Table 3

Thematic analysis and context explanation

ThemesProfession in focusRival professionNegotiated/non-negotiated
(cooperative or conflictual)
Historical eventBoundary work strategies deployedOutcomes of boundary-work strategyConditions responsible for the outcome
Self-regulation or
professional exclusivity
MedicineNon-medical health professionsNon-negotiated1960: 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 exclusivityKnowledge 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 scientistsMedical and other non-medical health professionsNon-negotiated2004: Establishment of Medical Laboratory Science Council of NigeriaEnhanced ability to negotiate professional welfare and challenge medicine’s autonomy
Pharmacy professionMedical and other non-medical health professionsNon-negotiated1992: Establishment of Pharmacy Council of NigeriaEnhanced ability to negotiate professional welfare and challenge medicine’s autonomy
Nursing professionMedical and other non-medical health professionsNon-negotiated1947: 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 workersMedical and other non-medical health professionsNon-negotiated1975: Establishment of the Community Health Worker scheme as part of the Basic Health Service Implementation Scheme 1975–1983Professional recognition increased the ability of CHEW to negotiate improved welfare
Vertical substitutionNursingMedicineNegotiated cooperative1971: Encroachment into clinical roles for contraceptive maternity servicesDue 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 casesIncreased 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
NursingMedicineNegotiated cooperative2014: Nurse-led HIV clinical managementShortage 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 scientistsMedicine (pathologists)Non-negotiated conflictual2013: Landmark legal ruling granting professional autonomySignificant 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 professionsAlliance with other non-medicine health professions
The use of legal instruments when other avenues of negotiation had broken down
Community health extension workersNursesNegotiated cooperative/conflictual2014: Task Shifting and Task Sharing (TSTS) Policy in Nigeria 2014TSTS 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 professionsMedicineNon-negotiated highly conflictual2006: 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 substitutionLaboratory scientistsNurses (and other non-medicine health workers)Negotiated conflictual2011: Decentralised HIV testingThe 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
SpecialisationMedicineNon-medical health professionsNon-negotiatedEstablishment of the National Postgraduate Medical College in September 1979Formalising and legitimising increased level of training/expertise and membership to a closed subgroup of the medical professionEnhanced autonomy and authority of medicine over other rapidly evolving health professions Increased professional security, social prestige, and financial rewardsMatured specialist programmes have allowed medicine to maintain dominance despite encroachment by other professions
PharmacyCreation of specialisation post-graduate institutesNon negotiatedEstablishment 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
DiversificationLaboratory scientistsMedicine and other non-medicine health professionsNegotiated conflictualControl of medical technology diagnosticsThe 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 generalThe influence of medical technology
Usage of legal instruments where other avenues for negotiation breaks down
  • MNCH, maternal, newborn and child health.