Were you surprised to read that physiotherapists, podiatrists, and dietitians will be able to administer COVID vaccines? Have you ever wondered how professional role boundaries are determined? Who decides what the different professions can and cannot do in terms of their clinical practice? Or how decisions about role boundaries and scope of practice are made? What does it take to shift or reposition the boundaries between professions?
In this article, I will describe just one of the many sociological theories that explain how professional role boundaries are constructed, reinforced, and maintained, and then ultimately, renegotiated and changed. I will also highlight the opportunities allied health have to reshape their roles during the current COVID-19 pandemic.
A brief look back in history
The health professions have each been socially constructed and shaped by social, political, and other external influences.
Medicine was the first profession to become officially recognised in the Western World and was underwritten by legislation in the mid-nineteenth century. This set the scene for the professions that came after and continues to shape the role boundaries and scopes of practice of the non-medical health professions. This includes the more established allied health professions (e.g., physiotherapy and speech pathology) and the contemporary ones (e.g., music therapy, genetic counseling).
There have been advancements made by all the non-medical professions over time, but these have not been easily won. Here are some of the approaches the professions have taken to protect their turf and creep onto that of others.
What makes an occupation a profession?
The professions are all based on occupations or jobs, but not all occupations are considered professions. So what is special about the professions?
- They are perceived to hold special or higher-level knowledge
- Their knowledge is held in high social or cultural esteem
- They have a degree of autonomy or authority in their field
- They have access to opportunities to gain higher status and recognition
It’s not surprising that the occupations are eager to achieve professional status. To do this, occupational groups must establish and maintain their unique sphere or scope of practice. This rarely occurs without resistance and so there are some tried and true strategies used to achieve, maintain, and advance professional status.
Social closure and professional role boundaries
In the late 1960s, the concept of social closure was introduced by Weber. Social closure (or professional closure) explains how the professions legitimize themselves, their role boundaries, and scopes of practice within a competitive field of other players (professions).
Professional closure involves two key tactics
- Exclusionary closure, to keep outsiders out
- Usurpatory closure, to make gains on the boundaries or tasks of other, superior professions
A third, ambitious tactic is known as dual closure. This is when a profession works to expand its role boundaries by simultaneously protecting its existing boundaries all the while creeping into the domain of another profession.
Professional closure can be achieved using two key strategies
- Credentialist strategies to formalise professional education and credentialing processes and in turn restrict access to professional knowledge
- Legislative strategies to reinforce a task domain using regulation
Let’s look at the former strategy first. Formal education is a hallmark feature of the professions. It makes complete sense that the health professions need theoretical knowledge to develop the practical skills they require to do their jobs. That said, it takes more than knowledge to take exclusive ownership over task domains.
An example of this is non-medical prescribing. Podiatrists, pharmacists, nurses, and other non-medical professions learning about pharmacokinetics in their undergraduate degrees but do not graduate with the authority to prescribe medicines.
Professions also have systems of credentialing or accreditation set up to ensure that only the individuals that meet the criteria of the accrediting body are endorsed. Accreditation systems can be set up for individual professions (e.g., dietitians) or for post-professional, interdisciplinary groups (e.g., diabetes educators).
The latter strategy is the most powerful. By securing legislation to support and reinforce task domains (e.g., prescribing medicines), professions can really stake their claim. This makes it very difficult for other professions to creep into their domain.
Take the example of podiatry prescribing. Podiatry endured a protracted battle to secure the right to prescribe some schedule IV medicines. Regulatory approval was finally passed in the State of Victoria in 2009. In Australia, the Podiatry Board has established two prescribing pathways for podiatrists to become endorsed. This includes both education and credentialing (credentialist strategy) and the regulation (legislative strategy) underwrites this.
What else shapes professional role boundaries?
I must first point out that Weber’s social closure is just one of the sociological theories that explains how the professions and their role boundaries come to be. You can find out about some others including Bourdieu’s social world, social capital and habitus, Foucault’s power-knowledge concept, and Fournier’s boundary work, in this paper.
Politics and social factors, such as changing demographics, also play a key role in shaping professional role boundaries. Crises such as workforce shortages often stimulate the expansion or shifting of role boundaries. To return to the example of podiatry and prescribing, during the 1950s, podiatrists (known as chiropodists at the time) serving in the medical corps of the British Army would routinely perform minor surgeries. In the face of staunch resistance from the medical profession, this provided leverage for the profession to lobby for and eventually secure legislative approval for podiatrists to administer local anaesthetic. The establishment of podiatrist surgery then followed.
The current pandemic is an example of a combination of social factors and an extreme crisis of the health workforce. Low and behold, numerous professions that may not have even had ambitions to become endorsed prescribers, or administer medications, have been given the right with little evidence of resistance.
This highlights the way politics can interfere with sensible approaches to developing a flexible workforce and optimising scopes of practice.
What can allied health learn from the pandemic and use it to shape their professional role boundaries?
We have seen many examples of allied health stepping up to fill gaps in healthcare systems created by increasing cases of COVID-19. For example, increased physiotherapy presence in the acute setting including the intensive care unit. Community-based allied health professionals (e.g., social workers and occupational therapists) supporting their clients’ mental health needs during prolonged lockdowns and other sources of distress during the pandemic.
Allied health plays a key role in the COVID-19 response, particularly by keeping people out of hospital. Although allied health represents a diverse range of individual disciplines, we are, on the whole nimble, flexible, and ready to step up.
As the pandemic continues, allied health will have more opportunities to blur, reshape and expand its role boundaries and sphere of practice. This will ensure allied health is used optimally and to its full scope.
Professional role boundaries are shaped by multiple social and political factors. The professions must work to establish, maintain and expand their roles in the face of interprofessional competition and resistance. Under extreme circumstances, re-negotiation of role boundaries can occur with little (or no) resistance.
We would love to hear from you about your experiences or ideas about healthcare professional role boundaries and how these have shifted during COVID-19. Please comment below or like and follow us on Facebook.