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

Across the Western world, demographic changes have led to healthcare policy trends in the direction of role flexibility, challenging established role boundaries and professional hierarchies. Population ageing is known to be associated with a rise in prevalence of chronic illnesses which, coupled with a reducing workforce, now places much greater demands on healthcare provision. Role flexibility within the health professions has been identified as one of the key innovative practice developments which may mitigate the effects of these demographic changes and help to ensure a sustainable health provision into the future. However, it is clear that policy drives to encourage and enable greater role flexibility among the health professions may also lead to professional resistance and inter-professional role boundary disputes. In the foot and ankle arena, this has been evident in areas such as podiatric surgery, podiatrist prescribing and extended practice in diabetes care, but it is far from unique to podiatry. MethodsA systematic review of the literature identifying examples of disputed role boundaries in health professions was undertaken, utilising the STARLITE framework and adopting a focus on the specific characteristics and outcomes of boundary disputes. Synthesis of the data was undertaken via template analysis, employing a thematic organisation and structure. ResultsThe review highlights the range of role boundary disputes across the health professions, and a commonality of events preceding each dispute. It was notable that relatively few disputes were resolved through recourse to legal or regulatory mandates. ConclusionsWhilst there are a number of different strategies underpinning boundary disputes, some common characteristics can be identified and related to existing theory. Importantly, horizontal substitution invokes more overt role boundary disputes than other forms, with less resolution, and with clear implications for professions working within the foot and ankle arena. <br/

Linkage to chromosome 2q32.2-q33.3 in familial serrated neoplasia (Jass syndrome)

Causative genetic variants have to date been identified for only a small proportion of familial colorectal cancer (CRC). While conditions such as Familial Adenomatous Polyposis and Lynch syndrome have well defined genetic causes, the search for variants underlying the remainder of familial CRC is plagued by genetic heterogeneity. The recent identification of families with a heritable predisposition to malignancies arising through the serrated pathway (familial serrated neoplasia or Jass syndrome) provides an opportunity to study a subset of familial CRC in which heterogeneity may be greatly reduced. A genome-wide linkage screen was performed on a large family displaying a dominantly-inherited predisposition to serrated neoplasia genotyped using the Affymetrix GeneChip Human Mapping 10 K SNP Array. Parametric and nonparametric analyses were performed and resulting regions of interest, as well as previously reported CRC susceptibility loci at 3q22, 7q31 and 9q22, were followed up by finemapping in 10 serrated neoplasia families. Genome-wide linkage analysis revealed regions of interest at 2p25.2-p25.1, 2q24.3-q37.1 and 8p21.2-q12.1. Finemapping linkage and haplotype analyses identified 2q32.2-q33.3 as the region most likely to harbour linkage, with heterogeneity logarithm of the odds (HLOD) 2.09 and nonparametric linkage (NPL) score 2.36 (P = 0.004). Five primary candidate genes (CFLAR, CASP10, CASP8, FZD7 and BMPR2) were sequenced and no segregating variants identified. There was no evidence of linkage to previously reported loci on chromosomes 3, 7 and 9

Health workforce reform: dynamic shifts in the division of labour and the implications for interprofessional education and practice

Reform of the healthcare workforce has become a central component of Government health policy initiatives across many of the Anglophone nations in recent years (Willis, 1983; Nancarrow and Borthwick, 2005; Allsop, 2006; Coburn, 2006). Innovative steps to ensure a healthcare workforce that is 'fit for purpose' are necessary to successfully address a looming crisis in healthcare provision (Boyce, 2008; Cameron and Masterson, 2003; Sibbald, Shen et al., 2004). In this chapter we explore health workforce reform from the perspective of the sociology of the professions and the inherent difficulties that the jurisdictional, boundary and competitive positions that underpin the notion of profession posits for implementing authentic interprofessional education and practice. By examining key features of the international workforce reform agenda together with the motivations of professions that are revealed from a sociological analysis, we show that the division of labour in healthcare is in a state of intense and dynamic change. These changes create a new challenge for interprofessional education and practice through an increased complexity of the health workforce arising from shifting boundaries, new roles and new types of workers

Assisting role redesign: a qualitative evaluation of the implementation of a podiatry assistant role to a community health setting utilising a traineeship approach

Increasing demands for podiatry combined with workforce shortages due to attrition, part-time working practices and rural healthcare shortages means that in some geographical areas in Australia there are insufficient professionals to meet service demand. Although podiatry assistants have been introduced to help relieve workforce shortages there has been little evaluation of their impact on patient, staff and/or service outcomes. This research explores the processes and outcomes of a 'trainee' approach to introducing a podiatry assistant (PA) role to a community setting in the Australian Capital Territory (ACT) Government Health Service Directorate. Method A qualitative methodology was employed involving interviews and focus groups with service managers, qualified practitioners, the assistant, service users and consumer representatives. Perspectives of the implementation process; the traineeship approach; the underlying mechanisms that help or hinder the implementation process; and the perceived impact of the role were explored. Data were analysed using the Richie and Spencer Framework approach. Results Although the impact of the PA role had not been measured at the time of the evaluation, the implementation of the PA traineeship was considered a success in terms of enabling the transfer of a basic foot-care service from nursing back to podiatry; releasing the Enrolled Nurses (ENs) from foot-care duties; an increase in the number of treatments delivered by the podiatry service; and high levels of stakeholder satisfaction with the role. It was perceived that the transfer of the basic foot-care role from nursing to podiatry through the use of a PA impacted con communication and feedback loops between the PA and the podiatry service; the nursing-podiatry relationship; clinical governance around the foot-care service; and continuity of care for clients through the podiatry service. The traineeship was considered successful in terms of producing a PA whose skills were shaped by and directly met the needs of the practitioners with whom they worked. However, the resource intensiveness of the traineeship model was acknowledged by most who participated in the programme. Conclusions This research has demonstrated that the implementation of a PA using a traineeship approach requires good coordination and communication with a number of agencies and staff and substantial resources to support training and supervision. There are added benefits of the new role to the podiatry service in terms of regaining control over podiatric services which was perceived to improve clinical governance and patient pathways

A comparative study of allied health workforce issues in Australia and the UK

Background: Workforce planning and development typically proceeds at the level of government or its agencies. Recent shifts in workforce planning techniques are stressing a greater focus on integrated inter-professional or service-focused approaches together with attempts to critically appraise the types of roles and expertise needed for the workforce of the future (Davies 2003). Lack of knowledge about the allied health professions has been consistently identified as an impediment to progressing workforce reform in these professions (Boyce 2004). In this paper we outline the main issues identified by senior profession managers and clinicians. By comparing issues identified by professionals in both countries, we are able to evaluate the impacts of allied health policies on the allied health workforce in two different policy contexts. Methods: This study involves a survey administered at a multidisciplinary allied health conference setting in the UK (n=38) and Australia (n=123) in which participants were asked to respond to a series of open questions about key issues and barriers to workforce change. Results: Data is analysed independently for each country using thematic analysis on NVIVO software before being compared to assess the extent to which identified issues and barriers were rated of similar importance. Australian’s rated ‘professional tribes” and status and hierarchy highly as key issues. UK respondents rated explicit Department of Health policy initiatives and funding issues highly. Respondents from both countries highlighted several issues as shared concerns in allied health: recruitment and retention issues, changing roles, lack of involvement in policy development and a lack of research capacity. Conclusions: Despite differences in organisational, political and policy contexts a significant number of key issues and barriers to workforce management and change were identified as shared concerns

Defining and identifying common elements of and contextual influences on the roles of support workers in health and social care : a thematic analysis of the literature.

Rationale, aims and objectives: Support workers are the largest single group of staff involved in the delivery of health and social care in the UK; however, their roles are heterogeneous and are influenced by several contextual factors. The aim of this study was to elucidate the contribution of the elements and context of work undertaken by support workers in health and social care. Methods: Thematic review of the literature 2005/2006, updated in 2008. Results: A total of 134 papers were included in the review, from which we identified four domains of work and four core roles of support workers. The four domains of support worker work are direct care, indirect care, administration and facilitation. The four 'core' attributes of support worker roles were being a helper/enabler, a companion, a facilitator and a monitor. The more 'technical' components of support worker roles are then shaped by contextual factors such as staffing levels and the delegation processes. Conclusion: Despite the heterogeneity of support worker roles, there are some uniting 'generic' features, which may form some or all of the role of these practitioners. Contextual factors influence the specific technical aspects of the support role, accounting in part for their heterogeneous role

Place, policy and practitioners: on rehabilitation, independence and the therapeutic landscape in the changing geography of care provision to older people in the United Kingdom

A growing body of literature in geography and other social sciences considers the role of place in the provision of healthcare. Authors have focused on various aspects of place and care, with particular interests emerging around the role of the psychological, social and cultural aspects of place in care provision. As healthcare stretches increasingly beyond the traditional four walls of the hospital, so questions of the role of place in practices of care become ever more pertinent. In this paper, we examine the relationship between place and practice in the care and rehabilitation of older people across a range of settings, using qualitative material obtained from interviews and focus groups with nursing, care and rehabilitation staff working in hospitals, clients’ homes and other sites. By analysing their testimony on the characteristics of different settings, the aspects of place which facilitate or inhibit rehabilitation and the ways in which place mediates and is mediated by social interaction, we consider how various dimensions of place relate to the power-inscribed relationships between service users, informal carers and professionals as they negotiate the goals of the rehabilitation process. We seek to demonstrate how the physical, psychological and social meanings of place and the social processes engendered by the rehabilitation encounter interact to produce landscapes that are more or less therapeutic, considering in particular the structuring role of state policy and formal healthcare provision in this dynamic

Evaluation of a system of monitoring allied health service provision, quality and outcomes

Allied health professionals provide a diverserange of patient care. However funders and purchasers of alliedhealth services have few mechanisms for defining theinterventions carried out by allied health providers; for definingepisodic care; or for monitoring the quality and outcomes ofallied health provider interventions. As a result, third partyfunders tend to allocate allied health services by establishing aceiling on the number of appointments allowed, or “cappingcare” regardless of the condition or patient need. This paperreports on the effect of the monitoring systems by a third partyfunder to introduce more patient centred funding models. Aim:To evaluate a system of monitoring allied health serviceprovision, quality and outcomes. Method: A large third partyfunder piloted the introduction of a comprehensive care planningtool to investigate the potential for post-payment monitoring ofservice quality. Results: Practitioner perceptions of providerquality were quite different from what was measured andaudited. The heterogeneity of allied health services means that nostandardised classification system of interventions is appropriatefor service benchmarking. There were large variations in serviceprovision, within and between practitioners. Conclusions:Ongoing monitoring should include easily auditable measures,such as occasions of service mapped against broad indicators oftype of appointment. There is a need for ongoing systems ofquality improvement to ensure the quality of patient care isoptimised