This section discusses the role shift undertaken by the IPCCs within the context of theory that highlights the constructed and continually shifting nature of boundaries between different occupational groups. Findings mainly drawn on are those that throw light on the first objective of the study, that is to describe the characteristics of the IPCC role.
The findings in the previous chapters illustrate that, over time, the IPCCs took on aspects of nursing work. These shifts in who does what in health care are reflected in other empirical studies and in contemporary theory. This theory states that the actual work performed by different occupational groups changes over time in response to a range of factors including ongoing attempts to establish and maintain jurisdiction over high status work, the introduction of new technology, labour supply factors, the development (or demise) of related occupations, organisational factors and government policy (Abbott 1988). Abbott describes how occupations38 are bound to a set of tasks by ties of jurisdiction. However, none of these ties are permanent or absolute, and the processes of work can result in a reconfiguration of who does what. The findings of this study reflect these normal processes.
Occupational groups succeed in establishing a monopoly over higher status work and achieving status as a profession (Larson 1977; Macdonald 1995) by leaving
behind lower status or ‘dirty’ work for other groups to perform (Allen 2001; Hughes 1971). This in turn presents opportunities for other groups to achieve professional status by occupying the vacancy left behind (Abbott 1988). The research literature contains many examples of these shifts in jurisdiction between nursing and other groups (for example, Jones 2003; Read & Graves 1994; Roe, Walsh & Huntington 2001). A shift often focused on is the uptake of medical work by nursing, and this is often theorised as evidence of the quest by nursing to take on higher status work (Allen & Hughes 2002; Salvage & Smith 2000). What is less well researched is the work that nursing discards and more recent empirical work to explore the boundary between the work that registered nurses and health care assistants attempts to address this gap (Allen 2001; Spilsbury 2004; Thornley 1998; Thornley 2004). What, however, was unknown prior to this study was what
happens when a group outside of the jurisdictional control of nurses altogether takes on work from nurses, particularly a group that does not have an equivalent training. These findings help to fill this empirical gap but also indicate that it may not always be the most routine work that is discarded to lower status occupations. The IPCCs took on discharge planning work from nurses. Nursing shortages meant that other nursing work was prioritised. Abbott (1988) notes how increases in the demands made for a particular type of work or decreases in the capacity of an occupation lead to the ‘degradation’ of aspects of that occupation’s work. Professional work can be divided into routine and non-routine elements, with routine work (that is, work of lower status) falling to the lower segments of a professional group (for example, juniors or trainees) or outside of the professional group altogether to ‘paraprofessionals’ (Abbott 1988, p. 125). The passing on of discharge planning suggests a priority order to aspects of nursing work, in which the work of discharge planning is seen as ‘dirty’ or routine enough to be managed by a group without qualifications (Abbott 1988; Hughes 1971). However, the IPCCs took on the discharge planning of the most complex patients while nurses retained the most routine patient discharges.
This finding challenges contemporary theory that it is always the most routine work that is passed on to lower status groups. Abbott’s (1988) theory does not explain why it is that nurses discarded the more complex discharges (presumably
higher status) while holding on to the more routine discharges (presumably lower status). These findings suggest that there may be other factors at play.
While Abbott’s (1988) theory includes an acknowledgement of the impact of external forces on jurisdictional ties, and uses illustrations that include the
influence of central government and trends such as bureaucracy, the theory in this area is weaker. For instance, Abbott illustrates how the organisational context can influence jurisdictional ties but an opportunity is missed to explore what shapes the organisational imperatives that can dictate who does what. The second chapter of this thesis illustrated how increasing intervention by central government is
influencing how health services are shaped and delivered. If, as the theory on new managerialism indicates, central government control is strong, its influence on the goals of individual organisations would seem important to acknowledge in a theory that already acknowledges the strong influence that organisational goals and other external forces can have on the interprofessional system.
Abbott’s (1988) theory, however, is largely devoid of an appreciation of a wider socio-political context. In this study, it may be that it was a managerial agenda that informed nursing opinion as to what work to discard or retain, or, given the passive role taken on by nurses indicated in the findings, that dictated to nurses and IPCCs who was to do what. This study’s findings illustrate the importance of the Trust meeting the goal of acute efficiency that was an early driver of New Labour health policy. The IPCCs’ success in helping to meet this organisational goal, particularly when they took the lead in discharge planning for the most complex patients, could have influenced decision-making about who could best achieve this goal. Or it may be that, in an organisation focused on acute efficiency (that is, a concentration on providing only the physical care an individual needs while acutely ill),
technical, medical work is valued above all else. These values influenced nursing views as to what high status work is. The findings illustrate that the physical care of patients was top of the nursing agenda and perhaps nurses did not reflect on who was doing what in discharge planning, as long as the work was getting done. If either or both of these scenarios is the case, it is evidence of the central government agenda influencing local decisions about who does what. Contextual issues are returned to later in the chapter.
These findings lend support to the theories of a continuous dynamic to occupational jurisdiction that enables lower status occupations to take up the discarded work of higher status occupations. They also, however, make a new contribution to the body of knowledge by challenging contemporary theory that it is always the routine work that is discarded and the non-routine work retained by higher status groups. The findings suggest that factors other than the desire for occupational advancement may influence jurisdictional ties. The next section discusses the findings relating to the impact of and issues arising from this jurisdictional change.