Although there has been criticism of the use of criteria to identify a profession because the criteria alone provided little understanding of the power of particular groups and nor did it acknowledge the common characteristics between occupational groups,159 it has nonetheless been recognised by others that the most frequently cited elements of a profession do provide a useful starting point to define and explore the shape and character
156 Michel Foucault, (1979) Governmentality. Ideology and Consciousness 6(1): 5–21 cited in Julia Evetts,
‘The construction of professionalism in new and existing occupational contexts: Promoting and facilitating occupational change.’ International journal of sociology and social policy 23.4/5 (2003): 22-35.; Michel
Foucault, Power/Knowledge: Selected Interviews and OtherWritings 1972–1977 (Harvester Press, 1980).
157 Eliot Freidson, Professionalism: The Third Logic (Polity Press, 2001) 221.
158 The Declaration of Geneva was developed in response to Nazi doctors ‘just following orders’.
159 Julia Evetts, (2014)The Concept of Professionalism: Professional Work, Professional Practice and
Learning in Stephen Billett, Christian Harteis, Hans Gruber (eds.), International Handbook of Research in
of both a profession, the process of professionalisation and professionalism.160 The empirical reality is that professions continue to be discussed as a sociological phenomenon. The more than one hundred years of analysis of the way in which this particular group of workers (professions) is structured and the way they function in our society has provided a rich understanding of the way in which this category of workers is distinct from other workers, including the way in which they are regulated. Freidson’s theory of professions, which was developed over a period of thirty years, identified that professionalism is a form of organising and controlling a group of workers that is still relevant today.161 It has provided an understanding both of why regulation by professionalism is important and useful, and of the evolutionary process occupational groups move through to acquire professional status. Therefore, this thesis will use a set of elements for a profession based on the work of Freidson as a lens through which to examine paramedics as an occupational group and to undertake a critical analysis of the group’s professional evolution.
As outlined in Chapter 1, this thesis will examine paramedics and consider whether they are a profession, whether they are in the process of professionalising, and why they should be regulated by professionalism. This involves examination of both the attributes of paramedics and the ‘process’ of the professionalisation of paramedics, because they are not mutually exclusive.162 Freidson argues that placing an emphasis on the process of professionalisation rather than the attributes of a profession does not help define the subject of a discussion and renders the discussion about process ‘virtually meaningless’.163 As such, the criteria that form the analytical tool used in this thesis are made up of the attributes of a profession as acknowledged by Freidson164 (hereinafter the ‘Freidson elements’), supported by Wilensky’s professionalisation trajectory. This tool will help provide an understanding of the way in which paramedics, as a unique group of workers in our society, have moved from being unorganised and inconsistently regulated, to evolve to become
160 Eliot Freidson, Professionalism Reborn: Theory, Prophecy and Policy (Polity Press, 1994) 15; Mike Saks,
‘Defining a Profession: The Role of Knowledge and Expertise’ (2012) 2(1) Professions and Professionalism
1–10 <https://journals.hioa.no/index.php/pp/article/viewFile/151/355>; David Carr, ‘Professionalism, Profession and Professional Conduct: Towards a Basic Logical and Ethical Geography’ in Stephen Billett,
Christian Harteis and Hans Gruber (eds), International Handbook of Research in Professional and Practice-
based Learning (Springer International, 2014) 8.
161 Eliot Freidson, Professionalism: The Third Logic (Polity Press, 2001).
162 Eliot Freidson, Professionalism Reborn: Theory, Prophecy and Policy (Polity Press, 1994) 15.
163Ibid.15.
organised by uniform piece of regulation that will have the effect of shaping the discipline both internally and externally.
The core comparative criteria of a profession are:
1. that the nature of their work serves a significant public service (unique purpose)
2. that they undertake a prolonged period of training and can apply discretionary specialised knowledge and skills (specialised knowledge); this service orientation and specialist knowledge provides them with
3. technical and moral authority (power) which allows them to
4. gain and maintain a system of control over their own work (autonomy/self- regulation) and
5. self-regulation includes regulation by professionalism (a code of ethics). Wilensky’s trajectory also intersects with other criteria identified through the work of the sociologists examined in this chapter as being associated with professionals. As professions develop their role and associated specialised knowledge and skills their education requirements shift from a merely competency-based training school to tertiary education where critical thinking is taught to facilitate the discretionary decision making required of a professional. This establishes the occupational group’s technical and moral authority over their specialised area and allows them to organise into a local association, and later a national association, that can utilise the group’s unique purpose and specialised knowledge as power to lobby for the legal authority to self-regulate on the basis that they provide a significant public service that requires specialised knowledge that non-professionals are not equipped to evaluate or regulate. As such, only members of the group can regulate others members of the group who fail to work competently or ethically to a standard set by the profession itself and captured in a code of conduct.165
This study mapped Freidson’s elements that are common to a profession against Wilensky’s professionalisation trajectory (or process of becoming a profession), as outlined
165Tanina Rostain, ‘Self-regulatory Authority, Markets, and the Ideology of Professionalism’ in Robert
in Table 1, and found the correlation between professionalisation and the development of professionalism.
Table 1: Professionalisation-Professionalism Sociological Correlation The Freidson elements for a
profession166
Wilensky’s professionalisation trajectory
Significant public service/unique purpose167
Specialised knowledge and skills168 Training school->university Technical and moral authority becomes
power169
Local association->national association Gain and maintain control over work
(autonomy/self-regulation)170
State licensing laws Regulation by professionalism (code of
ethics*)171
Code of conduct *Which incorporates virtues of trust and integrity.
Table 1 does not reflect the movement of the process of professionalisation but Wilensky’s professionalisation trajectory moves in one direction from top to bottom. Freidson’s elements are however less linear and more likely to move on a continuum that acknowledges the way in which the concept and various elements change in levels of importance to different groups over time.172 Freidson identifies that in order to become a profession, an occupational group must have the legal power to self-regulate delegated to it. In order to have this power delegated to it, the occupation must be organised as an identifiable group and the group must persuade the state that the group’s purpose (‘largely for the wellbeing of individuals or society at large’173), specialised knowledge and skill is of ‘such special character’ that it warrants the privilege of self-regulation. It must
166 Freidson did write about the ‘elements of a theory of professionalism’ where he identified that the
elements are a synthesis of characteristics identified by a number of sociologists over many years and referred to be Freidson in order to provide some clarity and definition for a discussion on the professions.
Eliot Freidson, Professionalism Reborn: Theory, Prophecy and Policy (Polity Press, 1994) 15, 47; also
Eliot Freidson, Professionalism: The Third Logic (Polity Press, 2001).
167 Eliot Freidson, Professionalism: The Third Logic (Polity Press, 2001) 59, 127, 217. 168 Ibid 32 127.
169 Ibid 56, 127, 214. 170 Ibid 55, 127, 198. 171 Ibid. 197, 214.
172Eliot Freidson, Professionalism Reborn: Theory, Prophecy and Policy (Polity Press, 1994) 16.
demonstrate that it will be organised in such a way as ‘to be able to control itself without abusing its privilege.’174 This is because the nature of the work they do is likely to be difficult for others outside the profession to understand. However, the group must first have established that public purpose and specialised knowledge and skill in order to demonstrate its technical and moral authority to persuade the state that it can and should regulate itself. A ‘code of ethics’ and other policies and guidelines can then be developed by the group to ensure that the privilege is not abused. The code and other documents that reflect the elements of professionalism, provide members of the group with guidance as to expected standards of behaviour, they provide a benchmark to assist with the peer-review of member performance and they facilitate the development of a professional conscience, culture and ethos of professionalism within the group, all of which builds and protects the public’s trust in the profession.
Paramedics in Australia have been attempting to professionalise for around a decade. The next chapter of this thesis will use Freidson’s common elements for a profession, referred to in Table 1, to analyse the historical and social development to identify if paramedics are professionals. It will identify the elements that paramedics currently have and those they still must acquire to become a profession, and it will examine which stages of the professionalisation trajectory they have completed and those that remain to be achieved.
The Evolution of Paramedicine
The previous chapters provided an overview and theoretical framework to contextualise the study. This chapter examines the historical development of paramedicine. It provides a brief history of the evolution of the discipline and then sets out what paramedicine looks like today. The second part of the chapter critically analyses the application of the theoretical framework—in particular the five Freidson elements—to the current state of paramedicine to establish what professional characteristics paramedicine currently has and what elements it needs to professionalise.
Freidson recognised that archetypal professions like medicine develop an ideology that gives the group power to establish and maintain their positions of privilege.175 This ideological construct includes reference to the occupation’s purpose, their provision of a public service, allusions to altruism and in healthcare, commonly, an occupational identity associated with virtue—the angelic nurse, the God-like doctor. In the case of paramedics it may be the heroic rescuer running towards danger while others run from it.
This chapter examines the unique character of paramedicine and the way in which it has developed its role as a significant public service and solidified itself as an area of specialty not just in practice but in education and training standards. It examines the way in which the profession has had its moral core shaped by its historical associations with charitable services like the Order of St John. It considers how the combination of providing a significant public service that requires specialised knowledge and skills, delivered in accordance with an historical moral imperative, has contributed to the development of both technical and moral authority over their work.