially, can also be shared and socialized among professionals through formal and informal interactions. Authors such as Schön (1983) and Argyris and Schön (1974, 1995) claim the legitimacy of a new epistemology of professional knowledge constructed through action by a reflective practitioner.
More recently, and on the same lines, reflections emerge in the sociology of professions defending the existence of tensions between academic knowledge and its application in professional practice, namely, in complex tasks. The complexity of working situations and practices creates margins of indeterminacy, uncertainty and ambiguity (Freidson, 2001; Evetts, 2002), allowing discretionary or prudential judgements (Champy, 2011), which also become an important base for securing professional autonomy and a source of learning and production of professional knowledge and, in this sense, can also be assumed as incorporating professionalism and processes of professionalization.
As the knowledge society/economy and neo-liberal and NPM tendencies emerged, authors’ attention moved, on one hand, to the increasing formalization and rationalization of professional knowledge, mainly underpinned by a market-based technical rationality logic, and, on the other hand, to its use and (re-)creation within working sets. The increasing need for professionals to be accountable to their organizations and to society, along with an increasing rationalization of contemporary societies, led to a tendency to rationalize and codify professional knowledge, with evidenced-based medicine (EBM) representing one of the most popular examples.
Discussion over the implications of EBM for professionals is mainly related to how the ownership of formal and rational knowledge can still be interpreted as the main source of professionals’ autonomy. Some argue that EBM has the potential to limit physicians’ discretion and even put their authority in question (Timmermans & Kolker, 2004). Other authors, such as Kuhlmann (2006, pp. 200–201), suggest that expert knowledge ‘can also be used as a barrier against external regulation’, and consequently, both formalized and tacit knowledge can be strategically used by professionals to ensure power.
Evidenced-based medicine has not been as successful as expected (Knaapen, 2013). In the face of uncertain situations and in doubt about the way knowledge can be applied in practice, it is often ignored by professionals. The incapacity for EBM to be fully applied by professionals increases interest in the importance of non-knowledge or tacit knowledge in professional practices. For instance, Knaapen (2013) contends that the failure of EBM has occurred because it focuses only on the knowledge we have and misses the knowledge we lack.
Examining the co-existence of these dual tendencies, authors are increasingly emphasizing the importance of workplace learning over formal knowledge and formal processes of learning for professional knowledge, practice and identities (Jensen, 2014; Jensen & Lahn, 2005; Smeby, 2006; Klette & Smeby, 2012). The construction of professional identities can also be interpreted as the result of a continuous process of learning. Socialization processes within higher education in a formal learning context are followed by learning in the working context, where decisions have to be taken in an uncertain, unstable and conflicting environment (Champy, 2009).
Within this context, the sociology of professions makes use of diverse concepts drawn from different disciplinary areas. For instance, Smeby and Vågan (2008) explore how the theory–practice gap is perceived by newly qualified nurses and physicians. The authors refer to different disciplinary backgrounds to define each of the three categories composing their model used to classify knowledge acquired by new professionals during their professional education: (i) the codified knowledge, which includes general knowledge, specific knowledge, planning and organizational knowledge and insight into rules and regulations, (ii) the practical knowledge related to practical skills, ability to work under pressure, ability to work independently, and (iii) the relational knowledge, comprising co-operation skills, oral communicative skills, tolerance, empathy and ethical deliberation.
Another relevant example of the way reflections on professional practical knowledge promote a conceptual drift is in the adoption of concepts such as ‘epistemic object’ and ‘epistemic cultures’ (Knorr-Cetina, 1999, p. 1) to improve the understanding of professional learning. For instance, Lahn (2011) argues that these concepts are essential to understanding professional learning, and Smeby (2006) defends the suggestion that epistemic objectivity brings into discussion the emotional base of professional work and, in this sense, is also an essential element in promoting professional identity.
Similarly, the concept of ‘epistemic communities’ has been adopted to express the way expert occupational groups use, share, create, and reproduce work-related knowledge (Gorman & Sandefur, 2011); the term ‘informal communities of practice’ (Adler et al., 2008) is used to express how professionals who do not have an occupation’s body of formal knowledge can share and update work-related knowledge within informal groups. In this sense, communities of practice are then social networks, developed within organizations, in which professionals work and interact, and that can contribute to contesting the legitimacy of scientific knowledge to assure distinct professional conditions. Similar to post-Fordism in industry (Ward, 2012), the pressures over professional work for short-term results and flexibility generate tacit and unknown knowledge. The practical tools to solve specific problems that these teams develop are often conceived outside the scope of the available formal and codified knowledge.
To sum up, knowledge has always been a fundamental element in the analysis of professions. However, if early studies focused mainly on the importance of formal and abstract knowledge associated with academic knowledge for professionalism and professionalization processes, recent perspectives try also to incorporate other forms of knowledge, which include both the tacit and the unknown knowledge, mostly associated with the learning process professionals develop outside academia. The next section illustrates the relationship between formal and non-formal knowledge in professionalism using a Portuguese nurses’ study as an illustrative case.
The relevance of knowledge in the professionalization of nursing
After the creation of the National Health Service (NHS), and especially with the inclusion of Portugal in the European Union, in 1986, there was successful improvement in the professionalization of nursing. In 1988, nursing courses were integrated within the polytechnic subsystem of higher education, and in the 1990s the legal career statute was approved (Decree Law number 480/88), as was the creation of a professional association (Ordem dos Enfermeiros – Nursing Council) and the document that regulates the professional activities of nurses (Regulation on the Professional Exercise of Nursing, REPE). These documents established the centrality of caring notions in nursing labour practices, which were framed by a welfare state ideology and configured a professional identity based on care (Carvalho, 2014).
In this sense, Portuguese nurses have developed a relatively successful professionalization process seeking to achieve social closure. This makes it an interesting case to analyse the nurses’ relation to the different types of knowledge necessary for professional development and upholding professional values. Do nurses assume that the epistemic ground of their profession embodies the interrelation between abstract and formal knowledge and tacit knowledge? How do they interpret the contribution of these two types of knowledge to their professionalism?
As in other national contexts, nurses in Portugal have sought constantly to improve their professional status. Along this route, they have emulated doctors’ processes and, in this sense, have focused on defending and promoting the indispensability of academic knowledge as a means of support and, in particular, on the possibility of translating practical experience into knowledge with a scientific basis. After several attempts and political fights, framed by a specific political environment related to the integration of Portugal with the European Union and a revision of the national law for education, nurses were able to establish a traditional process of social closure.
The locus of formal and abstract knowledge in the nurses’ professional project
The main support of the conceptual insights proposed in this section draw on the findings of two qualitative-interpretative studies based on 103 interviews conducted with nurses in Portugal in 2005 and 2012 (Carvalho, 2009, 2012, 2014). Data analysis from these interviews revealed that nurses recognize the centrality of the acquisition of academic knowledge in the development of their professional project. The relevance of having higher education credentials to practise nursing is particularly emphasized in relation to professionals’ autonomy in the organizational context.
Empirical studies developed in other national contexts had already demonstrated this phenomenon. In an ethnographic study carried out in an English hospital, Allen (2000) concluded that nurses used knowledge and theoretical training in the organizational field as a support for the demarcation of their activities in relation to other professional groups (particularly doctors, managers and assistants).
In the Portuguese case study, nurses’ discourses also revealed the importance they gave to scientific knowledge in defining their jurisdictional boundaries, particularly in relation to the medical profession. They stressed the importance of the accreditation of knowledge (Carapinheiro, 1998), based on a formal academic high-level degree, as a way to promote their professions’ autonomy. Besides, nurses recognize that having this degree is a fundamental element in legitimately removing nursing from a subservient position in the field of medicine and turning it into a profession with recognized jurisdiction in the social health division of labour. The perception that training in higher education provides the necessary tools to advance professionalism and see autonomy recognized is a widely shared idea.
Assuring a greater recognition of boundaries and formal knowledge obtained through the institutional certification of expertise, based on academic training and a diploma, was seen as the main condition to promote social recognition of the profession and also to improve working conditions. In fact, nurses are aware that the opportunity to promote social closure based on a higher education diploma resulted especially in improvements in their level of income, even if in more recent years, due to economic and political changes framed by an NPM context, these achievements have been seriously questioned.
Nurses’ valorization of academic or scientific knowledge is also expressed in the way they proclaim the need to promote and develop autonomous research in the field of nursing. This is an essential requisite to improve scientific knowledge learned at the highest levels of formal training in order to legitimate professional practices on a basis of rigour and rationality. In this sense, it seems that nurses are also valuing the need to develop independent scientific knowledge as a way to maintain their autonomy in a context of increasing rationalization and codification of work.
Because they face complex situations, specialized knowledge is the main way to support nurses in resolving these situations. Proclaiming the need to develop research and produce knowledge, nurses intend to reduce routines and strengthen their professional power and autonomy over what Abbott (1988) identifies as the relationship between diagnosis, inference and treatment. Moreover, again according to Abbott, increasing the degree of inference between diagnosis and treatment contributes to solidifying and improving professional jurisdiction over the nursing sphere of working processes (Brint, 1994). At the same time, the construction of a body of knowledge specific to nursing serves to support intervention in practice and in affirming the profession, and also to allow the existence of ‘epistemic authority’ (Cash, 1997, p. 137) in relation to society.
The attempt to create and legitimate a specific body of knowledge, based in the appeal to specific language and in the use of specific scientific methods, can also be interpreted as an attempt to enlarge the nursing epistemological scope in order to protect and increase nurses’ technical authority (Freidson, 1986, 2001). Eventually, this power can be used as a way to mediate negotiations occurring in organizational practices (Strauss, 1988) and, particularly, in care practices. It seems that nurses ‘do not need knowledge just as a basis for carrying out their tasks; they also have to a greater extent to defend their professional practice scientifically to other professional groups’, as Smeby (2006, p. 6) states for other professionals.
Nevertheless, the centrality of formal and rational knowledge also emerges in the nurses’ prospects as an instrument to internally stratify the profession through the valorization of the sub-disciplinary professional knowledge-based hierarchies. Nurses assert that career-advancement decisions are based on the acquisition of more specialized knowledge. The main argument is that the academic or scientific knowledge should be the main criterion for reaching top leadership positions. In a bureaucratic logic, academic and scientific knowledge is established as a legitimate basis for the technical authority attributed to the position.
In this sense, specialized knowledge enables the internal hierarchy in the nursing profession and simultaneously represents the possibility of expanding the professional roles and sustaining nurses’ professional identity and credibility. Specialized knowledge allows vertical stratification and legitimizes the power relations within the profession. Valuing sub-disciplinary nursing fields thus appears clearly as a result of a professional ideology: the differentiation of higher technical skills would benefit at the horizontal level across the field and the profession. At the vertical level, stratification eases the legitimization of some professionals within the group. This trend seems to be ambiguous in the nurses’ discourses.
Tensions and paradoxes in formal and practical knowledge in nursing
The criteria of logical consistency and rationality underlying scientific knowledge are usually presented as opposed to the traditional characteristics (spontaneous, emotional, and irrational) which frame care professions (Davies, 1995; Traynor, 1994, 1999). The mismatch between scientific knowledge and professional practice seem to cause a dilemma for Portuguese nurses, who find it difficult to deal with. Although nurses grant, indeed, a certain primacy to scientific knowledge and its application as an ideological orientation in the professionalization process, some nuances were observed in the nurses’ positions, which express some paradoxes.
The professionalization of nursing is based on care assumed as the specific task in the health division of labour. But this is not enough, by itself, to promote professional development. Care has been used strategically by nurses in more recent years to claim the relevance of their work in the health division of labour within an NPM context. However, with NPM and austerity-driven political initiatives implemented in healthcare in Portugal, nurses have experienced a degradation of their working conditions and have also been losing power and status within institutions. In this context, nurses are developing a hybrid professionalism which incorporates valorization and revalorization of care, scientific knowledge and managerial values (Carvalho, 2012, 2014). These trends suggest that different and even conflicting institutional logics persist in nurses’ professionalism.
Scientific knowledge is valued as a professionalization strategy but, at the same time, it is also a threat to care as the fundamental identity element in the profession. Borrowing Freidson’s (2001) reasoning, nurses seem to have some difficulty combining descriptive with prescriptive forms of knowledge, or, as Smeby and Vågen (2008) argue, combining codified knowledge with relational knowledge.
The same dichotomy seems to be present in theoretical reflections. Some authors argue that the centrality of care as the essence of the profession is one of the myths of nursing and therefore is insufficient to form the basis of the establishment of a professional jurisdiction (Dingwall & Allen, 2001), while others consider that the problem is instead the attempt to sustain the process of professionalization in scientific knowledge. The particular characteristics of this type of knowledge, because it is too rational and objective and linked to the male domain, leave no room for an overall understanding of the concept of care, not capturing the essentially feminine nature of the profession (Davies, 1995).
Aligned with this perspective, Portuguese nurses expressed some criticism with regard to higher education training, maintaining that the emphasis on scientific knowledge promotes a devaluation of care, even if, as Smeby (2006) pointed out, care is a knowledge object due to its relevant importance in creating and sustaining professional identity.
The emphasis on care does not necessarily mean that Portuguese nurses are defending an alternative professionalization process that ignores scientific knowledge, as is indeed advocated by some researchers (Davies, 1995). In the nurses’ view, the gap between scientific knowledge and the valorization of the relationship with the patient results mainly from a failure of the interconnection between professional schools and research on nursing or between formal education and professional practice (Smeby & Vågan, 2008). This is not just an issue in the nursing field but is also familiar to the wider professional landscape, as Argyris and Schön (1974) and Schön (1983) have tried to demonstrate. This mismatch has been, more recently, assumed by others to be highly relevant for autonomy in professional practices (Evetts, 2002; Champy, 2011).
Nurses recognize the importance of scientific knowledge in the affirmation of the authority and autonomy of the profession, due to its role in legitimating the professional practice in relation to other professional groups, but they also highlight the risks of more technologically oriented care that moves away from traditional personal or emotional care work (Carvalho, 2012, 2014). However, as a large profession trying to distance itself from a semi-profession label, Portuguese nurses complain that there is a lack of common identity and professional jurisdiction, which they see as an obstacle to professional progress (Carvalho, 2012, 2014).
Although different identity concepts were identified in nurses’ discourses, three emerged as dominant (Carvalho, 2009, 2012, 2014). First, there is a discrepancy between the theory and the practice of nursing, which induces the perception that some nurses are more technologically oriented while others put greater emphasis on personal relations. The results mirror the discrepancy between a professional identity built on theoretical higher education training and an identity developed in practice (this is sometimes assumed to be a generational gap).
Second, the different cultures and dominant modi operandi of each health institution influence principles and practices. Third, different pathways and nursing models structured during the development of the profession in different historical moments are also pointed to as a reason for the different conceptions of the profession.
Concerning issues related to the diversity of nursing references, Hewison and Stanton (2002) stress that professional ideologies of nursing never had a logical or linear progression since Florence Nightingale’s proposals. The authors also argue that there has always been a lack of agreement on the theories and models of the nature and roles of nursing. Some theories have emerged from clinical practice based on the analysis of professional and work processes; others emphasize the need to develop a priori theoretical frameworks as guides to practice.
The successive professional ideologies that have emerged since the 1960s need to be considered as a strategy to establish a professional project, strengthening the attempt to establish nursing as a profession, rather than as theoretical constructs serving as a reliable source for practice. Both the perception that nurses identify a certain lack of common references in the profession and the diversity of the professional positions also reflect the diversity of theoretical approaches and paradigms that have been observed since the second half of the twentieth century (Hewison & Stanton, 2002). Taking these factors into consideration, one can argue that Portuguese nurses do not see the profession as a homogeneous corpus but as a result of distinct epistemic cultures and also of different communities of practice.
Some nurses suggest that experiential learning and reflection over practice are important to build the expertise of nursing. The professional ideology no longer results only from scientific and technical knowledge, identified with the biomedical model as expressed through conventional or formal training, but from the field of practice. In fact, nurses emphasize in their discourses the relevance given to practical knowledge.
The importance of the practical dimension of the profession is especially highlighted when nurses refer to: (i) collective discussion over the profession’s problems and practices, based on reflections of their daily activities; (ii) a closer articulation between theoretical and practical training; (iii) the adoption of an inductive attitude with respect to the notion of nursing; and (iv) the assumption of practice as a central element in the socialization of new professionals.
Learning through practice, or rather, reflecting on professional practice (Argyris & Schön, 1974; Schön, 1983) is also an important element in the construction and development of the Portuguese nurses’ professional project to achieve social closure (Larson, 2013) and professionalism (Freidson, 2001). There is indubitably the co-existence of or, at least, attempts to articulate scientific and reflective knowledge as an overall background toward the institutionalization of a nursing professional project. Care is acknowledged as a structural element of professional identity. However, distinct positions arise concerning the relevance scientific knowledge should assume. To a great extent, scientific knowledge on its own is not as capable of promoting nurses’ professional status per se but only when it is interrelated with practical knowledge.
Thus, scientific knowledge is an almost inevitable structural element in sustaining the nurses’ project of professionalization. In line with the importance given to it by classical literature of the sociology of the professions, Portuguese nurses also consider scientific knowledge as indispensable, since it helps to create a unique area for nursing in the social health division of labour. In particular, it strategically distinguishes nurses from other professional groups, especially physicians. Scientific knowledge also enables a hierarchical organization of nurses in sub-disciplinary specializations, which supports an expansion of roles and the construction of a professional identity, giving more credibility to academic nursing as a profession and legitimizing professional autonomy in a context of increasing rationalization and codification of work.
It is also undeniable that scientific knowledge is seen as more technical than human, removing professionals from care and close relationships with patients, thus contributing to a possible emptying of meaning and downgrading of the significance of the profession, until professional identity retreats completely. In this context, nurses add to scientific knowledge practical knowledge, which seems also to take a prominent place in their claims for professionalism. The impossibility of translating the emotional and subjective characteristics of care into the formal codes of scientific knowledge and imposing its presence as a condition to maintaining professional identity leads nurses to value, to an equal degree, the tacit and implicit knowledge flowing from professional practice and even from different epistemic communities of practice.
The attempts to articulate both scientific and practical knowledge in the Portuguese nurses’ professional project are actually expressed in a new mechanism of social closure introduced by the Nursing Council. To be able to practise nursing in Portugal, one needs a higher education diploma and to be a member of the professional association. To be recognized as a member, the association requires that the candidate experience a period of ward practice in a certified clinical centre having the necessary conditions to develop nursing practices. Thus, we should pay greater attention to the role of tacit and implicit knowledge in professionalism and professionalization processes within the knowledge society.
The acquisition of formal and abstract knowledge, especially by higher education institutions, has been identified as an important condition of considering an occupational group a profession. While classic theories of the sociology of professions almost exclusively focused on scientific knowledge, more recent work brings into perspective the importance of the way this knowledge is used in the professional practice to overcome uncertain situations and to legitimize autonomy.
The analysis of the Portuguese case of the nursing profession demonstrates the relevance of both practical/tacit and formal/scientific knowledge in nurses’ professional identity. Following the canons of the classic professions, nurses’ professional project mainly relies on the jurisdiction of a body of formal or scientific knowledge, while traditional values of nursing are rooted in care, which is a more ambiguous field of knowledge. Data analysis reveals that nurses’ experiences of practices, and the knowledge that results from these practices, are essential for constructing a collective identity and defining jurisdictional boundaries. Hence, the major source of identity is the concept of care, which is difficult to measure, thereby furthering the persistence of hidden and tacit knowledge.
Even if tacit knowledge is part and parcel of their professional identity, nurses tend to interpret this type of knowledge as being in tension with the scientific knowledge that foregrounds their professional project. The hegemony of scientific knowledge is rooted in its strategic relevance for building an autonomous field of practice, but nurses also value tacit and practical knowledge as the cornerstone in their constitution of a community of practices, and they perceive it as complementary to scientific knowledge. Consequently, the epistemic legitimacy to develop nurses’ professional work not only derives from higher education credentials but also from reflections on shared experiences in care work. These findings challenge classic assumptions in the sociology of professions.
Enlarging nurses’ epistemological scope to include tacit or practical knowledge can be interpreted as a way to protect and increase nurses’ technical authority and professional jurisdiction. In this sense, the Portuguese Nursing Council gives the same weight to formal and practical knowledge, assuming both as mechanisms of social closure. In doing so, the Nursing Council is also trying to reconcile the professional project with professional identity.
The role of practical and formal knowledge in the construction of professional projects within the knowledge society is a relevant issue that needs further reflection in the sociology of professions. More attention should be given to the inductive processes of knowledge production based on professional reflexions over practices and to the way this production may be used in professional projects.
References
Abbott, A. (1988) The System of Professions: An Essay on the Division of Expert Labor. Chicago, IL: University of Chicago Press.
Adler, P. S., Kwon, S. W., & Heckscher, C. (2008) ‘Perspective-professional work: The emergence of collaborative community’. Organization Science, 19(2), pp. 359–376.
Allen, D. (2000) ‘Negotiating the role of expert carers on an adult hospital ward’. Sociology of Health & Illness, 22(2), pp. 149–171.
Argyris, C., & Schön, D. (1974) Theory in Practice: Increasing Professional Effectiveness. San Francisco, CA: Jossey-Bass.
(1995) Organizational Learning: A Theory of Action Perspective. Boston, MA: Addison-Wesley.
Bell, D. (1973) The Coming of Post-Industrial Society: A Venture in Social Forecasting. New York: Basic Books.
Brint, S. (1994) In an Age of Experts: The Changing Role of Professionals in Politics and Public Life. Princeton, NJ: Princeton University Press.
(2006) ‘Saving the soul of professionalism: Freidson’s institutional ethics and the defense of professional autonomy’. Savoir, Tavail et Soviété. Knowledge, Work & Society, 4(2), pp. 101–129.
Carapinheiro, G. (1998) Saberes e Poderes no Hospital: Uma Sociologia dos Poderes Hospitalares. Porto: Afrontamento.
Carvalho, T. (2009) Nova Gestão Pública e Reformas da Saúde: O profissionalismo numa encruzilhada. Lisbon: Edições Sílabo.
(2012) ‘Managerialism and professional strategies: A case from nurses in Portugal’. Journal of Health Organization and Management, 26(4), pp. 524–541.
(2014) ‘Changing connections between professionalism and managerialism: A case study of nursing in Portugal’. Professions and Organization, 1(2), pp. 1–15.
Cash, K. (1997) ‘Social epistemology, gender and nursing theory’. International Journal of Nursing Studies, 34(2), pp. 137–143.
Champy, F. (2009) La sociologie des professions. Paris: Presses universitaires de France.
Champy, F. (2011) Nouvelle théorie sociologique des professions. Paris: Presses Universitaires de France.
Davies, C. (1995) Gender and the Professional Predicament in Nursing. Buckingham, UK: Open University Press.
Dingwall, R., & Allen, D. (2001) ‘The implications of healthcare reforms for the profession of nursing’. Nursing Inquiry, 8(2), pp. 64–74.
Drucker, P. (1959) Landmarks of Tomorrow. New York: Harper.
(1993) Post-Capitalist Society. New York: Basic Books.
Evetts, J. (2002) ‘New directions in state and international professional occupations: Discretionary decision- making and acquired regulation’. Work, Employment and Society, 16(2), pp. 341–353.
Faulconbridge, J. R., & Muzio, D. (2012) ‘Professions in a globalizing world: Towards a transnational sociology of the professions’. International Sociology, 27(1), pp. 136–152.
Freidson, E. (1970) Professional Dominance: The Social Structure of Medical Care. New York: Atherton Press.
(1986) Professional Powers. Chicago, IL: University of Chicago Press.
(1994) Professionalism Reborn. Cambridge: Polity Press.
(2001) Professionalism: The Third Logic. Cambridge: Polity Press.
Giddens, A. (1990) The Consequences of Modernity. Cambridge: Polity Press.
Gorman, E. H., & Sandefur, R. L. (2011) ‘“Golden Age,” quiescence, and revival: How the sociology of professions became the study of knowledge-based work’. Work and Occupations, 38(3), pp. 275–302.
Hewison, A., & Stanton, A. (2002) ‘From conflict to collaboration? Contrasts and convergence in the development of nursing and management theory (1)’. Journal of Nursing Management, 10(6), pp. 349–355.
Jensen, K. (2014) ‘Signing communities dealing with non-knowledge: Some cases from nursing’. Professions and Professionalism, 14(2), pp. 1–13.
Jensen, K., & Lahn, L. (2005) ‘The binding role of knowledge: An analysis of nursing students’ knowledge ties’. Journal of Education and Work, 18(3), pp. 305–320.
Jensen, K., Lahn, L. C., & Nerland, M. (2012) Professional Learning in the Knowledge Society (Vol. 6). London: Springer Science & Business Media.
Johnson, T. (1972) Professions and Power. London: Macmillan.
(1982) ‘The state and the profession: Peculiarities of the British’. In A. Giddens and G. Mackenzie (eds), Social Class and the Division of Labour, pp. 45–67. Cambridge: Cambridge University Press.
Klette, K., & Smeby, J. (2012) ‘Professional training and knowledge sources’. In K. Jensen, L. Lahn and M. Nerland (eds), Professional Learning in the Knowledge Society, pp. 143–162. Rotterdam: Sense Publishers.
Knaapen, L. (2013) ‘Being evidence-based in the absence of evidence: The management of non-evidence in guideline development’. Social Studies of Science, 43(5), pp. 681–706.
Knorr-Cetina, K. (1997) ‘Sociality with objects: Social relations in postsocial knowledge societies’. Theory, Culture & Society, 14(4), pp. 1–30.
Knorr-Cetina, K. (1999) Epistemic Cultures: How Sciences Make Knowledge. Cambridge, MA: Harvard University Press.
Knorr-Cetina, K. (2000) ‘Postsocial relations: Theorizing sociality in a postcolonial environment’. In G. Ritzer and B. Smart (eds), Handbook of Social Theory, pp. 520–537. London: Sage.
Kuhlmann, E. (2006) Modernising Health Care: Reinventing Professions, the State and the Public. Bristol, UK: Policy Press.
Lahn, L. (2011) ‘Professional learning as epistemic trajectories’. In S. Ludvigsen, A. Lund, I. Rasmussen and R. Säljö (eds), Learning Across Sites: New Tools, Infrastructures and Practices, pp. 53–68. New York: Routledge.
Larson, Magali Sarfatti. (2013) The Rise of Professionalism: Monopolies of Competence and Sheltered Markets. New Brunswick and London: Transaction Publishers.
Olssen, M., & Peters, M. (2005) ‘Neoliberalism, higher education and the knowledge economy: from the free market to knowledge capitalism’. Journal of Education Policy, 20(3), pp. 313–345.
Parsons, T. (1968) Professions. International Encyclopaedia of the Social Sciences (Vol. 12). New York: Macmillan Company and The Free Press.
Parsons, T. (1972) ‘Culture and social system revisited’. Social Science Quarterly, 53(2), pp. 253–266.
Polanyi, M. (1967) The Tacit Dimension. New York: Doubleday.
Schön, D. (1983) The Reflective Practitioner: How Professionals Think in Action. London: Temple Smith.
Seabrooke, L. (2014) ‘Epistemic arbitrage: Transnational professional knowledge in action’. Journal of Professions and Organization, 1(1), pp. 49–64.
Smeby, J. (2006) Epistemic Cultures Among Beginning Professionals. Working paper no 8, Center for the Study of Professions, Oslo University College.
Smeby, J.-C., & Vågan, A. (2008) ‘Recontextualising professional knowledge: Newly qualified nurses and physicians’. Journal of Education and Work, 21(2), pp. 159–173.
Strauss, A. (1988) Negotiations: Varieties, Contexts, Processes, and Social Order. San Francisco, CA: Jossey-Bass.
Timmermans, S., & Kolker, E. S. (2004) ‘Evidence-based medicine and the reconfiguration of medical knowledge’. Journal of Health and Social Behavior, 45, pp. 177–193.
Traynor, M. (1994) ‘The views and values of community nurses and their managers: Research in progress‐one person’s pain, another person’s vision’. Journal of Advanced Nursing, 20(1), pp. 101–109.
Traynor, M. (1999) Managerialism and Nursing: Beyond Oppression and Profession. Hove, UK: Psychology Press.
Ward, S. C. (2012) Neoliberalism and the Global Restructuring of Knowledge and Education. New York/London: Routledge.
Wilensky, H. L. (1964) ‘The professionalization of everyone?’. American Journal of Sociology, 70, pp. 137–158.