Activity theory, discourse and power: a critical perspective on assistant professional roles in healthcare

Abstrak / Ringkasan

The development of new roles within healthcare has occurred within a discourse of ‘modernisation’ of public services with ‘workforce remodelling’ and ‘patient choice’ associated with increasing marketisation of the health sector (Drewry, 2007). This paper considers the development of one of these new roles, the Assistant Practitioner, analysed retrospectively through the lens of Cultural-Historical Activity Theory (CHAT) (Engestrom, 1987, 2001). This analysis positions the emerging Assistant Practitioner role as the ‘object’ in an activity system based on an education-healthcare partnership established to develop it. The study considers how the role is shaped by the ‘multiple voices’ in the activity system represented by the professional roles and hierarchies of those involved. The Marxist underpinnings of CHAT identify ‘use value’ and ‘exchange value’ as the primary source of contradiction which creates tensions and stimulates expansive learning. Despite this ideological basis, activity theory arguably under-theorises the role of power in determining whose voice counts, and supports Avis (2009) view that the questioning of practices within activity systems is ‘set within an acceptance of capitalist relations’ (p.159). This paper develops the role of power further, bringing a Foucauldian discourse analysis perspective in revealing competing discourses which have shaped the Assistant Practitioner role in ways which have consequences for the ‘use value’ and ‘exchange value’ of the Assistant Practitioners themselves, and for wider educational and healthcare practice. The paper draws on the findings of an empirical study of the partnership, established in 2002 between a university and the Strategic Health Authority, to train Assistant Practitioners through a foundation degree. The study is located within an interpretivist paradigm from the viewpoint of an ‘inside researcher’ responsible for the design and delivery of the curriculum. The Assistant Practitioner role is intended to be ‘patient centred’ in crossing traditional occupational boundaries which has required a process of ‘workforce re-engineering’ to prepare the workplace for the generic role. The establishment of the role has in fact been successfully achieved, although there are ongoing challenges to generic working (Benson and Smith, 2007). Drawing on the focus group findings, the paper debates how a powerful managerialist voice and a less powerful, but resisting, academic voice, act to shape the AP role and tailor the foundation degree curriculum to meet the practice requirements. The findings suggest that the ‘use value’ of the AP role in practice exceeds the ‘exchange value’ of the qualification, and provides evidence of an associated discourse of commodification of the workforce. This resonates with concerns that foundation degrees are indicative of a policy which promotes learning with the explicit purpose of increasing potential in the labour market (Coffield, 2002). Furthermore, the process of ‘remodelling’ the healthcare workforce has consequences for registered professional staff whose autonomy may be challenged in the interest of a capitalist agenda.

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