Some of the key elements found in traditional definitions of PA are deeply problematic in themselves. As a result PA is conceptually a challengeable notion which may pose significant dilemmas for the AHP. The elements I am referring to here are notions such as ‘freedom’, ‘self-regulation’ and ‘responsibility’.
The Chartered Society of Physiotherapy (CSP) states in its code of Professional Values and Behaviour that its members (CSP 2011) “Members demonstrate appropriate professional autonomy and accountability”. This claim is a standard to be met and as such is a normative claim (i.e. members ought to…..). But “ought to” does not equal ‘does’ or ‘can do” or “is empowered to do”. Even though the intension of this standard is clear, it is by no means clear what PA actually means in this context. Lets explore then how the CSP defines PA?.
Their Quality Assurance Standards Section 1 asserts that ” […] means that a member makes decisions and acts independently within a professional context and is responsible and accountable for these decisions and actions. A key element of professional autonomy is to understanding and working within the limits of personal competence and scope of practice.”
It seems that on the basis of this definition, PA entails knowing your own limitations and that the therapist “is” (i.e. absolutely) responsible and accountable for their decisions (and their actions, presumably). The CEO of the CSP asserts that “…clinical autonomy is definitely not doing what we want […] [but that it is entirely constrained by our professional guidelines…” (Frontline Magazines, letters, 3/12/2014). This claim implies that all aspects of clinical practice are covered by professional guidelines. One reply to this claim would be to say that guidelines (and professional standards and rules of conduct) define rather than constrain, in that they clarify the role and scope of practice of the professional. In other words, they clarify what society may expect from members of the physiotherapy profession. Physiotherapist, being autonomous agents, who have chosen to join the profession are unlikely to feel that their professional autonomy is, or will be constrained by the professional standards/guidelines they have chosen to accept and practice by.
The College of Occupational Therapy (COT) seem to have adopted a different perspective, in that it seems not to have defined professional autonomy per se but rather prioritises the autonomy of the service user quite explicitly.
So how does the Health Care Professions Council (HCPC) define professional autonomy? It seems that they expect that registrants “… be able to practise as an autonomous professional, exercising their own professional judgement.” (Standards of proficiency-Physiotherapists/Occupational Therapists 2013), and describe PA in the active sense in that the therapist should:
“4.1 be able to assess a professional situation, determine the nature
and severity of the problem and call upon the required
knowledge and experience to deal with the problem
4.2 be able to make reasoned decisions to initiate, continue, modify
or cease treatment or the use of techniques or procedures, and
record the decisions and reasoning appropriately
4.3 be able to initiate resolution of problems and be able to exercise
4.4 recognise that they are personally responsible for and must be
able to justify their decisions
4.5 be able to make and receive appropriate referrals
4.6 understand the importance of participation in training, supervision
These standards seem unconditional and independent from their organisational context, with its all its enablers, constraints, competing priorities and demands. By being on the HCPC register, the AHP expresses their wish to adhere to these standards and that they wish to meet the HCPC exceptions regarding their autonomy. This is inherent to being a professional.
PA as described by the CSP and HCPC seems to be considered as an unconditional set of conducts, characteristics, abilities of the individual therapist.
Reflecting on those standards (4.1-4.6), they can be interpreted as personal and professional prerequisites for having PA (independently from the organisational context) rather then a description of PA itself.
But what if the therapist who has all these capabilities (by virtue of their education and by virtue of being an ethical and moral agent), has to comply with certain constraints or treatment protocols (imposed by a senior/team lead, manager or commissioner) which impacts upon their decisions actions and practice? Clearly the therapist has responsibilities and accountabilities towards those agents as well. Such imposed constraints (impacting on the kind and duration of the intervention) may not be negotiable (in the short term) but would pose a dilemma for them, irrespective of whether they believe that their professional autonomy is affected by those constraints or not. For example if they have to meet imposed performance targets they might prioritise the kind of decisions and actions that will enable them to meet those targets, (instead of prioritising the needs of individual patients). Where organisational targets are solely expressed in terms of meeting the needs of individual patients there would be no problem. But where they are not and the therapist does not have the authority to amend or influence those organisational/departmental targets, the dilemma is bound to exist and persist. Hardy (1993)said about such dilemmas that “responsibility without authority is masochism”.
The claim that ‘centrally’ imposed constraints on the kind and duration of physiotherapy interventions are mainly (but not solely) associated with the governance of scarce resources and other political priorities would seem self-evidently true. The point of making this claim is that having the ‘authority to control resources’ (in the managerial and clinical sense) precedes having PA within the organisational context . In other words having PA is contingent on having such authority. Having delegated authority to control the full range of necessary resources does not mean that “we can do what we like”. Quite the opposite, it entails taking on the responsibility to directly negotiate service contracts, and to prioritise and rationalise services within the financial realities associated with those contract.
The perceived relevance of having PA in that sense may only resonate with policy makers if it can be argued (or proven) that delegating such authority tto the physiotherapy profession is a necessary condition for the delivery of cost effective patient care within the contemporary healthcare system in UK. And that such a scenario will positively contribute to meeting organisational priorities.
‘Acting autonomously’ seems subtly different from ‘taking initiative’ and also different from having professional autonomy. We can take the initiative to do something that benefits our patient or colleagues or the service. Such an action may fit within the parameters of standards and expectations and negotiated contracts. Alternatively the initiative taken may not fit within those parameters but is not prohibited and does not incur additional expenditure. The consensus within the literature (philosophy and psychology) seems to be that in order for an individual to ‘take initiatives’ in the world (i.e. exercise their agency) they need to be autonomous as a person. In other words, it is necessary to be autonomous qua person in order to be able to initiate actions. The source of our Professional Autonomy is not our autonomy qua person or even that we have the ability to act autonomously and exercise our agency. It is mainly associated with the level and kind of autonomy we as professionals have been entrusted with by the employing organisation (and society).
It seems that the current definitions of PA (CSP and HCP) take insufficient (if any) account of relevant organisational contexts. Therefore these descriptions of professional autonomy are not enough to help us understand from what source our professional autonomy is derived.