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Table 5 Template analysis

From: Contested professional role boundaries in health care: a systematic review of the literature

Strategy to expand role boundaries Authors year Professions involved Overt or subtle dispute Boundary work strategies observed Outcome/s of dispute observed in study
Diversification Norris 2001 [31] A range of practitioners working with musculo-skeletal pathologies including physiotherapists, orthopaedic surgeons, chiropractors, massage therapists and others Subtle Occupations made claims of their ability to provide superior musculo-skeletal treatment based on concepts including: others being limited (because they lack something), their approach being holistic (where others are too focused) and prevention as part of their practice Although professions somewhat succeeded in distinguishing themselves from others, and in some cases pointing out their advantages, it does not appear as though any professions are effectively limiting the practice of others
Specialisation Martin Currie and Finn 2009 [29] GPs with special interest in genetics (GPSIs) and clinical geneticists Overt GPSIs were eager to extend their skills vertically and practice clinically however geneticists were protective of their professional boundaries. Geneticists argued the indeterminacy of their knowledge, lengthy training and ongoing interaction with a team of experts as their unmitigated advantage over GPSI. GPSIs cited their autonomy as a GP as a strength The highly specialised status of the geneticists was effectively used to limit the ability of GPSIs to practice in a clinical capacity in genetics. Geneticists successfully limited GPSIs from encroaching on their role, in this particular case
Salhani and Coulter 2009 [32] Psychiatric nurses, psychiatrists, occupational therapist, social worker and other allied health professionals and unit managers Overt Significant gains of power were made by psychiatric nurses in a setting which traditionally saw medicine (psychiatrists) in a more powerful position. Psychiatric nurses exercised a number of tactics to gain allies in other allied health professions and managerial support, which enabled them to establish their treatment model which contradicted the psychiatric model Psychiatric nurses were able to not only expand their scope of practice by way of specialisation, they were able to exert their influence and power to achieve a level of autonomy from psychiatry and prevent encroachment from other non-medical professions
Sanders and Harrison 2008 [20] Geriatricians, Cardiologists, GPs and heart failure nurses Subtle The authors identified four prominent discourses that were used by the heart failure care professional groups, to establish their professional legitimacy and emphasise their advantage over the other professions. These were: expertise, competence, organisational efficiency and patient-centredness Overt boundary disputes were not evident. Although reluctance of the medical professions to inter-refer may indirectly limit the involvement of certain professions, the role boundaries of one profession are unaffected by another
Vertical Substitution McIntyre et al. 2012 [30] Medicine (including specialist obstetricians, general practitioners (GPs) and rural doctors), and midwives (nurses) Overt Vertical substitution enabled obstetrics to dominate maternity services. Midwives and their related professional associations birth as a normal, non-medical occurrence. Obstetrics and their professional associations, emphasised the risks associated with childbirth and the importance of a medical professional adopting a senior role in each case Authors concluded that the historically elite position of obstetrics in maternity care is being challenged by not only midwifery, but also by consumers, maternity service managers and even some medical professions
Horizontal substitution Bach, Kessler and Heron 2012 [4] Registered nurses and health care assistants (HCAs) Overt The boundary preservation work of the registered nurses focused on attempts to distinguish themselves from the HCAs and assuming an authoritarian role. Alternatively HCAs emphasised their similarity to nurses and their team-based approach to patient care. HCAs were eager to blur the lines between their role and nursing, where nurses were keen to reinforce the divide Although HCAs are treated as an inferior, marginalized group, nurses appeared unable to prevent them from undertaking traditional nursing work, especially direct patient care activities
  Timmons and Tanner 2004 [25] Theatre Nurse and Operating Department Practitioners (ODPs) Overt Both theatre nurses and ODPs used atrocity stories to illustrate the advantage of their profession over the other. Atrocity stories were categorised into themes: the role of technology; doctor-support versus caring for patients; being patient centred; and the status of Operating Department Practice as a “proper profession” Theatre nurses did not appear to be able to prevent encroachment on, or extend their own role boundaries