Professional Autonomy for Ostriches

Professional Autonomy (PA) is sometimes defined in various ways by various authors. For example Bebeau, Born and Ozar (1993) as “…the extent to which [a profession] or an individual feels freedom and independence in [their] role…”. As critical physiotherapists you will have spotted the problem with this kind of description as a perceived personal experience. We are likely to experience ‘freedom’ differently in different situations, roles and grades. I don’t intend to compare the various definitions of PA, because (strange as it may seem) that would divert us from our real purpose.

Throughout the literature definitions of PA comprise phrases such as “Freedom to decide and act”, “being responsible” and “self regulation”. It may seem tempting to explore autonomy from a philosophical, ethical and moral perspective.  I believe that makes for a  worthwhile project because it is associated with how we perceive our professional identity and role. However that approach on its own may not yield the analysis we need,  to explore the most relevant aspect of PA (in the real world) and in order to understand how we might  prevent (or manage) perceived and actual erosion of our professional autonomy. While the theories around (professional) autonomy are interesting and relevant due to their associations with personhood, ethics, morality and professionalism, we should take a focused perspective from a high vantage point in order to reflect on it in its appropriate context. This involves viewing our PA from the perspective of other, more powerful agents in the system.

It is very interesting that over the last eleven years I have supervised several post-graduate research project that focused on professional autonomy (in a variety of countries). One theme that emerged from all those projects was that most participants talked about “barriers to autonomy” “obstacles to autonomy” and ‘blocks’. The underlying assumption may have been that they themselves considered themselves to be professionally autonomous, but something was stopping them from exercising their autonomy as a physiotherapist. While it is a perfectly legitimate expectation  to be regarded and treated as an autonomous professional, their experiences kind of demonstrate to me that PA is not some inherent property of the physiotherapist. Neither is a a generally respected right that we acquire when we graduate, or become more senior clinicians. There are always other agents higher up in the departmental/organisational food-chain (hierarchy) who have the power to delegate and/or curtail the level of autonomy (in accordance with their own agendas) that we believe we need to provide optimal care to our patients. This does not necessarily mean that they are barriers to our autonomy. It could mean that we don’t fully appreciate that professional autonomy is the outcome of negotiated and ever changing understandings of each others perspectives, believes and motives. In other words PA is the outcome of inter-relational and organisational processes. To claim that we as physiotherapist have the right to be regarded as autonomous, is to hide from the reality that society views the professional differently and that healthcare organisations are complex, facinating human activity systems with ever changing power-dynamics, organisational priorities and financial realities. The role of most professions (managerial and clinical) changes (to some extent at least) with each and every health policy change.

We need to demonstrate the link, the association between our professional autonomy and clinical outcomes. If we don’t or can’t, then why should our PA be respected.

I don’t believe that “professional autonomy” is what we need or want for two reasons. First try and define it in a way that is acceptable to all relevant agents AND meaningful. My second reason is that we don’t need PA, but control; the authority to control all aspects of our services. Clearly this requires (among other things) collaboration, negotiation and a very different way of engaging with other agents within our organisations.

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