Reconfiguring Professional Work: Changing Forms of ...

509242 research-article2013

AASXXX10.1177/0095399713509242Administration & SocietyNoordegraaf

Administration & Society OnlineFirst, published on November 6, 2013 as doi:10.1177/0095399713509242

Article

Reconfiguring Professional Work: Changing Forms of Professionalism in Public Services

Administration & Society XX(X) 1–28 © 2013 SAGE Publications DOI: 10.1177/0095399713509242 aas.sagepub.com

Mirko Noordegraaf1 Abstract Many public services are produced by professional workers who deal with cases and clients on the basis of professional knowledge and skills. As groups of workers, they acquired autonomies to structure professional knowledge and skills and to regulate case treatment. During the previous years, professional work has changed. Most often, the “new public management” is seen as the main driver: Service provision is said to be managerialized to make services more efficient and effective. This article rejects this simple explanation and argues that public professional work is affected by much more than managerial reform. It presents an analytical framework for tracing broader societal forces that reconfigure professional work. Professionals are not merely managed and measured; professional work in public services might be (a) reorganized, (b) restratified, and (c) relocated. Increasingly fragmented and dependent professional fields might have to seek new forms of control and new understandings of public professionalism are required. Keywords public services, professionalism, professional work, managerialism, societal change

1Utrecht

University, Netherlands

Corresponding Author: Mirko Noordegraaf, Utrecht School of Governance (USG), Utrecht University, Bijlhouwerstraat 6, Utrecht 3511ZC, Netherlands. Email: [email protected]

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Introduction Many public and nonprofit services are provided by professional workers. The provision of, for example, health care, care, welfare, education, and judicial and police services heavily depends on workers who are knowledgeable and skillful. These professionals treat case and clients—patients, pupils, criminals—by relying on knowledge and skills that they use to assess situations, make decisions, and act and intervene. As groups of professionals, they have been granted autonomies to regulate client and case treatment, to structure and strengthen knowledge and skills, and to improve assessment and action. Medical doctors, judges, policemen, and lecturers are members of protected professionals associations that set up educational programs, codes of conduct, and selection and supervision procedures to guarantee autonomy as well as the appropriate usage of autonomy. In this sense, professionalism is a regulative affair. Knowledge, skills, and expertise as well as their application in specific situations are regulated by groups of workers themselves. Professionalism is a matter of “(self)controlled content” (cf. Noordegraaf, 2007 ) whereby professional self-control is executed inside professional domains, also to protect these domains against outside forces (e.g., Abbott, 1988; Freidson, 2001). This classic model worked quite well for many decades; in fact, in case of medical and legal fields, it has become the exemplary model for organizing independent or liberal professionalism (e.g., Reed, 1996). Individual professionals like medical doctors or lawyers are part of well-established professional fields—that is, professions—that are largely self-regulatory. Backed by the state and linked to universities (cf. Burrage & Torstendahl, 1990), these professional fields have established highly institutionalized regulatory mechanisms that ensure that professional workers are selected, trained, and supervised by peers and that work is defined and standardized in such a way that effective services are delivered, that norms and values are upheld, and that professional work is trusted and legitimated. This model was never pure, however (cf. Noordegraaf, 2007). Inside independent professional fields—let alone outside these fields—work became increasingly situated and hybrid. Especially during the past few decades this model started to lose its strength. Since the 1970s, protected forms of professionalism were criticized for their presumed counterproductive interventions. Instead of helping clients, people became more dependent, it was argued (e.g., Illich, 1976). Since the 1980s, professionalism is criticized for its inefficient use of (public) resources; professional work has to be rationalized and rationed (e.g., Kirkpatrick, Ackroyd, & Walker, 2005; Pollitt, 1993). Since the 1990s, professionals were criticized for their monopolized and


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subjective use of knowledge; new information and communication technologies made services more transparent and accountable (e.g., Brint, 1994). As a result, new images of professionalism have been proposed, such as expert professionalism (Brint, 1994), organizational professionalism (Evetts, 2011), and hybrid professionalism (Faulconbridge & Muzio, 2008; Kirkpatrick, Jespersen, Dent, & Neogy, 2009; Kurunmäki, 2004; Noordegraaf, 2007). They represent searches for more opened-up notions of professional work, whereby professional autonomies and knowledge/skill usage are maintained but professional work is also linked to outside worlds, especially organizational contexts (e.g., Evetts, 2011; Numerato, Salvatore, & Fattore, 2011; Suddaby, Gendron, & Lam, 2009). Organizationally, professional workers were drawn into organizational structures and systems that forced them to work in more accountable and evidence-based ways (e.g., Kirkpatrick et al., 2005). The “control” of “content” turned from professional to organizational control; professionals are managed and measured. The redesign of public professional work was mainly linked to managerialism and new public management (e.g., Foster & Wilding, 2000; Freidson, 2001; Hwang & Powell, 2009). Although this shift must be emphasized, as professional work settings have undoubtedly been reformed, merely emphasizing this shift fails to capture the broader dynamics in and around public professional services. More recently, changes in and around professional work are viewed differently. Professionalism is not so much linked to organizational settings, but to wider institutional, social, and societal forces that affect professional work and also professional work settings in more fundamental ways. There are many pressures on professionals, especially on public professionals (cf. Noordegraaf & Steijn, 2013), but these pressures do not only come from politics, policies, and managers. The socioeconomic, cultural, and technological reordering of labor markets, service models, preference formation, action spaces, and career structures, all produce service contexts that have little to do with neoliberal policies, managerialist politics, and organizational performance systems. Professionals are not merely managed and measured; many more changes are affecting professional work. To mention a few: professional labor markets become more volatile (e.g., Reed, 1996); professional careers become less consistent (e.g., Leicht & Fennell, 2008); professional education becomes more fragmented (e.g., Daly, 2002; Faulconbridge & Muzio, 2009); there is deskilling of professional (routine) tasks, as well as increasing specialization (e.g., Currie, Finn, & Martin, 2009); client demands and preferences become more ambiguous (e.g., Plochg, Klazinga, & Starfield, 2011); services are rendered in transnational markets (e.g., Faulconbridge & Muzio, 2012; Suddaby, Cooper, & Greenwood, 2007); risks fuel safety concerns


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(Noordegraaf, 2011); and media exposure shows professional failure (e.g., Millenson, 2002). All in all, “the combination of new places, new people, new technologies, and new clients has pushed professionals in new and uncharted directions” (Leicht & Fennell, 2008, p. 431). Instead of opening up professional work to outside worlds and redesigning professional work, this implies a more radical reconfiguration of public professionalism as such. It is not only changing control modes that count as far as “(self)controlled content” is concerned, the nature of control itself is at stake. Professional self-regulation was never pure and increasingly, professionalism becomes dispersed and distributed instead of uniform and concentrated. Whereas public professional workers could protect themselves against the outside world, the outside world is increasingly penetrating professional domains, work, and practices, also in case of independent professional fields (e.g., Currie et al., 2009). This will fundamentally alter the meaning of professional/organizational control. Suddaby et al. (2007) even speak of “an era of post-professional regulation” (p. 357). The latter conclusion might be drawn too early, at least empirically, as many professional services are not always or necessarily radically reconfigured. But images of professionalism are shifting. Because changing forms of control are difficult to understand and because these changing forms might occur to varying degrees and in varying speeds and ways, we need analytical frameworks for tracing changes more systematically, for assessing how far moves toward post-professionalism are actually occurring and for facilitating new understandings of professionalism. This article offers such an analytical framework. First, we analyze which changes affect professional work in public services and we identify several “forces” that might fuel the reconfiguration of professional work. Then we discuss each of these forces and elaborate analytical implications. We present a framework for (empirically) tracing the reconfiguration of professional work in different contexts, and we discuss the effects on images of professionalism. Finally, we draw conclusions.

Changes In and Around Professional Work At first sight, professional work is changing because organizational contexts are changing. Because public service organizations adopt new public management and are turned into businesslike organizations, it is argued frequently (e.g., Evetts, 2009; Farrell & Morris, 2003; Freidson, 2001; Thomas & Davies, 2005), professional work is embedded within cost- and customeroriented managerial frameworks. Increasingly, professional work becomes managed and scrutinized by outsiders (managers, controllers, auditors, and so on) and professionals become normal employees who have to work within


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(tight) budgets and have to satisfy (critical) clients-as-customers. This does not mean, it is argued by others, that professionals really become regular employees, as they have many possibilities to resist managerial intrusions (e.g., Currie, Lockett, Finn, Martin, & Waring, 2012; Kirkpatrick et al., 2005; Waring & Currie, 2009). But also when professionals apply their professional powers to guard autonomies or when “custodial managers” do so (cf. Ackroyd, 1996; Ackroyd, Hughes, & Soothill, 1989; Ackroyd, Kirkpatrick, & Walker, 2007), professional work cannot escape the implications of neoliberal policies and managerialism (e.g., Ackroyd et al., 2007; Harrison & Pollitt, 1994; Leicht, Walter, Sainsaulieu, & Davies, 2009; Reed, 2002). In fact, many authors blame neoliberal policies and their subsequent managerialist interventions and instruments, including new public management tools, for the “attacks” on professionalism (e.g., Foster & Wilding, 2000) and “persecuted” professionals (Farrell & Morris, 2003). Leicht et al. (2009) argue, In Western developed economies and nations, the biggest trend affecting managerial work in the past 30 years has been the call for greater accountability and efficiency in service delivery. (p. 581)

As has been argued earlier (e.g., Faulconbridge & Muzio, 2012; Noordegraaf, 2011; Suddaby et al., 2007), this dominant line of reasoning has several drawbacks. First, it generates rather black and white dichotomies, such as between “professionals and managers” or between “professional” and “organizational logics,” whereas professional service realities are less black and white. Professionals can be managing professionals (e.g., Exworthy & Halford, 1999), for example; professional and organizational logics can be intertwined, for example, in “bureau-professional” regimes (Clarke & Newman, 1997). Second, changing organizational contexts and managerialism are not only causes, they are also caused by something. Managerialism and its “management and measurement” bias deserve further explanation. Some of these further explanations—for example, managerialism is caused by politicians and public policies (e.g., Barzelay, 2001; Foster & Wilding, 2000)—are not really satisfactory. They lay exaggerated powers in the hands of politicians and policy makers and neglect powerful forces that influence political decision making. Alternative explanations, stressing the dynamics within professional fields as well as institutional “adaptations” or “institutional work” by professionals themselves (e.g., Currie et al., 2012; Greenwood & Suddaby, 2006; Suddaby & Viale, 2011), are equally disappointing. Isomorphic pressures might be highlighted (cf. DiMaggio & Powell, 1983) and how professional associations “theorize change” might be traced (e.g., Greenwood et al., 2002),


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but it is unclear how these pressures and processes are linked to more substantive changes—changes that explain the lack of order and meaning. When broader, more substantive forces are analyzed, economic forces will unavoidably be highlighted (see, for example, Hood, 1991). Economic conditions that have arisen since the 1970s (economic downturn, fiscal stress, financial and economic crises) have turned costs and customers into organizational priorities. This explains the aforementioned rise of neoliberal (economic) policies. But from a broader economic perspective, professionalism might be affected differently. Instead of merely or mainly generating cutbacks and cost control, shifts in capitalist economies have generated changing professional landscapes. “The global shift towards more reflexive and flexible forms of capital accumulation,” Reed (1996) argues, has produced “a more fragmented division of labor within and between the professional and managerial middle classes” (p. 573). In addition, other, societal forces will have to be highlighted as well. Individualization, globalization, digitalization have not only altered political playing fields, they have also affected service realities (e.g., Noordegraaf, 2011; Faulconbridge & Muzio, 2012; Noordegraaf & Steijn, 2013). When clients express more varied preferences or assertive attitudes, for example, they might desire new service modes or service value. Although the rise of the “sovereign consumer” in and around professional fields must be handled with care (e.g., Korczynski & Ott, 2004), clientele and clients might acquire new meanings. When services become transnational—when health care patients fly to Thailand for eye treatment, for instance—health care providers and insurers cannot stick to traditional images of client populations and payment methods. When technologies enable the rise of transparency, service organizations cannot shelter work practices and performance outcomes. Consequently, “structural-functional, political and social pressures” contribute to the “deinstitutionalization of professional governance” (Suddaby et al., 2007, p. 343). Third, these societal forces are exogenous, that is, not only affecting professional work from the outside but also affecting professional work from within. Endogenous changes in professional work might relate to, for example, changing work standards (e.g., Francis, 2005) and technologies (e.g., Boone, Ganeshan, & Hicks, 2011; Faulconbridge & Muzio, 2008; Plochg et al., 2011). Medical or police work are adapted, because medical professionals and policemen have new techniques for treating clients and for solving crimes; legal professionalism changes because ethical standards change (Francis, 2005). In addition, there are changes in professional workforces. Their demographic and sociocultural composition is relevant for understanding work preferences and work modes. Careers of professional


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workers change, for instance (e.g., Bolton, Muzio, & Boyd, 2011; Leicht & Fennell, 2001, 2008). Younger professionals like medical doctors have different occupational ideas, identities, and dedications than older professionals (e.g., Zuger, 2004) and they have different ideas about connections between work and life (e.g., Gjerberg, 2003; Heiliger & Hingstman, 2000; Jones & Fisher, 2006), backed by stricter working time requirements (McDonald, 2008). All in all, analyses of changing professional work in public services have been too organizational and too little social and societal. Many analyses presuppose some core idea of professionalism, which is either adapted by creating organizational frameworks, or defended by professionals who resist organizational frameworks. The rise of rational economic models, cost control, and customer satisfaction is quickly seen as weakening institutionalized autonomies and harming professional identities—or as “alien” forces that are resisted by professional groups and fields. In many ways, these intrusions are happening. Organizational, managerial, and professional fields compete over autonomies and jurisdictions (e.g., Abbott, 1988; Kurunmäki, 1999; Suddaby & Viale, 2011; Noordegraaf & Schinkel, 2011). But, related to the previous points made, changes in and around professional work are much more than mere changes in economic policies and more than “organizational versus professional” conflicts. Individual and institutional meanings of professional work are adapted because of broader societal forces, which occur around as well as inside professional work. What it means to work as a public professional has always been hybrid, but more importantly, what it means to work as professional and to regulate professional fields in flexible capitalist economies, transnational spaces, and digital realities has become especially unclear and contested. This means there are all the more reasons to reframe understandings of professional work.

Forces Affecting Public Professional Work Traditional understandings of professional work were unavoidably broad, as they were rooted in, for example, occupational sociology, the sociology of professions, and the sociology of professional education (e.g., Becker, Geer, Hughes, & Strauss, 1961). They had little to do with organizations and organizational contexts. But since the 1980s, there has been a tendency to narrow down analyses, including sociological analyses, to growing relations and conflicts between professional work and organizations. More recently, there have been various attempts to broaden understandings of professional work, partly from sociological points of view and partly from the point of view of


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organizational policy and governance sciences (e.g., Faulconbridge & Muzio, 2012; Kirkpatrick et al., 2005; Kuhlmann, 2006; Kuhlmann & Allsop, 2008; Kuhlmann & Saks, 2008; Muzio & Kirkpatrick, 2011; Suddaby et al., 2007; Noordegraaf, 2011). Many of these broadened analyses focus on complex—instead of divisive or simple—connections between professions and organizations. Transitions of professional service organizations, from organizations of professionals toward “professional service firms” or “PSFs” (e.g., Brock, Powell, & Hinings, 1999; Suddaby & Greenwood, 2001; Greenwood, Suddaby, & McDougald, 2006), have been well documented. This has been partly related not only to changing scales in service delivery and rising service standards but also to transnational developments in, for example, big accounting and law firms (e.g., Faulconbridge & Muzio, 2007, 2009, 2012; Suddaby et al., 2007). This, in turn, has major implications for professional associations and education. When professional service organizations become more transnational, associations and educational programs change as well. Big firms are capable of organizing their own professionalism, including professional education (see also Francis, 2005). Within changing professional fields and organizational forms, connections between professional work and managerial systems are analyzed as well. Increasingly, there is a tendency to speak about “hybrid professionalism” and “hybrid professional/managerial roles” (e.g., Dent, 2003; Noordegraaf, 1997; Kirkpatrick et al., 2009). Research projects focus, for example, on how medicine and management are “integrated” in contemporary health care. In the meantime, more sociologically oriented scholars remain hesitant of reinterpreting professionalism, although some sociologists (e.g., Evetts, 2011; Evetts, Gadea, Sánchez, & Saez, 2009) tend to speak about “organizational professionalism.” We can go beyond these reinterpretations, as they often remain too organizational. Organizational developments should be related to wider social and societal trends and developments. When we leave aside (neoliberal) managerial influences on professional work, other influences and forces come to the fore. In the remainder of the article, we focus on the effects of societal forces on professional work. We argue that professional work is not so much redesigned but might be reconfigured. Beneath, we discuss three major reconfigurations: 1. The reorganization of professional work. Instead of organizational capture of professional work, professional work itself becomes more organizational due to new circumstances that call for well-organized services.


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2. The restratification of professional work. Instead of divisions between organizational and professional fields, professional fields themselves become more divided. 3. The relocation of professional work. Instead of clear boundaries between professional work and outside worlds, professional practices and their boundaries become more fluid. These reconfigurations do not always occur and they do not necessarily all occur at the same time, but they might be affecting professional work in one way or the other. To what extent they affect practices, how and with what implications, is an empirical matter. The analytical discussion of reconfigurations, then, not only enables us to reflect upon developments and forces, it also enables us to develop a framework that can be used to empirically analyze changing professional work. This framework, which we present beneath, can be used to detect which reconfigurations happen where, how, and when. Although our examples will mainly come from the (well-established) medical field, embodying the legacy of independent and liberal professions (e.g., Reed, 1996), the various reconfigurations might also hold for other public professional fields like policing and (higher) education, which represent less pure forms of bureau-, expert, and organizational professionalism (e.g., Clarke & Newman, 1997; Reed, 1996). In the latter part of the article, we pay attention to these contexts, as contexts of professional work will (also) affect which reconfigurations occur, how, and why. The reconfiguration of independent professional work like medical work will differ from the reconfiguration of less independent professional work like policing, welfare, or education.

The Reorganization of Public Professional Work When professionalism and organization are taken together, they are most often set apart. It is common to highlight the contrasts and conflicts between professional and organizational logics. Even when they are not really set apart, for example, when academics show that professionals incorporate managerial techniques to strengthen their position, they are set apart. Managerial techniques are still seen as “alien” as far as professional action is concerned. This is increasingly becoming problematic. To begin with, professional fields have always been organized and they have depended on organizational principles to survive. The building and “making” of professional fields and jurisdiction, and the establishment of associations, education, regulatory codes, and bodies—this all has to be organized and managed (e.g., Willmott, 1986). Sometimes, this is explicitly acknowledged, for instance, when organizational scientists pay attention to


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organizational aspects of becoming a profession (e.g., Hall, 1946; Hinings, Greenwood, Reay, & Suddaby, 2004). Furthermore, the provision of professional services also depends on organizational principles. It has to be coordinated and it even grounds a distinctive organizational form, the professional bureaucracy (Mintzberg, 1983). What did become “alien” is not so much organizing and managing, but neoliberal and businesslike organizing. This should not be used to propagate a strict return to autonomous or “un-organized” professional practice, however, as there are other, noneconomic forces that affect professional service delivery. Some forces that call for professional organizing (i.e., organizing by professionals) are exogenous; they embody new service pressures that force professional service delivery to adjust action modes. Noordegraaf, (2011) highlighted two shifts in service delivery. First, there might be new service pressures that call for multiprofessional action. Cases and clients could easily be put or “stored” in professional categories, but connections between cases and categories break down. When cases are multiproblem cases, it will be ineffective to link such a case to a particular professional. Two or more professionals might be relevant, and they might come from different disciplines. This generates a push for multidisciplinary professional action (e.g., Edwards, Daniels, Gallagher, Leadbetter, & Warmington, 2009; Huotari, 2008; Sanders & Harrison, 2008). Professionals need to find ways to organize cooperation. Even within professional fields, such as the medical field, there are segments and these segments might oppose each other (e.g., Bucher & Strauss, 1961). Holsinger and Beaton (2006) speak of a “professionalism gap” and argue that “the 20th century’s preferred ‘independent physician’ model” need to be replaced by “a new professional structure based on teamwork and collaboration” (p. 473). Second, there are new risks when services are provided. These risks might partly come from technological advancements, for example, when complex medical or legal technologies have unknown side effects. But more importantly, these risks might come from changing sociocultural spheres, in which risks can be exposed immediately and can generate widespread public concern (e.g., Millenson, 2002; Stallings, 1990). Risks might become visible due to incidents, failure, and disasters. When a medical doctor mistreats a patient, it can become front-page news and generate public concern. In various countries, there have been many sorts of incidents and failures that generate public discourses on “medical errors.” Some of these incidents have also attracted academic attention (e.g., Sutcliffe & Weick, 2003). These discourses explain public pressures to realize “quality and patient safety” in fields like health care (e.g., Currie, Waring, & Finn, 2008; Millenson, 2002; Waring, 2007). This again might generate an organizational push, also for professionals. As


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(perceptions of) professionalism can be harmed, professionals have a strong incentive to detect and contain risks, and to implement organizational risk management systems, to work according to medical checklists (e.g., Leistikow, Kalkman, & De Bruijn, 2011) and to establish safety cultures (e.g., Vogus et al., 2010) to reduce the number of unwanted complications, (fatal) errors, and everyday mishaps (e.g., Sutcliffe, Lewton, & Rosenthal, 2004). Other forces on professional work are more endogenous (also Noordegraaf, 2011; Leicht & Fennell, 1997, 2001); they embody new service realities that relate to changes within professional fields and work. Within professional fields, there might be changing work preferences and work patterns, and they also contain an obvious imperative to organize. Younger professionals might have different professional ideals and different preferences regarding work– life balance; they might have less “24/7 dedication” that can be found among older professionals. This is related not only to general generational shifts but also to gender dynamics. In many professional fields, more women might enter professional labor markets. This generates gendered divisions inside professional domains (e.g., Kuhlmann & Bourgeault, 2008; Muzio & Bolton, 2006; see beneath) and different skill mixes (e.g., Muzio & Bolton, 2006). From a more judicial point of view, professional work patterns might be changing as well. Even in classic domains like medical fields, legislative frameworks that regulate working times have been introduced (certainly in EU countries, for example, Hellawell, Kahn, & Mumtaz, 2005; McDonald, 2008; Pickersgill, 2001); this limits “limitless” professional dedication, which resonates with work desires of younger medical doctors (Heiliger & Hingstman, 2000). This means that professionals might have to organize their work more explicitly. Older doctors might less easily delegate tasks to younger doctors, for example, at less desirable working hours (during evenings and at night). This is not a mere organizational matter, in the hands of managers; professional action itself becomes organizational action.

The Restratification of Public Professional Work Professional work changes because professional fields might change in terms of composition, social structure and relations. This is induced by the foregoing developments, especially developments that affect work preferences and work patterns. Within professional fields, which in some cases—like medicine—might have been rather homogeneous or were composed of rather homogeneous segments (cf. Bucher & Strauss, 1961), new and more fragmented or “differentiated” segments might appear (e.g., Halford & Leonard, 2006). When professionals opt for less dedicated professional identities,


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groups of professionals who are dedicated or “true” professionals to a higher or lower extent might suddenly become visible. As already indicated, gendered divisions might be generated within professional domains (e.g., Crompton, 1987), such as medical domains (e.g., Currie et al., 2009; Kuhlmann & Bourgeault, 2008; West, 1984; Witz, 1990) or legal domains (e.g., Bolton & Muzio, 2008). Despite optimistic messages about the added value of women in professional work, “Our analysis challenges such optimistic assessments, revealing patterns of segmentation and stratification which underlie the feminized professions” (Muzio & Bolton, 2006, pp. 89-90). In addition to gender, age is used to “construct subject positions” that might be invoked to resist, modify, or accept (businesslike and entrepreneurial) changes (cf. Kuhlmann & Bourgeault, 2008). These fragmentary and divisive tendencies are not neutral; they might set the stage for more stratified relations between segments, whereby some segments are seen as “leading” or “lagging” as well as “higher” and “more effective” or “lower” and “ineffective.” Such stratification is not only linked to demographic developments and changing work preferences, but it might also occur due to other forces (e.g., Faulconbridge & Muzio, 2012). It might be difficult to determine the limits or borders of professional fields, not in the least because their reach is increasingly decoupled from traditional institutional arrangements. Whereas traditional professions were tied to states and (policy) sectors (e.g., Burrage & Torstendahl, 1990), contemporary professional fields easily transgress state and sectoral borders. It is less possible to stick to strict borders, because cases and clients move around; in addition, it is less necessary to stick to borders, as arrangements aimed at serving clients become more flexible, also aided by technology. Professional service organizations might follow these trends and they might become transnational professional service firms (e.g., Brock et al., 1999) in global service economies (e.g., Covaleski, Dirsmith, & Rittenberg, 2003). In its most “extreme” manifestation, this might mean that certain professional fields or parts of it might become transnational (e.g., Suddaby et al., 2007) and that professionals might become “global expert workers” (Covaleski et al., 2003). This, in turn, has major effects of the development and makeup of professional groups. Professional groups might be tied to professional service firms that operate internationally and these firms might become important for the reconfiguration of professionalism. “ . . . conglomerate professional firms have become less the subject and more the site of professional regulation . . . ” (Suddaby et al., 2007, p. 334; see also, for example, Cooper & Robson, 2006). Corporate professional firms might set up their own educational programs (see, for example, Faulconbridge & Muzio, 2009; also Francis, 2005). Firm-based distinctions will be strengthened due to reputational effects; prestigious firms


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will be set apart from less prestigious firms. This is something that has already happened in other fields, such as higher education and accounting. In the field of accounting, the “Big Four” are dominating “the transnational field for professional service” (cf. Suddaby et al., 2007, p. 335). Restratification does not necessarily originate from international forces that draw professionals into transnational spaces. It might also originate from more national and regional economic forces that generate more differentiated professional labor markets and opportunities for service providers to differentiate highly specialized interventions from routine professional acts. Professions, Reed (1996) argues, Are being restructured into more hierarchically controlled occupational associations and groups in which there is a much clearer stratification division between an administrative elite and a rank-and-file mass of routine “workers.” (p. 587)

In short, also within professional (sub)fields and professional service firms, there is stratification, especially between those who perform routine tasks and those who perform innovative and risky tasks. Economic and technological resources are distributed more unevenly and more differentiated assemblages of specialized and/or routine forms of professionalism are shaped and structured. Within traditional professionals fields, such as the field of general practitioners, there is increasing specialization, carried by, for example, “general practitioners with a special interest” (GPSI), as well as more generalism, carried by rank-and-file GPs, also connected to secondary care circuits (e.g., Pickard, 2009). Such differentiation plus stratification might be reinforced by outside linkages. Firms might serve a differentiated clientele (e.g., Liu, 2006) and task distinctions (in addition to task divisions) might mirror this. Although this does not necessarily affect all health care organizations, as occupational closure of traditional groups of health care professionals might be strong and as increasing dependencies might be resisted (as was found by, for example, Currie et al., 2009), it might affect GP work.

The Relocation of Public Professional Work Finally, professional work might be relocated. In some ways, this is linked to the previous points. When professional service provision becomes part of transnational service arrangements, rooted in professional service firms, professional careers will be adapted and internationalized (e.g., Faulconbridge & Muzio, 2007, 2008). When technological advancement enables professional specialization, moreover, it is likely that specialized professional work is concentrated in certain designated places that fuel and facilitate further


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specialization. This is in fact what is happening in many countries, not only in medical service provision but also in higher education. Medical doctors are forced to specialize and specialized groups of doctors are concentrated in specialized centers of excellence, which attract complex cases and wellequipped professional workers. Relocation also has other manifestations, and they might have little to do with international and specialized professional services. First, there is digital relocation and sometimes digital dislocation. In case of higher education, universities might offer digital study programs that can be followed at a distance. In case of health care delivery, service provision might be facilitated by digital techniques and clients might be treated without going to hospital. The internet and telemedicine might affect the ways in which health care information is used and distributed, how medical diagnosis and treatment take place, and how pills are used. In addition, (chronic) patients might increasingly use technological equipment to treat themselves, at home, facilitated by eHealth (e.g., Plochg et al., 2011; also Ball & Lillis, 2001; May, Finch, Mair, & Mort, 2005; Mechanic, 2008; Nicolini, 2007). Existing boundaries between professional work and clienteles become fluid. Whereas medical work is “mostly organized around the convention of the physical copresence of the two parties,” medical practices will increasingly “stretch out in space and time” (Nicolini, 2007, p. 899). Patients and especially chronic patients will become “more proactive and independent, and it saves money for the system” (Nicolini, 2007, p. 904; see also Ball & Lillis, 2001). "New artefacts," like telemonitoring logs, "are introduced in the care process" (Nicolini 2007, p. 894), affecting how work and tasks are divided, how professionals work, how they account for their actions and how power is (re) distributed. Electronic health records (EHR) and disease management systems “can contribute to both professionalism and quality of care” (Mechanic, 2008, p. 327). Blumenthal (2002) argues, “As a result of the information revolution, the magic, mystery, and power of the profession might be somewhat diminished in the future from what it has been in the past” (p. 543). “E-mail, video conferences, webinars, text messaging, text pagers, websites, blogs, and social networking sites” contribute to the rise of eProfessionalism (e.g., Spector et al., 2010, p. 345). Second, there is geographical relocation. When service fields become more global (e.g., Allsop et al., 2009), service provision might shift; certain regions might gain or lose strength, as service providers might choose or avoid certain places to set up service centers. In markets that were globalized before, such as financial markets, this happened longer ago. In rising professional markets, such as markets for health care (e.g., Relman, 2007), this is currently happening. This includes changing connections with major


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industries, such as pharmaceutical industries (e.g., Relman, 2007). In case of health care provision, certain regions are becoming increasingly attractive, for example, in parts of the Middle East and Asia (e.g., Whittaker, 2008, on medical travel). In this case, the relocation follows the rerouting of patient flows. Instead of localized patient care, patients might travel and they might be treated by medical doctors elsewhere in the world. Increasingly, professionals are not only working inside professional service firms, as discussed earlier (also, for example, Von Nordenflycht, 2010), but they also work for different, more commercial, and more powerful clients (e.g., Suddaby et al., 2007). Suddaby et al. stress the importance of client capture, which for example happens when professionals work for companies instead of individual clients. This might not only alter service interactions but also professional education and development; clients might start influencing how professionals are trained. Suddaby and Viale (2011) have shown how institutional changes happen within professionalization projects that seek to incorporate new circumstances. Finally, there is physical relocation. It is questionable whether traditional organizations, including its physical and ideational manifestation, will continue to exist. In case of health care, for example, there are increasing signs that traditional hospitals—as constructs and buildings—are losing their selfevident position in health care domains (e.g., Raad voor de Volksgezondheid & Zorg [RVZ], 2011). In addition to specialized health care centers and clinics, we witness transitions from medicalized to “societalized” care (e.g., Plochg et al., 2011). Instead of focusing on “curing” a particular health problem, medical professionals and citizens might develop a concern for preventing health problems to arise and for dealing with multimorbidity. A particular health problem is often related to other health problems and to socioeconomic circumstances. Even when hospitals survive, they will be torn between contradictory forces. They have to grow and prepare themselves for more globalized, specialized, and concentrated service delivery; they also have to maintain local communities and secure small-scale service delivery that does not alienate professionals and clients (e.g., Adler, Kwon, & Heckscher, 2008). This tension between more specialized and more generalized care and cure that might be occurring within professional fields (e.g., Pickard, 2009) is not only affecting how work is performed but also where.

Tracing New Forms of Public Professionalism Taken together, these forces represent multiple ways in which professional work might be reconfigured. Although these reconfigurations will not all occur fully and definitively, they show which changes might occur and they


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signify the increasing outdated nature of traditional notions of professionalism that focus on “(self)controlled content.” As indicated, these changes might have been taking place longer ago, especially in case of less independent professional fields like policing and education, in which self-regulation was less pure and autonomies were less secured. Professional work then might already have been more organized, more stratified, and more dislocated. But even in these cases and especially in case of more independent professionals fields like medicine, changes might recently or currently be happening or they might occur soon. As argued, each of the reconfigurations and the forces behind them must not immediately be seen as actual; in many ways, the reconfigurations represent potential changes. Whether and how they take place, will vary from context to context. In some fields, like the medical field, changes might now occur at the same time, whereas in other fields, like the educational field or field of policing, changes might be more modest. Moreover, in some regions or countries, changes within one and the same field—for example, the medical field—might be more modest than in other countries or regions. To facilitate empirical research, Table 1 offers an analytical framework, summarizing the conceptual elaboration of reconfigurations. The (potential) reorganization, restratification, and relocation of professional work are highlighted, including the various pressures and changes that cause these processes. This framework can be used to trace actual changes; which pressures and processes occur, when, where, and how? The more they occur, the more professional work is reconfigured. The framework can also be used to link changes to contexts; the context of professional work might affect which changes happen, when, and how. Beneath we pay attention to descriptive and explanatory sides of our analytical framework.

Describing Changes The more professional work is reconfigured, the more traditional notions and images of professionalism will lose their value. Traditionally, professionalism was linked to protected autonomies, regulated case treatment, and stable professional identities. The more professional work is reorganized, restratified, and relocated, the more we need to emphasize constrained autonomies, contingent case treatment, and ephemeral identities. To put it differently; whereas professional fields were traditionally seen as rather homogeneous, current fields must increasingly be seen as heterogeneous and fragmented (also, for example, Francis, 2005). Whereas traditional divisions were located around and outside professional groups, including professional/managerial divides, current divisions are either less sharply marked or they are clearly


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Noordegraaf Table 1. Analytical Framework for Tracing Changes In and Around Professional Work. Reconfigurations 1. Reorganization

Pressures and changes a. Multiproblem cases b. Risks and incidents c. Work preferences

2. Restratification

a. Gender and age

b. Transnational spaces

c. Task distinctions

3. Relocation

a. Digital dislocation

b. Geographical distance

c. Physical concentration

Elaboration Clients and cases that cannot be clearly categorized Safety and quality issues that signify bad performance Working times and perceptions of work, life, and meaning Divisions between male/female and older/younger professionals Powerful professional firms that deliver transnational services Elite professionals performing complex work Information and communication technologies Clients consume services that are produced far away Concentration and specialization of services

marking professional fields and segments. Above all, these segments are not only becoming more fragmented, but they also become increasingly dependent on outside worlds. The more new pressures and processes are occurring (again, see Table 1), the more professional work becomes fragmented and dependent. The various reconfigurations brought together in Table 1 enable us to understand the extent to which and ways in which specific forms of professional work are (becoming) fragmented and dependent. As indicated, this might be happening now. The various examples given before, mainly coming from health care, show that health care provision is experiencing many of the operational changes that are listed in the right-hand column in Table 1. This will vary not only from health care system to health care system (in other words, from state to state, from region to region) but also from organization to organization. When hospitals introduce new technologies to treat clients differently, for example, more at a distance, or when they start initiatives to establish safety cultures, or when they establish specialized clinics, this will unavoidably affect health care professionals and their work. As also indicated, this differs from other less independent professional fields, such as policing and education. Because policemen and


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teachers belong to “less professionalized” fields, in traditional terms, and are more embedded in state and welfare state arrangements, they were already more fragmented and dependent. But still, police forces and education might also have been relatively isolated from outside pressures and might also be undergoing changes, depending on national, regional, and organizational contexts. Police work, for example, might become more dependent on citizen initiatives and actions; judges in law courts might become responsible for improving quality, efficiency, and client satisfaction; higher education might move toward forms of learning at a distance; and schools might opt for wellorganized teamwork.

Explaining Changes Whether and how changes occur depends on conditions that are difficult to summarize, because they are situated at different levels of analysis, as indicated before (national, regional, organizational), and because changes do not flow from clear and conscious choices. Nevertheless, different contexts contain some distinctive aspects that at least partly determine the dynamics of change that can be found through comparative research. First and foremost, there will be institutional conditions that affect whether reconfigurations are likely to happen and how they happen (compare, for example, Ackroyd et al., 2007). In case of the British National Health Service (NHS), which is a statebased system, changes are more likely to happen than in health care systems that are nonowned, like in The Netherlands. More commercial health care systems, like in the United States, will already contain reconfigured forms of professional work, as there will be more necessity and opportunity for reorganized, restratified, and perhaps relocated professional acts. When health care is compared with policing, or education, the same line of reasoning applies. As police work is highly dependent on states, it will be—generally— more sensitive to change. Institutional conditions, in other words, might contain or lack certain buffers that will work against change because they reduce necessity and opportunities for change. Second, there might be vehicles for change that partly determine whether such necessity is perceived and whether opportunities are used or not, linked to the various operational dimensions of reconfigured professional work, summarized in Table 1. When there are many publicly exposed safety incidents, for example; when there are demographic changes within professional workforces; when there are new technologies for treating clients, the reconfigurations of professional work might be more far-reaching than is such vehicles are absent.


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Finally, there will be individual abilities and actions that determine whether reconfigurations really happen or not. Inside or around professional fields, there might be people who resist or realize changes in professional work. When certain health care professionals like medical doctors start to initiate new training programs, or when they start to use new technologies for treating patients, they redefine medical work and identity. The same holds for policemen or teachers; when they respond to service pressures by seeking work innovations, they might set new standards.

Discussion Less empirically and more analytically, the foregoing implies we need new notions and images of professionalism. Instead of enforcing professionalism upon members and outside environments, professionalism has become an unstable category and has to be manufactured and legitimized in active ways. Instead of establishing and maintaining as much “(self)controlled content” as possible, professionals and others will have to enact new forms of control that enable them to cope with constrained autonomies, contingent case treatment, and ephemeral identities. Whereas classic professionalism rested upon isolation (i.e., separation between inside and outside) and exclusion (i.e., keeping nonprofessionals out; for example, Suddaby et al., 2007), new professionalism is unavoidably much more connective (see, for example, Noordegraaf et al., in press). Professionals and organizational logics, divided professional segments, and shifting boundaries—they all call for renewed connections that do not maximize homogeneity but reduce heterogeneity. In terms of the reconfigurations that were discussed above, professionalism will be connective in three respects: 1. Professional acts and practices are connected, for example, when professionals cooperate. Whether and how professionals will (re)organize their work will affect whether and how they combine client treatment and cost and quality control. 2. Professional segments and groups are connected, including stratified groups. Whether and how stratified segments will work together will affect the strength of professional fields. 3. Professional workplaces and sites or spaces are connected, also digitally. Whether and how professionals are able to cope with the digital and spatial relocations of their work will determine the effectiveness of professional work. This has various consequences. Changes will affect professional values and criteria that can be used to determine whether professionalism “works”


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or not. Whereas traditional professional values were clearly “professional,” that is, set and regulated by professional fields themselves, such as quality, reasonableness, and equity, current values are much more ambiguous and less predefined. Professional behaviors might also relate to values like efficiency, impact, and evidence, which were traditionally seen as alien. Whereas we tended to judge professional acts on the basis of procedural effectiveness (“operation successful, patient died”), currently we tend to judge professional behavior on the basis of outcome effectiveness (did it work?), accountability (can you show it?), and legitimacy (do we trust it?). In addition, it has major implications for professional education, socialization, and training and development. Instead of “merely” teaching methodical skills, professionals will have to be taught how they can connect to other professionals, other disciplines, and outside worlds. Professionals themselves will need to acquire connective capacities, which they use to tackle cases, build careers, and secure authority. Research should also focus on whether and how these shifts are enacted. All in all, instead of pure, organizational or hybrid professionalism, professionalism might be increasingly becoming connective. As argued, this sheds new light on the nature of professional/organizational control. Many scholars have focused on the shift from professional to organizational control. The rise of connective professionalism shows another shift, namely, a shift from professional or isolated control to more embedded forms of control. When organizational control is emphasized, scholars tend to focus on managed and measured professionals, and they analyze how professional groups can resist, conform to, or use organizational intrusions. This might be used to develop new professional competencies, for example, leadership and management competencies, such as medical leadership and management. When embedded control is emphasized, analyses should focus on relations inside professional groups and fields as well as between professional fields and outside worlds, and we should analyze how professionals comply with, adapt to, or cope with societal and stakeholder pressures. This is not so much a matter of (individual) competencies but of professional relations and repertoires, which include certain amounts of reflexivity. When professional work is reconfigured, professional workers act professionally when they are able to (collectively) reflect upon when and how they act professionally. When heterogeneity and dependencies increase—to be identified in Table 1—and when occupational definitions and standards are influenced and set by outsiders and outside forces, professional fields will have to acknowledge the fact that they are no longer in control. Reflexive awareness of the limits of professional control and the lack of regulatory purity enables professional fields to keep some grip on professional work.


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Conclusion It is tempting to stick to traditional images and ingredients of professionalism, especially as many changes affect professional acts and services. The foregoing, however, has made clear that these changes are not only antiprofessional. On one hand, they represent shifts and societal tendencies that highlight the constructed and therefore relative nature of traditional professionalism. They also highlight the necessity of constructing new images of professionalism. On the other hand, they do not only represent destructive influences that harm service provision, but they also generate opportunities for renewing and improving professional service delivery. Digital techniques, specialized treatment and localized services can all help in making service delivery more sustainable. Costs, clients, and quality can be managed in more balanced ways. New images of professionalism are difficult to clarify, as professional fields will undoubtedly become more varied and heterogeneous. This is caused by the weakening of ties between established professional fields (professions) and professional members (rank-and-file). When professional careers become more volatile, when organizations get a grip on professional education and socialization, when divisions appear between specialized and routine work, and when services are either globalized or localized, it is increasingly difficult to speak about the prototypical professional who has a strong technical base and a clear professional identity and who is supervised strictly by his or her professional association. Instead of searching for a renewal of enforced forms of professionalism, there will be a need for more connective forms of professionalism. Heterogeneity is accepted; instead of maximizing homogeneity, heterogeneity is reduced. This is done by installing more embedded forms of control, which acknowledge the fact that occupational standards are set and controlled by outsiders and outside forces, as well as by seeking new professional relations and repertoires. In case of reconfigured professional work, professionals should then become reflexive—they should be able to cope with how they cope in complicated service realities. Author’s Note An earlier version of this paper was presented at the EGOS Colloquium 2012, Helsinki, Finland, SWG Organizing the public sector. The author thanks discussants and participants for their valuable comments.

Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Funding The author received no financial support for the research, authorship, and/or publication of this article.

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Author Biography Mirko Noordegraaf is full professor of Public Management, Utrecht School of Governance (USG), Utrecht University. He focuses on organizational and management themes in public domains, with particular emphasis on public services, public professionalism, professional work and professionals. Recently he published in Administration & Society, Public Administration and Organization Sciences. With Bram Steijn, he published Professionals under Pressure (2013).
