Background

Health care services in the UK, Australia and elsewhere across the Western world are under significant pressure to provide innovative, effective and timely services to an ever growing and ageing population [1,2]. Trends in demographic data suggest that an unprecedented rise in chronic and complex health care conditions will continue to emerge, alongside advancing technology, economic uncertainty and financial restraint, all of which constitute a major challenge for healthcare policy [3,4].

For foot and ankle specialists in Australia and the UK, the prevalence of diabetes is increasing more rapidly than any other chronic health condition, and workforce requirements already exceed current levels of supply [5]. In Australia, there are 1.1 million people currently living with diabetes, with approximately 100,000 new cases diagnosed each year [6]. Diabetes-related complications impact not only the individual, their quality of life and life expectancy, but also place significant burden on an already stretched health care system [6].

In light of these challenges, health policy responses support professional role flexibility and innovation in health care practice, in order to meet population health needs [7,8]. Increasingly there has been a strategic move towards interprofessional practice, with an increased likelihood of role blurring. Interprofessional practice describes a team-based approach to health service provision, hinging upon a willingness to abandon traditional role boundaries and relinquish claims of exclusivity to health care practices and knowledge [9]. This blurring of boundaries in the health care workforce may see different professions taking on practices previously “owned” by others [7] thus shifting the focus from the professions themselves, to better meet the health needs of the service-user [8]. However, uncertainty around role delineations and service funding constraints militate against unproblematic and seamless transitions [10]. Inter-professional disputes involving allied health professions concerned with foot and ankle work, for example, have been well documented but nevertheless remain rare [10-13]. A broader exploration of the strategies, forms and outcomes of healthcare boundary disputes across the healthcare professions is likely to yield deeper insights into the complexities and intricacies of role boundary disputes, and thus better inform future policy decisions on feasible solutions – solutions which may equally apply across the health sector [14].

Social theory also provides insights into the way in which role boundary disputes operate [15-18]. Occupational closure is a widely recognised means of attempting to secure exclusivity, most powerfully via legal and regulatory mechanisms, such as certification and credentialing processes, leading to a “market shelter” [19]. However, strategies to ensure the exclusion of competitors is necessarily threatened by the advent of workforce flexibility models intent on imposing role re-design [20,21]. Most commonly, healthcare role boundary disputes emerge between medicine and other non-medical professions seeking to acquire roles previously exclusive to medicine [15,22-24].

However, relatively few papers address boundary disputes between professions considered to be of equal status [25]. It was therefore important to view the literature across all the healthcare professions, and not confirm the search to studies of disputed medical boundaries alone. The literature review seeks to explore reported boundary disputes, how these came about, what these contests or disputes looked like and what, if any, outcomes resulted from these inter-professional role boundary contests.

Methods

Literature search

Only peer reviewed research articles were considered for inclusion in the literature review. A STARLITE framework was used to guide the search [26]. See Table 1 for STARLITE framework detailing search strategy including terms, databases, inclusions and exclusions.

Table 1 STARLITE framework
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Synthesis and analysis

In synthesising and analysing the findings from the seven papers, a framework analysis akin to template analysis, described by Brooks and King [27] is used. Template analysis is a technique which employs thematic organisation and analysis of data. The data being analysed can be any kind of textual data however interview transcripts are the most common form of data for which this approach is used. The key to this form of analysis is the use of a priori template, or pre-determined code set, to extract, organise and analyse qualitative data.

The pre-determined template used to code and analyse data in this literature review is the framework described by Nancarrow and Borthwick (2005) [8] which relates to the dynamic health care workforce. The authors describe the directions in which workforce boundaries can shift. These directions of role boundary shifts serve as a priori themes in which the papers will be coded.

Diversification is the identification of a new approach to practice that has previously been claimed and “owned” by another profession. It may mean the creation of a new task or it may be performing an existing task with a new method, resulting in professional role expansion. Specialisation is defined by Nancarrow and Borthwick (2005) [8] as “the adoption of an increasing level of expertise in a specific disciplinary area that is adopted by a select group of the profession and legitimised through the use of a specific title, membership to a closed sub-group of the profession, and generally involves specific training”. Specialisation is more successful at post-registration level.

Boundary expansion can be also achieved by role substitution. Substitution see a profession taking on work previously undertaken by another profession and can occur vertically or horizontally. Vertical role substitution refers to the delegation or acquisition of tasks across professional boundaries where one profession is considered to be superior on the hierarchy. The degree to which vertical substitution expands role boundaries is highly dependent on the profession considered to be superior. Boundary expansion can also occur by horizontal substitution, which occurs when a profession considered to be have a similar level of expertise and training as another one, takes on part of their traditional role. For this form of role expansion to be successful roles must be quite flexible to enable other professions to adopt them. Horizontal substitution is thought to be occurring more frequently with the rise in interprofessional education and practice [8].

Results

Initial database searching using the terms in the STARLITE framework, yielded 616 results. See Figure 1 for a pictorial summary showing the location of papers at each stage of the literature search process.

Figure 1
figure 1

PRISMA diagram - pictorial summary showing the location of papers at each stage of the literature search process.

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Studies which focused on contested role boundaries; including the drivers for contestation, evidence of boundary disputes and the means by which professions defended their occupational territory were included. Papers referring to boundary disputes but not focused on them and those looking at intra-professional boundary disputes, were excluded. See STARLITE framework (Table 1) for details of inclusions and exclusions. With only four papers remaining, a citation search of the paper which seemed most relevant [25] was undertaken. This turned up a further three papers; two citing the relevant paper, one cited by its authors. There were seven papers in total included in the literature review and were published between 2001 and 2012.

Quality indicators

The seven selected papers were assessed for quality using the critical appraisal skills programme (CASP) qualitative research checklist [28]. See Table 2.

Table 2 Quality indicators
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All of the included studies used qualitative methodology, which is well-suited to the topic. Table 3 provides an overview of the main characteristics of each of the included papers.

Table 3 Main characteristics of included studies
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The majority of papers focused on the micro-level strategies employed by individual professionals at a local level in order to protect their role boundaries. Macro-level strategies are typically implemented by the professional associations; however the objective - to construct and defend their occupational boundaries - is the same as micro-level. A comparison of the main factors related to the role boundary disputes within the seven papers is presented in Table 4.

Table 4 Features of the role boundary disputes
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Template analysis

Nancarrow and Borthwick’s [8] framework describing the means by which professions can expand their scopes of practice, often into the domain of other existing professions, is used to categorise how each of the boundary disputes came about. See Table 5.

Table 5 Template analysis
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In the only case of diversification as the method used by professions to expand and define their scopes of practice, efforts to distinguish their profession from others did not appear to result in other professions being limited in their practice. There were three cases in this review where specialisation was used by the professions involved to expand their scopes of practice. In two of these cases their efforts to distinguish themselves from other professional groups practicing in the same field did not result in limitation of their practice, however in one case, it did. In this particular case, involving clinical geneticists and GPs with special interest (GPSI) in genetics, there was a hierarchal component involved which was effectively used by the clinical geneticists to limit the practice of GPSI.

There was one case illustrating vertical substitution, implicating professions directly involved in maternity care. This is actually an example of vertical substitution in reverse. Maternity care was once undertaken by lay women however medicine commandeered the practice and medicalised it to the point where it became the medical speciality known as obstetrics [8]. In McIntyre et al. [30] study, they found that some progress had been made on the part of midwifery to regain some of the power assumed by obstetrics in maternity care services.

There were two examples of horizontal substitution as the means by which professional groups expanded or defined their practice. Both of these examples were new professions whose core work was considered part of nursing’s traditional work domain. Both of the relatively new professions sought to highlight their similarities to, and in one case, their advantage over nursing in their particular work domain. While nurses sought to distinguish themselves and cite their superior capabilities in both cases, this did not appear to hamper the ability of the newer professions in encroaching on nursing’s traditional occupational territory.

Discussion

Specific role boundary changes in allied health professions such as podiatry, have been captured in papers deploying social theory and these give some flavour of the type and form of boundary shifts and disputes that have emerged to date [10,33-35]. However, a broader sweep of literature across the health sector gives a clearer picture of the complex relationships giving rise to boundary disputes which may impact on other professions concerned with foot and ankle work.

It is clear that disputes between the professions take various forms, some more overt than others. However, the events preceding role boundary contests appear to be similar and revealing. In each case selected there was either a shortage of qualified staff to undertake a particular healthcare role, or an underpinning governmental modernization agenda driving role change to alternative providers, the latter often involving a community or consumer drive, prompting the genesis of a new profession in some cases and the extension of scope of practice in others. Both sought to establish themselves and their role boundaries by way of diversification, specialisation, vertical or horizontal substitution, often into the domain of an existing profession [8]. In each instance, where the profession concerned enjoyed established roles, it sought to protect them when threatened, with the response more vociferous when the boundary was perceived to be more vulnerable.

Some of the selected studies focused on those strategies employed by the encroaching profession, others on those defending boundaries. In each case, the common theme derived from the use of discourse to discredit the competitor profession, either on the basis of their approach to clinical care or their skills or competence. There were several references made to macro-level strategies adopted by some professional associations, where emphasis was placed on highlighting the advantages of one profession over a neighbouring one [31]. However, in all cases the micro-level strategies employed by professionals were at the forefront of the discussion.

In cases where the focus was on resisting encroachment on an existing occupation’s domain, both success and failure were demonstrated. Unlike much of the theory of medical dominance, in which medical specialities would, by virtue of their social and cultural authority, be more successful at protecting boundaries and resisting change, evidence in the studies selected suggest a change, based on aligning demands with policy direction. Salhani and Coulter [32], for example, found in their study of nurses working within a multidisciplinary team in a mood disorder unit, that nurses were successful in securing autonomy from psychiatry, a move which enabled them to overrule psychiatrists intervention, whilst also resisting encroachment from other professions within the unit; a success based upon an overarching policy need for workforce flexibility.

In a study looking at the boundary work of both registered nurses and health care assistants (HCAs) in two NHS Trusts, Bach et al. [4] found that the nurses enthusiastically defended their unique ability to provide hands-on, patient-centred, holistic care. In this study, the nursing profession was portrayed as one seeking to expand their role boundaries into the domain of medicine whilst also preserving their current boundaries, thus preventing usurpation by HCAs – what Witz referred to as ‘dual closure’ [36]. However, the nurses were also keen to shed the “dirty work”, which proved to be a source of frustration for the HCAs, which thwarted their own professionalising ambitions [37].

In each of the five studies involving the nursing profession, references to “patient-centred” and “holistic care” were made, clearly as a form of professional rhetoric designed to support their bid for legitimacy in claiming role exclusivity, or at least primacy. In Timmons and Tanner’s [25] study the overt boundary dispute between theatre nurses and operating department practitioners (ODPs), nurse claims to a broad caring and holistic role gave them a perceived advantage over the ODPs, particularly in relation to gender claims, with nurses often referring to the insensitive masculine approach to patient care exhibited by the ODPs.

Similar to Timmons and Tanner’s [25] study, podiatrists utilise horizontal substitution as a means to expand their scope of practice into the diabetes educator domain. This type of role boundary expansion has been shown to lead to hotly contested role boundary disputes, between two professions of equal standing, yet waged across a field in which one occupies the ‘established’ role and the other the ‘usurper’ role [17].

Methodological limitations of the literature review

Whilst taking a systematic approach to this literature review confers a degree of objectivity, there is a risk that some relevant literature may have been omitted, such as grey literature, or that not all the relevant literature has been included. Literature which did not constitute research, nor actually focus on a disputed boundary was excluded, meaning that some material on role boundary disputes in health care was not considered. Equally, some databases which were not within the health field may have contained relevant papers shedding light on boundary disputes relevant to healthcare, such as PsycINFO or SocINDEX.

Generalisability of the findings is made difficult by the fact that only seven papers met the inclusion criteria and the use of qualitative methodologies rendered this problematic. With relatively small sample sizes, including some single case studies, application of the analysis adapted to broader health care settings was not considered appropriate. Comparing and contrasting the finding of the papers was made difficult by the fact the various studies used different themes to code and analyse their data.

Conclusion

This literature review has explored cases of contested role boundaries, demonstrating that there are many different kinds of boundary disputes among the health professions, each with varying emphases and outcomes. The means by which professions attempt or succeed in extending their role boundaries - diversification, specialisation, vertical substitution or horizontal substitution - does not appear to directly influence whether or not a profession is able to extend its role boundaries where these are contested. However it is clear that horizontal substitution appears to invoke more overt role boundary disputes, with little likelihood of a negotiated resolution.

Persistent health professional role boundary disputes may impede role flexibility and are likely to undermine the development of the health care workforce in line with policy objectives aimed at workforce redesign and longer term service sustainability in the face of demographic change. Trends in health policy continue to support professional role boundary flexibility and innovation in service delivery, and the recent exemplar of extensions in non-medical prescribing illustrates the impact of role redesign on health service provision and highlights specific directions in policy implementation, governance frameworks and competency structures to support their implementation. Role boundary disputes may delay, but are unlikely to prevent, full implementation of policy and practice developments.

This literature review supports the widely accepted notion that the health care division of labour is based not on immovable professional boundaries, but on dynamic shifts influenced by forces such as the health policy agenda, and may not always favour the traditionally most powerful professions. It may signal a reduction in professional power and autonomy by some of the professions, each of which is increasingly vulnerable to the vagaries of the healthcare market, and the fiscal restraints imposed on healthcare budgets.