Reconfiguring organisational patterns of power: An ethnography on the functioning of academic credentials in Chile

Introduction

While the literature often speaks of technical processes surrounding the way occupations relate with one another, there has been little discussion about the self-ascribed identity of occupational groups. In analysing relations from the perspective of the authority of expert knowledge and the cultural identity of professional groups, this article arises from a study of social stratification among healthcare professions in Chile. The article reports on the reconfiguration of relational patterns with a focus on the interaction between nurses and doctors and recent changes in structures of power, and on how those patterns have been intimately intertwined with class differences and ethnic identity so as to make up a rather predictable organisational structuring.

Nursing in Chile has gained an excellent reputation among healthcare professionals and is now held in high regard within the larger Latin American nursing community (Ayala et al., 2014; Jara et al., 2009). Beginning in the early twentieth century, its continuous process of academisation has grown in length, sophistication and diversity, developing an ever-increasing and complex system of academic credentials. Such a system, although often brought into the discussion of education planning, has not been the object of analysis with regard to whether it has led to a redistribution of ‘usable resources and powers’ (Bourdieu, 1984) among professions, and whether such credentials have served to question established ideologies and structures that legitimise traditional patterns of power in organisations.

While the central debate about the professional development and academisation of nursing is well documented in the literature, research using fresh empirical data to help advance theoretical arguments is scarce and pays only lip service to the political influence of professional power building. Among international publications that have dealt with the subject, the overall conclusion is that non-medical professions negotiate power, positions and responsibilities in a context of new organisational models (Boyce, 2006; Nugus et al., 2010; Reeves et al., 2009), and yet the studies focus mostly on power negotiation in clinical contexts. While Boyce (2006) investigated the shaping of roles in a healthcare reform process, her focus was the ‘allied’ professions.

Nursing credentials in Chile have been analysed in isolation of changes in power structures; the overall concerns are the academic aspects – the rapid proliferation and content of degree programmes, and the national standards of quality for these programmes (Behn et al., 2002; Castellano et al., 2011; Jofré and Paravic, 2007; Rivas and Osorio, 2005). Despite three major works (Jara et al., 2009; Núñez, 2012; Urra, 2004) that have devoted some attention to the linkage between the two concepts – academic credentials and power – one cannot yet speak of an actual discursive shift in the scholarly debate. Urra (2004), on the one hand, points to the lack of regulation on the paths to nursing training and on requirements for specialised practice after degree studies, while Jara et al. (2009) and Núñez (2012), on the other hand, note the historical lack of recognition of postgraduate qualifications in the labour market and discuss some underlying ideologies for the continuous transformation of the nursing curriculum.

The latter is a concern that merits particular attention and is central to our analysis. Not only are academic credentials a rough indicator of a certain understanding in a given field and a ‘passport’ for the trained workforce to access the employment market and clients’ respect and trust; in the deepest sense, credentials are also devices for controlling occupations and acquiring better salaries and privileged positions, and therefore are a central element of modern social stratification (Collins, 1979, 1990; Rivera, 2011). Likewise, credentials symbolise cultural capital – status, standing and power – and therefore credential holders become not only members of a knowledgeable segment of society but also of professional groups driven by particular ideologies. Analysing credentials in fact helps to understand the ecological relations between professions, as in their representational capacity credentials may modify those relations.

Relationships and relational patterns in organisations can develop from cultural schemes, institutions as well as ideologies. In this article, we look at what ideologies lie beneath current patterns of power in nursing, what institutions have been used as legitimation devices, and how these ideologies and institutions have shaped ongoing processes in the making of contemporary relational patterns. Behind such concerns lies a central question: Do academic credentials make power shifts possible, and what credentials make nursing thrive?

Drawing on ethnographic data, these concepts are addressed in five major sections connecting patterns of relationships and cultural identity of professional groups: (1) the established patterns of power in Chilean society and in organisations; (2) the struggle for nursing validation in a current scenario of reforms; (3) the construction of partnership with bodies that become allies; (4) the structuring of credentials in nursing; and (5) the attitudes arising from context and nurse training. The article concludes by inviting readers to bring into the debate the use of academic credentials in shaping ideologies and powers in the making of contemporary working relations in Chile and elsewhere.

Background

The field experience: Setting and methods

This study is a part of a larger research project focusing on the social construction of nursing as a profession in Chile, resulting in an exploration of actual power relations at work, as opposed to the analysis of rhetorical constructions. Consequently, the ethnographic approach was chosen as the most suitable means to analyse the patterns of power in workplace settings. The field research spanned the period 2010–2011, and comprised reflexive engagement with 40 participants – nursing and non-nursing – joining in their day-to-day activities, writing fieldnotes, interviewing, having casual encounters, and developing an interpretive process of analysis and questioning.

The setting of our study, a 500-bed university hospital, was chosen owing to its reputation as a high quality institution, reflecting at least partly quality care and nurses’ performance (Aiken et al., 2011; Kutney-Lee et al., 2009; Lake et al., 2012) and the reputation of Chilean nursing as a leading example in Latin America. Studying the nursing profession in a setting whose standing is meaningful at a national and continental level was central in our methodology, as it was anticipated this would produce data pertinent to the understanding of nurses’ autonomy.

Access to the institution and the participants was granted by both the head nurse and the hospital director after obtaining the approval of the relevant ethics committee. To meet the ethical requirement that consent must be informed, each interviewee was given an explanation of the research project and then asked to discuss his/her experiences as a healthcare provider. They were told that our aim was not to scrutinise care quality but to gain an understanding of healthcare from a sociological point of view, with emphasis on nursing activities.

Alongside the observation process we interviewed a wide variety of informants, ranging from junior nurses to senior nurses, including clinical nurses, nursing leaders, managers, doctors and academics. In the course of the interviews, we explored several topics arising from the literature on professional development. We also compiled abundant organisational documentation.

The observation aimed to cover two theoretically diverging notions of quality care in nursing, namely technically expert nursing, such as that provided in the intensive care unit and the emergency room, and caring-oriented nursing, such as that provided within the chemotherapy unit and the general hospital ward.

In order to enhance the reliability of the data gathering process a second observer, who was an anthropologist, unfamiliar with hospital work, was engaged. This also minimised the risk that the main observer, who was a sociologist with a nursing background, might overlook naturalised hospital practices while recording fieldnotes. The two observers gathered data independently and compared their impressions and perspectives together periodically. Minor discrepancies about emerging patterns, particularly concerning nurses’ autonomy, were resolved after discussion and further engagement with the literature.

Since our interest was to study the construction of patterns and political behaviour in nursing, it was important to consider the development of processes and concepts. Accordingly, the Grounded Theory approach (Charmaz, 2006; Corbin and Strauss, 2008) provided the most appropriate means for conceptual integration. An initial open coding allowed us to face the data with an open-minded attitude – fieldnotes and interview transcripts were read and reread as they were constructed, and then contrasted with institutional documents, in a constant process of comparison; this enabled a deep understanding of the data from the field. The codes were later refined more selectively insofar as a pattern began to form, which we eventually connected to our conceptual frame to construct a meaningful answer to the question of relational dynamics.

Striving to validate a domestic metier

Healthcare in Chile has undergone a major restructuring as a result of a state reform begun in the 1980s, resulting in hospital reorganisation in the mid-2000s. The reform aimed at expanding healthcare coverage and improving the response of public services, leading to the technification of management and organisational accountability, across levels of service and across professions. Contemporary hospitals now face market constraints in response to pressures for survival strategies; increasing managerial responsibilities have been transferred to them, with the eventual aim of further self-direction. Such change has meant a highly specialised bureaucratic structure, namely a growing number of high-ranking positions and coordination bodies, and a number of goal-oriented control mechanisms. Once a medically centred domain, healthcare now witnesses the rise of hospital management; it is in this new scenario that nurses have seen a potential niche to become detached from medical domination. While this project proved to be appealing to the nursing community, questions arise about how the nature of nursing might differ outside the vertical, medically dominated conception of healthcare, therefore drawing on a notion other than that of a helping occupation. If this has mobilised a significant transition in nursing, where is nursing heading to? What are the ideologies underpinning the nursing project? Could it possibly hinder the healthcare reform process? How will hospital governability be still conceivable without medical dominance? Passages of interview, documents and fieldnotes serve as an example:

Nurses begin to feel uncomfortable with the bystander role. (Nurse representative)

There is no such a thing as a divide between curing and taking care of the patient, as nurses intend to demonstrate. The reality is that doctors know best their patients’ situation and lead the team accordingly. (Chilean Medical Association, 2013)

‘The thing is’, the nurse says to me while doing a bedside round, ‘the law is on our side. We’re recognised as the ones who take care of the patients, and that’s now our legal responsibility.’ As I became increasingly accepted as an observer, I noticed that in one way or another all nurses referred to the law when talking about their profession, as being fully aware of the new scenario they’re in. (Fieldnotes)

In charting the profession’s course, nurses have considered a carefully constructed plan basically aimed at validating their centrality as a connecting piece in the organisation and coordination of services (Ayala et al., 2014), in other words, their domestic metier. This domestic centrality thus becomes of political significance, as medical authority has meant not only technical prominence but also male dominance. As a result, depicting and assigning vocabulary to the nursing organising activity in part represented the legitimisation of a ‘female’ particular type of wisdom translated into a particular set of abilities, modifying in the process the self-interpretation and aspiration of nurses:

This move in nursing has, then, challenged socially constructed barriers, including ethnic background, gender relations and social class – in other words, nurses’ mobility defies a long-standing social stratification tied to the latifundio structuring. The Chilean Medical Association (2013) perceived this move as a threat, and sought to delegitimise the stance taken by nursing, as if reaching high-ranking posts would violate the social order of the organisations as much as the cultural expectations of what it means to be a nurse and what the cultural-identity behaviour should be. Such a reaction would eventually transfer to the public sphere, depicting an image of nurses as a non-conforming group, whose detachment would allegedly have rather damaging repercussions on the provision of care services and on doctors’, taken-for-granted, leadership.

In sum, the reform process has opened a unique window of opportunities for nurses, intertwining their collective interests with the interest of public health, a process that raises tensions between their new roles and the social order of hospitals.

Allies: Call and response

We have argued that validating its organisational role has been a crucial move in nursing in its attempt to become a freer occupation. This achievement has been aided by a number of forces and alliances. While the nursing project has been strongly opposed by medical leaders, this reform has opened up a rare scenario in the political history of nursing.

With the State as the grand ally in this process, its rather distant relation to nursing has now turned into a tacit pact of cooperation greatly rewarding for the profession: validation leads to legitimacy, legitimacy leads to rights. Among the state entities with importance for nursing’s political endeavour, two have been decisive in the current scenario: the Ministry of Health and the Legislative Body, one wanting administrative expertise and the other granting authority and privileges in return. A passage from an on-site interview shows how this process has been perceived by nurses:

We have reached a number of landmarks in such a short time. First, making our management of care official by law and as a responsibility exclusive to nurses. Then an agreement with the government on implementing high posts for nursing offices in every hospital as a requirement for accreditation. And now this new law regulating nursing education. Yes, we have done many important things. (Junior nurse)

In developing this pact, nurses would indisputably consolidate substantive growth while learning how to bargain, intertwining, on the one hand, the best interests of public health, and, on the other hand, their own collective interests. In other words, this is a result of nurses’ awareness of their political significance and the use of power accordingly. The medical community has historically endeavoured to acquire public office in the Chilean health bureaucracy (Molina, 2005), but nurses now enjoy a political renaissance, to some extent outranking doctors with regard to key positions and beginning to look at themselves more confidently as a political group pursuing a balance of power.

A second ally of nursing is the National Federation of Public Healthcare Professionals, an association of non-medical university-trained workers joining forces for improved working and living conditions. In general terms, nurses’ achievements are applauded by this association, and what cements such partnership is the shared aspiration of not fully established professions, those outside elite-ascendant groups, striving for social mobility and symbolic rewards:

This Federation rejects the Medical Association’s claim on the new nursing offices of management of care … management expertise cannot be ascribed to one single type of title; non-medical professionals have long performed those roles. (National Federation of Public Healthcare Professionals, 2013)

We also identified the formation of a third alliance, with patients, nurturing a relationship that induces a sense of loyalty towards the profession, engenders legitimation and establishes a conscious awareness of its powers. Discourses of ethical integrity have arisen over the last few years, which highlight that nursing’s ethical mandate is to defend the best interests of its patients, to advocate for their rights and to act on their behalf. There are genuine reasons to uphold such a mandate, and this has equally served to forge an implicit alliance, one that has been intelligently used by nurses in the public sphere under the slogan: ‘I take care of you’ (Chilean Nurses Association, 2012: 39, emphasis in the original). This passage from the field diary illustrates this further:

Difficult to miss, I spotted a recent framed photo on the nurse’s desk, one portraying a group of uniformed nurses marching in the street, protesting and chanting while carrying a massive banner with the slogan ‘I take care of you’ and a nursing icon printed on it. Next to the picture was a bundle of leaflets – same slogan and icon – awaiting to be given to discharging patients, and a bag of lapel pins for nurses to use. (Fieldnotes)

In the main, these three alliances set a new code of symbolic capital, which surfaces in the form of a shift in the use of nurses’ collective powers. Whether this shift results from the acquisition of further credentials in nursing is unclear at this point, though nurses could significantly shape rules of organisational governance as newer disciplinary developments can be used to wield power.

The structuring of nursing credentials

In this section we discuss changes in the structuring of credentials in nursing at both pre-registration and postgraduate level. Nursing credentialing has not only been influenced by the healthcare reform but also through a major educational reform, both constituents of a larger reorganisation of the State embracing dynamics of a laissez-faire economy.

In the 1980s, Chile’s traditional, public-oriented universities were affected by budgetary restrictions and new managerial approaches. Funding devoted to university education dropped from over 2.11% of GDP in 1972 to 0.47% in 1988 (Lehmann, 1990) and to 0.40% in 1996 (Bernasconi, 2015), a process intertwined with the deregulation and increase of higher institutional fees for both public and private universities, and a self-funding/credit policy. As occurred likewise in several other countries in the region, higher education institutions came to operate as ‘university companies’ (Cancino, 2010; Sotelo, 2000) within an education and training industry (Donoso, 2009). Accordingly, universities aimed at building their brands and publicity to seduce their targets, which resulted in an open race for credentials for those outside the educated elite. Even considering the fact that 70% of employees in Chile earn less than US$8500 per year and that non-elite study programmes may cost between US$3330 and US$7930 per year (Ministry of Education of Chile, 2013), the vast majority of the subjects studied at university level have positive returns on families’ investment (Meller, 2010), with nursing ranking among the top five (Ministry of Education of Chile, 2013).

The content and nature of the nursing curriculum have also changed, extending the course length up to five years. The latest modifications point to a more theoretically integrated programme, the introduction of a strong managerial approach to healthcare, and methodologies for database search and scientific research applied to nursing. And apparently this change also has other purposes, as surfaced during an interview:

We were told that getting the degree of Licenciado by increasing the number of years of training would allow us to pursue other degree programmes if we so wish, but also to acquire new knowledge to get better positions once graduated. Not many study postgraduate degrees but I feel that training was a good thing for our management role, perhaps we do need to learn more, I don’t deny that, but at least it gave us more confidence. (Clinical nurse)

Started in 2005, a debate on a law for university-based education as the sole route of entry to the practice of nursing has recently reached its apogee. Although detractors of the law presented more significant and compelling arguments than those advocating in favour of a nursing ‘universitisation’ (Chamber of Deputies, 2014), the legislation was passed by the vast majority of deputies. This result, so ideologically convenient for the nursing profession, may well reflect the greater abilities of nursing representatives involved in the lobbying activity, given also the awareness of nursing’s current position in the market, without which negotiation would have been inconceivable. In the political arena there must be agreement on the values to be exchanged between the parties, along with views on a range of acceptable concessions that equally protect particular interests. More importantly, a consciousness is necessary of the various machinations that each side could eventually implement in a given case scenario.

On the other hand, the demand for postgraduate nursing education has also changed, though at the level of non-degree practical training (diplomados) – noticeably that aimed at management skills – highlighting that nurses’ core occupational activity might still remain a rather applied field. The evolution of these particular types of credentials is best explained in terms of the social processes and mechanisms for expansion of professional jurisdictions (Abbott, 2010), those areas of work under one’s control – in our case here, the managerial detachment of nurses from the curative aspects of the medical practice, therefore from dependency. Similarly, requirements in the job market change over time, demanding more complex skills. Such is the case in which nursing, drawing on the notion of ‘management of care’, has placed administration and leadership at the core of the nursing professional project. Such differentiation, as relevant as it is on socio-political grounds, may be understood with reference to the concept of ‘social closure’ (Abbott, 1988; Evetts, 2013; Larson, 1977; Reeves et al., 2010) – professions develop market-oriented schemes, exclusionary mechanisms to gain monopoly control of an area of work, assuring self-interests in terms of power, salary and status, so as to thwart the interests of competing occupations. In this light, closure, as opposed to openness, draws attention to the differences between related professions, with the notion of ‘ownership’ of knowledge and expertise (Collins, 1979; DiMaggio, 1982; Heller and Wilpert, 1981; Larson, 1977) amalgamating the acquisition of legitimisation and authority.

Postgraduate degree programmes, however, have not necessarily been equally sought after (Jofré and Paravic, 2007). Collins’s (1979: 192) view on credentialing illuminates this apparent lack of interest: ‘education is part of a system of cultural stratification … the reason most students are in school is that they (or their parents on their behalf) want a decent job’; therefore their interests are not necessarily those of nursing academics, who find in the discipline a way to satisfy their own intellectual appetites. The employment market for master and doctorate holders in nursing remains fairly limited, as these degrees do not seem to be regarded by employers as a valuable contribution to nurses’ skills. During the interviews, we uncovered a general agreement explaining why credentials of this type remain undervalued:

The problem of nursing postgrad schools is that they’re disconnected to the practice and that there is a mismatch with organisations’ requirements, as they need a nurse ‘to do’, not to overthink things. (Manager nurse)

A nurse is a nurse, with or without postgrad schooling. (Hospital manager)

These degrees are, rather, used for mentoring new faculty nurses for the limited number of academic positions; additionally, nursing education is job-oriented and therefore nursing scholars often must combine their intellectual interests with technical teaching. Suffice it to say that this combination usually represents hardship and stalemate, especially in proposing and managing large research projects, and acquiring a researcher identity: a research career in nursing might then begin and end with a dissertation, as explained by one scholar nurse:

Lack of time has been for ages the argued reason – ‘nurses don’t have time to do research’. Equally, here at the university, nursing scholars have long argued the same. It is my personal belief though that even postgraduate nurses lack confidence to do research autonomously, and even to imagine themselves dealing with complex research projects and large budgets. (Senior lecturer)

Whereas the marketable value of postgraduate credentials is quite restricted, there is a sense in which nursing postgraduate schools have triggered a stronger identification of nurses with the nursing discipline. Until the 1960s, most nursing scholars in Chile had no postgraduate credentials; training expanded into specialities that mirrored the medical specialities (Jara et al., 2009) in ways that fragmented the nursing thinking into the practical aspects of the profession and those values embedded in the paradigm of health and illness. It was in the 1980s when some nursing schools began to organise master programmes and in the 1990s doctorate programmes, though their impact remains to be seen. Nevertheless, it is believed that they may signify an important influence in the rise of a more critical thinking among nurses, counterbalancing old, tired currents of thought, those relying on values such as selflessness and abnegation as the driving force of the nurse identity. This new image in fact contrasts nurses’ traditional cultural identity and challenges the organizational ideologies we have discussed. However, these new credentials also seem to be in conflict with doctors’ interests, for that identification has led to increased industrial action among nurses and, notably, to the detachment of some nursing schools from medical faculties.

Generally, theses changes in the credentialing system have not only consolidated the control of nurses’ knowledge base, but also reinforced both the validation of nurses’ new roles and their alliance with the State.

Changing attitudes

Having reviewed the structures, strategies and processes that lie beneath the making of nursing credentials, it is necessary to answer the main topic of concern, that of whether this machinery has served as a means of interrogating old-fashioned patterns of power.

With the Medical Association actively perpetuating a fear of destabilisation, the major nursing political project – which would allow nurses to become hospital directors – came to a rather abrupt end in 2004, an annus horribilis for the nursing community, when the few brand new director nurses who had only recently taken office were obliged to forfeit their posts, with no consideration of their merits. As one of our interviewees stated:

It was all over the press. We all perceived that as a hit below the belt; we didn’t really know those colleagues personally, but we felt so much empathy for them, they represented the end of a long, long struggle of nurses to get rid of doctors’ yoke. It somewhat revived the memory of old strains with doctors and there was some tension in the air. For them, it was just distressing that someone with a rather ‘housekeeping role’ could get the highest position in the hierarchy and be at the helm. (Senior nurse)

This, again, reflects an old pattern of working relations in hospitals, as explained by a nurse and a doctor:

Some doctors behaved like ‘awful landlords’ and were in fact referred to as such, ‘like bosses on a plot of land’. It wasn’t uncommon that some of them would come up the stairs and, as stepping into the ward, they would shout their head off: ‘Where is the nurse?! Nurse!’ almost as if they were calling their personal servants. (Senior nurse)

That’s undeniable. It used to happen. Some colleagues abused their position time and time again, I know. They played the despot over the nurses. The junior doctors now learn that professionalism and despotism cannot possibly flourish together; the one has its roots in our best reasoning; the other grows out of our worst moods. (Senior doctor)

Were the perceived failures of the nurses a consequence of attempting to be a leader in a male-dominated domain? It would appear to be partly so. Healthcare has a long-standing convention of male doctors sitting on hospital boards of management, particularly those building upon their political networks. In addition, hospitals are usually named after former director doctors, which, as we traced this practice back, became a pattern of homage surrounding the medical patriarchy.

There is a sense, however, in which gender differences cannot be the sole explanation for this conflict. In 2011, after an open call for applications, it was a nurse who beat all the competition and became the director of one of the largest and most symbolic hospitals in Santiago de Chile. Then, in 2012, a nurse gained the post of director in another metropolitan hospital. These landmarks were regarded by most nurses as both the pinnacle of a nurse’s professional career and an inarguable demonstration of their political latitude. Should we consider these events as a turning point in the historical power asymmetries in nursing? It would be unjustifiably deterministic to assume that the reach and impact of nursing credentials are the sole force behind nursing’s collective ability, ignoring that other types of credentials may equally contribute, and that individual candidacies rely heavily on personal trajectories and interests. For indeed the two director nurses both obtained further training after graduation, though not postgraduate degrees in nursing, and both are male-nurses. However decisive gender may have been, the figure of a nurse sitting at the top of the hospital board could become a sign that belies recurrent assumptions on nurses’ capabilities and nurses’ former cultural identity. Changes in perceptions and assumptions eventually surface in face-to-face contact between nurses and doctors, as this observational piece captures:

… repeatedly sitting in the nurses’ office, I have come to the understanding that nurses will no longer stand at attention upon the unexpected presence of a doctor. Instead of having a ‘sir, yes sir’ reaction, nurses keep talking to me making doctors wait for a few seconds, like they’re thinking to themselves ‘back off, I’m busy’. (Fieldnotes)

Despite this political transformation, our observations uncovered what may be considered a subtle incongruity between discourses which nurses have taken on and the actual relations at a technical level:

Why don’t we augment the fluid rate for this patient? – as if the doctor wished to disguise his order in the shape of a request. The nurse, at the other end of the desk, conceals the fact that she knows she’s been given an order with a tone of agreement.

Yes! – said the nurse. Nurse gets up and goes to the bedside, which seemed blurred from a distance. After a few beeps she comes back and looks at me saying with steady voice: – You see? This job is very dynamic – as if to say, this is another task to feel proud of. The doctor goes on checking other patients’ records. (Fieldnotes)

This picture echoed earlier signs we had encountered regarding the interaction between nurses and doctors to the extent that it became a predictable type of working relations: nurses reporting to doctors rather than making their own decisions; doctors dictating to nurses rather than implementing a task themselves. Relational patterns have changed, and yet the working logic seems to remain a counteracting burden for nurses. It can be argued that this logic only affects the clinical dimension of nursing, though this is its core occupational activity which takes up a considerable part of a nurse’s day.

All things considered, it becomes evident that there is a change in the way nurses experiment with and exert authority and approach the political sphere. This change seems to be influenced in a tangential manner by the emergence of nursing postgraduate programmes promoting new ideologies, a result facilitated by the transformation of the curriculum and the acquisition of extra-nursing skills. Rather than a complete failure, their annus horribilis was perhaps beneficial after all and may well have turned into what nurses were prepared for: the time for a more open attitude towards power.

Conclusions

As explained in recent studies, new processes have reshaped working relations between professional groups, and we have studied the nursing profession in the context of a healthcare reform accordingly. The focus of our study was the use of academic credentials to wield power and how the credentialing shift towards managerialism has served to question relational patterns embedding cultural stratification in organisations.

Overall, the literature suggests the potential impact of credentials on nurses’ positioning, though lacks explanation as to how exactly credentials are used to wield power. In this ethnographically informed article, we have explored what ideologies, structures and processes have mediated the development of nursing credentialing, and particularly the extent to which credentials may serve as a means of interrogating those established patterns of power which have historically undermined the nursing profession’s course. Regarded as the leading example of nursing development in Latin America, the setting of the study represented a meaningful case for gaining insights into nursing’s professional autonomy based on changes in cultural identity. By considering credentials as the means of social stratification in healthcare, we have looked into the transformations that the country has witnessed, with particular attention to the consistency between the traits of the cultural setting and the traits of patterned working relations explored during a process of state reform.

Established with colonisation, organisational patterns reflect to a large extent repressive means to maintain an authoritarian rule concerning class, gender and ethnic stratification. The state reform has led nurses – often described as a group lacking desire to exercise power – to adopt a more open attitude towards power.

At a political level, there are signs that represent an important rupture with the past. First, by focusing on external social dynamics produced by the state reform, it becomes evident how operationally induced political changes have made an implicit pact possible, which, it was foreseen, would garner a greater position for the nurse in the doctor–nurse power relation. Second, the state reform has promoted the rise of hospital management and with it a policy of individual candidacies for high-ranking posts, disregarding family ties and elite professional titles. Third, the materialist, technical component of nursing credentials has moved gradually into a more symbolic, cultural component (Wright, 1998), which, alongside a modification of the curriculum, has greatly shaped socio-political processes concerning upward mobility and cultural expectations, a process facilitated also by strategic alliances. Fourth, a project of social closure has successfully precluded the interests of other professions, such as midwives, in gaining monopoly, rights and privileges, and eventually produced a new code of power for nurses.

While these changes signify advances at the macro level, observations at the micro level suggest a persistence of asymmetries. Although there may exist a discontinuity of old patterns of relations, and notwithstanding discourses of autonomy fuelling a mass mobilisation of the nursing labour force, nurses have not been liberated in the clinical domain. Even so, we could not expect a completely new beginning despite the manifest ongoing process of renewal.

While some authors have contended that nurses’ take-up of power may result from a process of liberation from oppression and linear hierarchies (Daiski, 2004; Roberts, 2000), it would seem that this also represents a crucial dilemma for the fully established professions, due to processes of democratisation in organisations and society at large. This argument becomes increasingly plausible in light of the transformation of the nursing curriculum, which has espoused larger social reforms and opening up organisations for wider representativeness.

Finally, increasing representativeness in Chile bodes well for the non-elite professions collectively and will continue to challenge dominant positions more openly, leading to shift in power and ultimately forging a significant transition towards more commensurate relations. Irrespective of how consolidated the credential system may be, the perspective of credentialing as a social process offers a unique window of opportunity for further scrutiny of historical patterns of power shaping relations in the country.