Thematic analysis and context explanation
| Themes | Profession in focus | Rival profession | Negotiated/non-negotiated (cooperative or conflictual) | Historical event | Boundary work strategies deployed | Outcomes of boundary-work strategy | Conditions responsible for the outcome |
| Self-regulation or professional exclusivity | Medicine | Non-medical health professions | Non-negotiated | 1960: Establishment of Nigeria Medical Association (NMA) 1963: Establishment of Nigeria Medical Council | Formalising structures of training and credentialing to demarcate boundaries, define jurisdictions and grant professional exclusivity | Knowledge monopoly which provided medicine total control over its work (autonomy), over the work of others (authority) and in the wider health sphere (medical sovereignty) | The advantage of more rapid evolution and development of the medical profession provided an early advantage over other professions Leading to early state patronage, autonomy, and authority over other professions |
| Laboratory scientists | Medical and other non-medical health professions | Non-negotiated | 2004: Establishment of Medical Laboratory Science Council of Nigeria | Enhanced ability to negotiate professional welfare and challenge medicine’s autonomy | |||
| Pharmacy profession | Medical and other non-medical health professions | Non-negotiated | 1992: Establishment of Pharmacy Council of Nigeria | Enhanced ability to negotiate professional welfare and challenge medicine’s autonomy | |||
| Nursing profession | Medical and other non-medical health professions | Non-negotiated | 1947: Establishment of Nursing Council of Nigeria (NCN) | Enhanced ability of nurses to negotiate improved welfare and, in 1979, fought for the recognition of nursing as a profession rather than a support service | |||
| Community health extension workers | Medical and other non-medical health professions | Non-negotiated | 1975: Establishment of the Community Health Worker scheme as part of the Basic Health Service Implementation Scheme 1975–1983 | Professional recognition increased the ability of CHEW to negotiate improved welfare | |||
| Vertical substitution | Nursing | Medicine | Negotiated cooperative | 1971: Encroachment into clinical roles for contraceptive maternity services | Due to increasing popularity and population preference nurses became eager to extend their skills vertically into maternal contraceptive services normally performed by specialist doctors To ward off these threats doctors preserved control through occupational imperialism: the acquisition of high-status roles and skills in maternal contraceptive services while discarding or delegating the less desirable task of IUD insertion to nurses | Role-boundary shifts without upsetting the balance of power. Upward vertical encroachment of nurses into the higher clinical roles of IUD insertion; downward vertical encroachment enabled specialist doctors to dominate maternal services by emphasising the risks associated with IUD insertion and the need to assume a senior role in these cases | Increased need and population demand for contraceptive maternal services. The more powerful profession (medicine) was actively involved in generating evidence, building the capacity of nurses, and was in control of the extent of delegation |
| Nursing | Medicine | Negotiated cooperative | 2014: Nurse-led HIV clinical management | Shortage of doctors in the face of rapid scale-up of HIV care and treatment provided nurses the opportunity to stake a claim for their ability to provide the same quality of care as medical professionals. Doctors acquired higher status roles in HIV management (managing ART resistance, ART-switch, TB/HIV treatment) while delegating routine clinical assessment and granted nurses drug prescribing authority to initiate and maintain HIV treatment in primary care settings only | Although nurses were able to encroach into clinical roles in HIV management there was no significant effect on power-relations as a result **no money** | Policy environment promoting task-shifting due to general health worker shortage Clear policies on roles to be task-shifted to nurses Little conflict in the clinical workspace at the primary care level due to a general lack of doctors operating at that level Doctors were in control of the extent of delegation and still provided clinical oversight in more difficult cases | |
| Laboratory scientists | Medicine (pathologists) | Non-negotiated conflictual | 2013: Landmark legal ruling granting professional autonomy | Significant gains of power were made by laboratory scientists in a setting that traditionally saw medicine (pathologists) in a more powerful position Laboratory scientists exercised several tactics including the use of legal instruments and alliance with other non-medical health professions, which enabled them to limit the control of medicine and establish their autonomy in the clinical-laboratory workspace | Laboratory scientists were able to exert their influence and power to achieve a level of autonomy from medicine (pathologists) and also prevent encroachment from other non-medical healthcare professions | Alliance with other non-medicine health professions The use of legal instruments when other avenues of negotiation had broken down | |
| Community health extension workers | Nurses | Negotiated cooperative/conflictual | 2014: Task Shifting and Task Sharing (TSTS) Policy in Nigeria 2014 | TSTS policy approved in 2014 saw nurses/midwives delegate some tasks in MNCH, HIV, and TB care to CHEWs despite not having more specialised roles themselves to move into Ambiguity in reporting lines in the TSTS policy have also seen CHEWs reject nurses’ supervision and attempt autonomy from nurses | Vertical substitution through the creation of a sub-cadre of health professionals Despite now performing tasks owned originally by nurses, CHEWS appears to be somewhat attempting to distinguish themselves and obtain autonomy from nurses, and it does not appear as though the higher profession (nurses) are effectively able to limit the practice of CHEWS | The more powerful professions (doctors, nurses, etc) were involved and in control of the extent of delegation Increased demand and need for MNCH services | |
| Non-medicine health professions | Medicine | Non-negotiated highly conflictual | 2006: Establishment of Joint Health Sector Union (JOHESU; an alliance of non-medicine health professions) | Allied health professionals were eager to collectively attain autonomy from medicine within the clinical workspace while maintaining their adjacent individual boundaries from encroachment Healthcare management also becomes a contested terrain as allied health professions sought control of organisational resources. Such resources include health sector leadership positions and appointment into specialist consultancy roles, which was a requirement for headship of health management position Boundary preservation work of doctors focused on their holistic knowledge of clinical care as justification for continued leadership of clinical care and healthcare management. In response to the threat from allied health professions, doctors attempted to set up by law the office of Surgeon-General, a peak position in health only occupiable by a doctor Both parties have used strikes and legal instruments to achieve their aims | Some role-boundary and power shifts were achieved within the clinical domain of the contest. Following a court order, the Federal Ministry of Health temporarily appointed nurses to consultancy status. Laboratory scientists also achieved full professional autonomy The medical profession successfully limited the allied health professionals in the management domain of the contest; using the highly specialised status of doctors to ensure continued headship of hospital management and health organisations. All the professions have engaged in professional management activities by introducing management into training curricula to improve competitiveness for management roles | Mutual resentment for medicine arising from the shared experience of medical domination over the years provided fertile grounds for cooperation and collaborative governance among allied health professions than might have been under different conditions | |
| Horizontal substitution | Laboratory scientists | Nurses (and other non-medicine health workers) | Negotiated conflictual | 2011: Decentralised HIV testing | The arrival of newer, simpler and faster rapid diagnostic test kits provided grounds for other health professionals (especially nurses) to encroach into space primarily owned by laboratory scientists Boundary preservation work of the laboratory scientists focused on attempts to use quality control expertise to make claims for continued exclusivity or control over HIV testing | The need for rapid scale-up of HIV testing forced laboratory scientists to give up exclusivity or control over HIV testing Laboratory scientists moved up to higher status tasks in HIV laboratory practice that still required sophisticated technology (eg, viral load testing, early-infant diagnosis, TB testing, resistance testing) | Policy environment to meet increasing demand and need for HIV testing The arrival of new technology (rapid diagnostic tools) causing displacement of laboratory scientists Availability or arrival of technology for higher status tasks provided space for laboratory scientists to move into while giving up some tasks |
| Specialisation | Medicine | Non-medical health professions | Non-negotiated | Establishment of the National Postgraduate Medical College in September 1979 | Formalising and legitimising increased level of training/expertise and membership to a closed subgroup of the medical profession | Enhanced autonomy and authority of medicine over other rapidly evolving health professions Increased professional security, social prestige, and financial rewards | Matured specialist programmes have allowed medicine to maintain dominance despite encroachment by other professions |
| Pharmacy | Creation of specialisation post-graduate institutes | Non negotiated | Establishment of Clinical Pharmacy Programme (Pharm D) Pharmacy Technicians | Expansionary tactic for more direct involvement in clinical patient care Intra-disciplinary conflicts between pharmacists and trained pharmacy technicians; as the latter seeks some form of autonomy of their own | |||
| Diversification | Laboratory scientists | Medicine and other non-medicine health professions | Negotiated conflictual | Control of medical technology diagnostics | The explosion of the medical technology market in Nigeria created an occupational vacancy that was competed for. Using legal instruments, laboratory profession recorded significant and landmark power gains, being awarded the exclusive oversight of sale and use of all medical technology in the country Based on the use of these technologies, laboratory scientists step into the space of providing clinical advice | Significant power shifts, further establishing full autonomy of medical laboratory scientists both in the clinical workspace (autonomy from pathologists) and from the medical profession in general | The influence of medical technology Usage of legal instruments where other avenues for negotiation breaks down |
MNCH, maternal, newborn and child health.