Creating “Risky” New Roles in Healthcare: Identities,Boundary-Making,and Skilling Under Rationalization and Consumer Demand

Abstract

Healthcare is experiencing two countervailing pressures: to increase efficiency and be more responsive to consumer demands. Healthcare organizations often create new work arrangements, including “lay healthcare” roles, to respond to these pressures. Using longitudinal qualitative data, this article analyzes how one set of new lay healthcare workers attempted to construct a workplace identity, sell their value to existing professional workers, and navigate the precarious conditions of the new role. The authors find that workers in these new roles faced immense challenges stemming from their positions as “risk absorbers,” which ultimately harmed workers and reduced the efficacy of the new role.

Keywords

teamwork new roles healthcare identity upskilling risk

Healthcare is facing immense challenges to meet the needs of patients under increasingly fragmented and rationalized conditions. Changing technologies, consumer demands, and shifts in the funding environment make it essential that healthcare organizations change how they operate (Avgar et al., 2020; Timmermans, 2020; Vogus et al., 2020). Simultaneously, as an institution, medicine is slow, inflexible, and unlikely to change in large-scale ways (Micelotta et al., 2017; Powell, 2016; Scott et al., 2000). The end result is changes in the organization of healthcare work, in hopes of discovering new ways to improve care and efficiency (Berwick et al., 2008; Scott et al., 2000). However, organizational innovation is risky (Hage, 1998/2018; Khessina et al., 2018).

This article examines the experiences of one set of low-status healthcare workers as they navigate an innovative staffing model that uses lay healthcare workers to fill gaps in care coordination and tend to patients as whole persons. Called “care guides,” these workers were used to respond to patient needs and improve efficiency through moving low-skill work to lay people, which allows highly paid, skilled professionals to “work at the top of their license” (Russell-Babin & Wurmser, 2016). The creation of any new healthcare role can upset the existing balances of power and jurisdictions of the healthcare workforce (Kellogg, 2014; van de Ruit & Bosk, 2021), potentially producing personal and professional risk for the workers in these roles. Our study examines how this risk is unevenly absorbed by workers.

Using data from individual and group interviews with care guides, we find that workers in these new roles explicitly worked together to create a sense of value through boundary-making between themselves and professional workers, but that professional healthcare workers (with licenses and credentials) expressed hesitation and resistance toward this boundary work, reinscribing their own professional boundaries. Additionally, lay healthcare workers did not feel adequately protected by team managers, which at times created a stressful and toxic work environment for all. Ultimately, resistance from others, lack of managerial support, and the inflexibility of the organizational structures made the work of lay healthcare workers “risky” – and lay healthcare workers disproportionately absorbed the risk of the organizational innovation. We argue that although the creation of this new role may have had benefits for meeting efficiency and consumer demands, ultimately it was not sustainable within the larger organizational context.

Understanding lay healthcare workers’ experiences of this risky work has implications for the sociology of work, even beyond healthcare settings. Our article speaks to issues of workplace innovation and the creation of new roles meant to respond to efficiency concerns and increasing consumer demands. These experiences are especially relevant for sociological understandings of deskilling, boundary work, role jurisdictions, and risk within hierarchical, bureaucratic organizations, no matter the industry.

Healthcare Environment and Consumer Demands

Healthcare organizations are highly bureaucratic, professionalized, and increasingly rationalized, often making healthcare work inflexible and resistant to change (Light, 2010; Ritzer & Walczak, 1988; Vogus et al., 2020). Additionally, healthcare organizations have complex divisions of labor representing workers from the highest to lowest levels of credentialing, working alongside one another (Allen & Pilnick, 2005; VanHeuvelen, 2020). These workers are interdependent, and while extant research often focuses on the dominance of physicians (Broom, 2006; Light, 2007; Manners, 2017), scholars show a variety of intersections between differing sets of medical workers, who must find ways to coordinate their work (Mitchell & Boyle, 2021; Paradis et al., 2014). Coordinating between multiple groups of medical workers, especially during times of efficiency concerns, affects workers’ tacit and skill-based knowledge practices (VanHeuvelen, 2020), which has led to some claims that healthcare work is “intensifying” in demands (Granter et al., 2019). This intensification makes changes to the workplace difficult, but also increasingly necessary.

Simultaneous to changes in work arrangements, consumer expectations of healthcare services are also changing. Consumer demand has been one of the main drivers of change in medicine over the past several decades (Conrad, 2005; Timmermans, 2020). Studies of consumer demand and new work arrangements have largely focused on personalized services, including personal trainers (George, 2008), health coaches (Murphy, 2014), life coaches (George, 2013), lifestyle managers (Sherman, 2011), and personal concierges (Sherman, 2010). In each of these examples, macro-level changes produced demands for consumer-oriented services; workers taking on these new consumer-oriented roles attempted to construct an identity for the new type of work. Though important, these studies focus on services designed to tailor to the needs of the wealthy, and while they may have a health-related component, none are embedded in the healthcare environment. As a result, little is known about new consumer-oriented roles in healthcare, a substantially more bureaucratic and professionalized system in which change is difficult (Conrad, 2005; Schwartz, 2018).

Examining attempts to innovate on work practices reveals underlying contradictions within the workplace, especially in terms of how workers, management, and consumers relate to one another (Leidner, 1993; Vogus et al., 2020). Scholarship on service work brings attention to how consumers matter in service workplaces. Healthcare workplaces have two characteristics that make them a unique form of service work. First, in many healthcare settings, the relationships between the workers and the customers (care recipients) are longer-term relationships with a high degree of intimacy and emotional attachments (Cottingham & Erickson, 2020; Lopez, 2006; Vogus et al., 2020). Research on the “service triangle” between workers, customers, and management often centers on more transient encounters, finding that there are several different configurations of power within those encounters (Lopez, 2010; Subramanian & Suquet, 2018). In caring work, the long-term connections between workers and care recipients may shift the power dynamic to produce resistance against management, especially if management is seen to stand in the way of meaningful connections (Brown & Korczynski, 2010; DiCicco-Bloom & DiCicco-Bloom, 2019; Dodson & Zincavage, 2007; Vermeerbergen et al., 2021).

Second, as organizations attempt to create new ways of working that respond to consumer needs, frontline workers are most likely to absorb the costs of this innovation (van de Ruit & Bosk, 2021). However, studies of new roles in healthcare workplaces have largely focused on how professional and paraprofessional workers handle this risk (Kellogg, 2014). The experiences of low-status, non-professional workers is not emphasized, even as they may especially suffer the harms of risky work (VanHeuvelen & Grace, 2020). These two characteristics of healthcare work make it a strong case for building on service triangle literatures.

Theorizing Lay Healthcare Workers

A growing number of healthcare innovations use lay healthcare workers to offset rising healthcare costs (Gale et al., 2018; O'Brien et al., 2009; Singh & Sachs, 2013). Healthcare delivery systems use these low-status, non-clinical workers to provide a wide range of health services, including offering health advice and assistance, tracking a patient’s health status, and advocating for an improvement to a patient’s delivery of services (May et al., 2003; Ro et al., 2003). Additionally, they often work as part of a multidisciplinary team aimed at delivering health services at hard-to-reach communities (Kash et al., 2007). Because terminology can vary – lay health workers, community health workers, community health aides, and navigators are just some of the terms applied to this position – there is no official count of the number of these workers in the United States. Lay healthcare workers in our study were unique in that they were part of a new intervention within a large health system, and they were expected to help create the new role. While these workers were new to this project, the use of lay healthcare workers was growing in this organization and across all healthcare (Vogus et al., 2020).

Lay healthcare workers must work within medicine’s existing professional hierarchy. Professional work is defined by specialized knowledge, control over entry into the profession, and ownership of a set of tasks (Abbott, 1988; Light, 2010; Nancarrow & Borthwick, 2005). Within medicine, physicians have specialized knowledge over physiological processes, diseases, and illness; participate in professional associations that set standards of practice and educational/licensing requirements; and, have jurisdiction over tasks that involve treating or healing the body (Freidson, 1988; Manners, 2017). Physicians also define who is not able to do this work—anyone who is not a trained, licensed physician. The work of defending these jurisdictions is often studied in situations where the work of physicians and nurses intersect (Allen, 2000; Norris, 2001; Timmons & Tanner, 2004). Our study of lay healthcare workers complements this research by examining how a new role affects jurisdictions for a diverse set of medical workers.

The use of lay healthcare workers also raises questions about deskilling in medicine. Since Braverman’s (1974/1998) groundbreaking work on deskilling and exploitation of workers, scholars have documented how changes in technology affect the division of labor and workers’ experiences (Smith, 1994). There is debate about the extent to which current work arrangements are deskilling, with some scholars arguing that we are actually seeing an increase in skill expectations, or upskilling (Cappelli, 1993; Gallie, 1991; Heisig, 2009; Leigh & Gifford, 1999). Studies of deskilling and upskilling often focus on manufacturing, but these same pressures also affect healthcare work. Larger changes to the organization of healthcare work include elements of both deskilling and upskilling (Carey, 2007; Peng et al., 2018). For example, improved technology may increase technical knowledge and skill, but also creates new modes of managerial control (Carey, 2007). Manager control may reduce opportunities for skilled work, while new technologies demand new skill development.

Another trend toward deskilling may come from offloading of the lowest level relational work of caring onto lay healthcare workers. Deskilling is already common in nursing and care work segments of healthcare, and is part of a larger trend to make healthcare more rational (Ritzer & Walczak, 1988). Non-clinical healthcare assistants, for example, often work with and supplement the tasks of nurses, which risks undermining the professionalization of nursing while routinizing care work (Daykin & Clarke, 2000). Some have referred to the deskilling of medicine as the “proletarianization” of the profession, causing doctors to lose authority and influence (McKinlay & Arches, 1985). Scholars posit that competition from non-physician providers and changes to the organization of care are some of the drivers of this deskilling (McKinlay & Marceau, 2002). As other forms of low wage work become increasingly common as a cost-saving strategy, these changes may signal a larger shift to the organization of medicine and the status of professionals within it (McKinlay & Marceau, 2008).

Whereas the offloading of work onto lay healthcare workers could be seen as deskilling in medicine, often the use of these lay healthcare workers is premised on creating opportunities for professional workers to increase their skills, or upskill. Called “working at the top of their license” (Russell-Babin & Wurmser, 2016), this organization of work seeks to create more time for clinicians to complete skilled labor rather lower skilled tasks, providing more value to the organization and ostensibly higher quality care to patients (Findlay et al., 2017). However, when relational work is moved to lay healthcare workers, skilled professionals may resist how these changes reduce meaningful time with their patients (Cain et al., 2019; Cain et al., 2017). This reorganization of relational work creates change over time—not only in terms of knowledge and technical skills, but also moral, empathy-based skills especially needed in care work (Vallor, 2015). Because lay healthcare workers are expected to complete low skilled work and allow for the upskilling of professional workers, the use of lay healthcare workers presents a complex case for understanding the dynamics of deskilling and upskilling.

Workers’ Experiences of New Roles

Though innovation in healthcare requires the participation of workers (Lee et al., 2020), previous studies examining attempts to improve care and lower costs rarely consider workers’ experiences of these attempts (Rees & Gauld, 2017).To establish their new lay healthcare role within medicine, which is hierarchically organized and focused on strong role definitions, lay healthcare workers must explicitly define what they do and how they work with other providers (Michalec & Hafferty, 2015). Collaboration between lay and professional healthcare providers is a complex process that includes interactional, organizational, and system factors (Paradis et al., 2014; San Martín-Rodríguez et al., 2005; Zetka, 2008). In some situations, the creation of a new role can create a useful buffer between established professional groups (Kellogg, 2014), but in other situations, lack of clarity about the new role can create confusion and jurisdictional violations (Abbott, 1988; Lindblad et al., 2010). For work between lay healthcare workers and professionals to be successful, they have to coordinate, loosening some of the boundaries between roles while still respecting professional jurisdictions.

Workers’ identities are central to these negotiations of roles. For instance, if workers can balance their professional identities with their commitments to the team, they will be better positioned to be innovative (Mitchell & Boyle, 2021). But, those identities are uncertain, challenging to create, and subject to resistance and reframing from others (Murphy, 2014). Workers in new roles may feel the need to differentiate themselves from other types of workers (Fayard et al., 2017). In the case of healthcare work, they may do this through meaningful interactions with care recipients (Lopez, 2006), which may verify workers’ sense of self and self-value (Cain et al., 2019). Workers may also construct an identity by creating symbolic boundaries – that is, conceptual distinctions to categorize people and practices – between themselves and others (Hendley, 2016; Lamont & Molnár, 2002). Workers in new roles must identify the logics of the setting and then deploy them in ways readable by other workers (Cain, 2019; Goodrick et al., 2011), but it is not immediately clear how the logics work for the new role.

As the use of lay healthcare workers in medicine grows, studies like this one are important for understanding the future of medicine. Simultaneously, our study illustrates larger tensions in the field of service work, especially as workplaces try to cut costs and improve customer satisfaction. It is likely that these tensions produce both deskilling and upskilling of workers, but we currently know little about how workplace innovations are experienced by low-status workers. In this article, we ask: How do new lay healthcare workers experience pressures to be efficient, while also oriented to consumer needs? How is the risk of innovation distributed across workers? What are the organizational and field implications of their experiences?

Data and Methods

Setting and Participants

Our study is part of a longitudinal intervention study that took place within a large healthcare system. The intervention was designed by organizational leaders and university partners, and used lay healthcare workers to serve patients. Called “care guides,” these lay healthcare workers served as an additional support for patients with serious illness and worked with a team of professionals to try to improve quality of life. Unsure exactly how this experimental role would function, initially the care guide role was designed broadly; the hiring process focused primarily on bringing in people with communication skills and personal caregiving experiences. Care guides were expected to learn about the needs, preferences, and goals of patients and their family members, and then use that knowledge to help tailor care.

At the time of data collection, care guides worked within an interdisciplinary team, called the Care Group (pseudonym), which focused on supporting patients and their families. The size of the team changed throughout the project (from 5 to 17), and included nurses, social workers, a marriage and family therapist, chaplain, and pharmacist. The non-care guide team members were all licensed clinical professionals, so we distinguish these roles from care guides as “clinically-trained team members” or simply “clinicians” for clarity. The Care Group was supervised by a management team of two clinicians and three project investigators. Team managers initially gave limited direction and allowed the Care Group to discover and define roles as they worked with patients and families. Toward the end of the project, team managers directed the creation and implementation of a much more structured approach that included specific tasks for different domains of patients’ lives.

Our article analyzes data from 2013 to 2015, during the first two years of this intervention using care guides within a care team. The authors of this paper were employed by the health system to help study the intervention. We worked closely with team managers to define the scope of our research, but were a separate entity and our status as researchers was known by all participants. We regularly communicated with Care Group team members to discuss the goals of the research and to hear their responses to our emerging findings. Because we, as researchers, and the team members worked within the same project, we were peers in many ways. However, because we valued the confidentiality and comfort of participants, we limited our time in common meetings with Care Group members. We set firm guidelines about when and how we would share findings, and access to raw data was limited to only the authors of this manuscript. Additionally, we checked all quoted passages with the speaker (or group) to ensure that participants did not feel identified or vulnerable. Participants had an opportunity to raise issues, correct statements, and help provide context for the findings we present here. All aspects of this research have been approved by the necessary institutional review boards.

Data Collection and Analysis

We used two types of interview data for this study. First, we conducted two rounds of semi-structured individual interviews (18 months apart) with Care Group team members, including care guides and clinicians. In both rounds of semi-structured interviews, we asked team members to define their roles and reflect on what was working and not working in their daily work lives. In total, 13 team members participated in the first round of interviews (out of 14 possible); 9 participated in the second round (out of 12 possible). Because some of the team members were interviewed in both waves, our data include 22 interviews with 16 unique team members (out of 19 possible team members). Each interview lasted between 45 and 60 minutes.

Second, during 2014–2015 we conducted 31 group interviews with team members. Thirteen group interviews included only care guides; five included only clinicians; and, thirteen included the entire Care Group team. The composition of the team changed over time, but all team members participated in at least one group interview. During group interviews, we asked team members to discuss things that were working well and things that were emerging as problems. Group interviews lasted between 60 and 90 minutes. Between the individual and group interviews, we reached a level of saturation that permits analysis of care guides’ identity creation, other providers’ reactions to these identity claims, and ultimately, the consequences for the care guides, the team, and the attempt at innovation.

In this paper, we combined semi-structured individual and group interview data. All individual and group interviews were audio recorded and transcribed. We used an abductive process of analysis that used extant literature to guide our theorizing to surprising or theoretically puzzling patterns, balancing deductive and inductive approaches (Timmermans & Tavory, 2012). The first author read through all transcripts to identify segments that included discussions of the creation of the care guide role and collaboration with other healthcare providers. All authors then read through the retained text to generate a list of themes related to care guides’ attempts to define their role and work with others. Codes included role boundary work, identity claims, and work with other healthcare workers. We discussed themes, defined terms, and designated quotes that best exemplified the themes. Disagreements were discussed and reconciled in person. We then linked the codes to one another by examining the larger work context, including conflict with other healthcare workers, conflict with management, and consequences for the workers. We used NVIVO software to manage the coding process.

Because we were interested in understanding how care guides navigated this innovative new role, we analyzed all data from the perspective of care guides. Throughout the study period, eleven care guides worked on this team. We emphasize the voices of all eleven care guides in the text and discuss their perception of how others reacted to them. Practically, this means that most data points came from group interviews with care guides. However, we also included some data points from other team members as they reflected on their concerns or questions about care guides, which provides a broader perspective on the difficulties of creating and working with a new role. This movement between analysis of care guide experiences and other team members’ reactions loosely follows an institutional ethnographic approach, in that we sought to identify central issues and then analyzed data from each set of actors involved in the issue (Smith, 2005).

Findings

Early on, care guides frequently discussed their collective identity and what they thought their new role offered to patients. As their work continued, they used this rhetoric to define their role within the team and promote the care guide model to the larger healthcare system. Over time, however, challenges in collaborations with other healthcare providers as well as pressures from team managers led to a further refinement of the role, which changed the work environment and created new pressures for care guides. Care guides used a range of tactics to deal with these pressures, but ultimately felt “thrown under the bus” and turnover became common. We present results by first showing how care guides constructed their sense of identity, drawing boundaries between themselves and clinically-trained team members. We then discuss how they used these identities in interaction with their own team members, other healthcare providers, and team managers. Finally, we discuss how care guides attempted to deal with resistance and other stressors.

Creating Identities and Boundaries: “We Don’t Have an Agenda.”

In the earliest stages of the intervention, the care guide role was intentionally undefined. Care guides were hired and told that they would be helping to identify and fill holes in the current healthcare system for people with serious illness. Because of this openness, care guides spent much of our group interview time talking about the value of the care guide role. According to care guides, their value came from having no agenda for their meetings with patients; the development of a new form of expertise stemming from agenda-less relationships with patients; and, that their personal experiences and personality were more important than credentials for doing this work. Care guides used these three elements to draw boundaries between their work and the work done by clinicians.

One of the most salient distinctions care guides drew between their own work and that of clinicians is that care guides claimed to have “no agenda,” implying that clinicians’ work does have an agenda. Each clinician was seen to have a jurisdiction that drove the interactional agenda with patients. In contrast, at least in the beginning, care guide meetings with patients were unstructured and patients (rather than care guides) determined what they did together. During a full Care Group interview, a care guide discussed how this approach differed from clinicians’ work:
Care Guide 001: For me, I feel like a lot of the magic happens when I’m able to just say something as a human being, and that I know that they’re not going to interpret it as coming from a nurse or a social worker or a pharmacist. There are times when I say things and I’m so grateful to be a care guide because I can just say, ‘wow, it makes me wonder about how you felt when you lived through that.’ I can just say these things where I come across as just a fellow human being, more likely without a specific agenda that they understand. – Full Team Group Interview
One clinician challenged this statement by sarcastically saying, “I’m generally not a human being” (Clinician 015). Another care guide (003) then clarified by saying,
Care Guide: There are these assumptions on the part of the patient or family about what you’re saying to them, based on what you’re coming to the table with. Sometimes I’m really glad I come to the table as ridiculously void of an agenda. That’s where I think some of the magic comes is that people are saying things and that I’m able to just be. – Full Team Group Interview
In constructing their lack of agenda, care guides also suggested that clinicians’ professional agendas (real or perceived) could potentially hinder their relationship with patients. We analyzed care guides’ discussions of agendas to understand the source of this particular framing of professional work and how it changed over the course of the study. The earliest mentions of agendas took place as the team grew in size and project managers started to add more structure around expectations for visits. Early on, discussions of agendas were purely descriptive, with care guides trying to articulate how they fit into a system driven by professional work. But, as care guides continued to feel like they were not getting support from leaders, they began to be more critical of professional agendas. Care guides perceived that the rush to package the model for wide dissemination privileged professional agendas and left out their “agendaless” voices. Said one care guide (008), “I feel like the care guide voice is getting almost muffled. We don’t have the impact we used to have and all these things they’re rolling out in 2015, it’s very concerning” (Care Guide Group Interview).

The idea of having no agenda was so important to care guides’ construction of their own value that one care guide felt the need to apologize to a patient for being too “agenda-driven” as the role started to become more focused. One care guide (007) said:
I had one of my guys that I saw last week for the initial visit, I feel like next time I go see him I have to apologize because I was agenda driven. I was looking at the domains and I was trying to find out which domain or two domains I can do follow-up work in, because that’s what I’ve got to do. I’ve got to do follow-up work; I’ve got to come back with some type of resource, so that we can get things done, we can help and support and we can care for that whole person, because that’s what we do. I’ve got to go back and I think I’ve got to say, ‘I’m sorry. I was driving the conversation. Do you even really want to go where we said we were going to go today?’– start there. – Care Guide Group Interview
According to the discourse of care guides, the ability to help patients without being agenda-driven was a new form of expertise, necessary for healthcare. Some (003) even went so far as to say it was an art, rather than a credentialed skill:
I’m amazed at how much just about every part of my job requires so much thought, so much analysis, so much interpretation, so much evaluation and assessment. Any single interaction I have with a [patient], with a [family member], with a provider, I can start it in any number of different ways. I can take any number of different twists and turns. I can follow A, B or C. It’s just very, very complex and I get better and better at it, the more I stay in touch with myself and the more time I spend with these people … It’s an art. – Care Guide Group Interview
In a medical system focused on professional hierarchies, care guides used discourse about their new expertise to garner credit for this difficult but often invisible labor. Framing care guides’ unique contribution as stemming from their non-agenda and distinct expertise also meant that many care guides attributed their success to their own life experiences and personalities. They emphasized their personal backgrounds to create new symbolic boundaries that distinguish their position from an impersonal, professional medical model. One care guide (005) discussed how this framing allowed them to feel proud of their work, even if they were not credentialed:
Coming into this work, I’ve felt very naked most of the time because my previous work experience and life experience– because I’m not a clinician– didn’t count for anything, nothing, as far as where I came in from a compensation standpoint. I’ve done a lot of training personally outside of my work life that prepared me for this and that’s what brings me along. Every day that’s what allows me to do the work that I do, and I think I’m good at it. I think we’re all good at it and I feel proud of that. – Care Guide Group Interview
As the role of care guide was introduced and first tested, care guides spent a lot of time discussing what they thought was unique and valuable about their work. Some described it as “magic” or “lightning in a bottle,” that resulted from approaching relationships with patients in a more open, human way. They juxtaposed this relationship approach to clinicians’ work, which was framed as more transactional and agenda-driven. In the next section, we show how these constructions of care guide value were sometimes challenged in their work with clinicians on their team, many of whom identified a potential risk of the innovation. As care guides attempted to carve out their work, some clinicians perceived that care guides violated professional standards and challenged their professional jurisdictions. Care guides, however, saw some of those professional standards and jurisdictional lines as violations of their commitment to agenda-less relationships with patients.

Working With Team Clinicians: “Walking on Eggshells.”

Care guides worked with an interdisciplinary healthcare team during the study period, though the nature of that collaboration changed over time. Early on, the work was focused on figuring out how to divide up tasks and where lines between clinical and non-clinical work resided. Though supportive of care guides, The Care Group clinicians had concerns about how care guides carved out their scope of work. One clinician, for example, echoed a concern expressed by all team clinicians about how they held back information from care guides out of fear that the care guide would not have the expertise to understand it, and would therefore misuse or mishandle it. “You have your license,” she said, “but you don’t want to just provide information that can become dangerous as time goes by” (Clinician Group Interview, 013). In other words, she as a clinician knew what to do with sensitive information but could not be sure that someone without similar training could be fully trusted to adhere to professional standards. While care guides perceived their value to come from being open, intuitive, and without agendas, clinicians sometimes saw these traits as liabilities.

At times, clinicians resisted care guides’ constructions of their value, which created tensions between care guides and clinicians. While care guides claimed they did not want to undermine the value of clinician support, they argued that patients may avail themselves to care guides more easily precisely because they were not clinicians. For example, one care guide (004) critiqued a new set of “trigger questions,” developed by clinicians and team managers, that were designed to help care guides identify when concerns expressed by patients required professional training and clinician involvement. For care guides, these trigger questions ultimately felt like a mechanism for transferring patient care from the care guide to the clinician:
I’ve felt in the past that some of our clinicians – they’re all very well intentioned and [have] good skill sets– but I feel like because of their role they have agendas that we don’t have as care guides, and the discussion guide and those trigger questions, because that’s exactly where they’re coming from, are agenda questions that are triggering some insights. Some of them are trigger questions for care guide exploration, but a lot of them I feel like are triggers to bring the clinicians in. – Care Guide Group Interview
Many care guides felt that the trigger questions were problematic because they thought patients were more comfortable communicating with care guides, and thus may be hesitant to have their comments shared with clinicians. One care guide (006) suggested that patients were more likely to trust her than a clinician: “I think the people told me what they told me because I’m a care guide, not because I’m a therapist … some people don’t want access to those professional services” (Care Guide). Sentiments like this one suggested that some care guides perceived patients as being opposed to clinical support. Whether or not that perception is accurate, it may have inadvertently made collaboration with clinicians more difficult, especially when their work intersected with mental health clinicians.

As time went on, clinicians and team managers started sending more explicit messages regarding what kinds of patient engagement were outside the scope of care guides. Care guides saw those distinctions in reference to medical care: “I don’t give medical advice. I tell people when I first meet them, ‘you don’t want me coming with a scalpel; that’s not what I’m here to do, so I’m not licensed’” (Care Guide Group Interview, 007). However, care guides were not always as clear about distinctions when it came to psychosocial tasks. Questions about scope of practice created a lot of angst for care guides, who felt like they did not know their place:
I just think as a care guide, because I’ve never experienced so much angst in my life, in my career, because I don’t quite understand where we fit in. Where does [intervention] fit into [healthcare] and where does the care guide role fit into it, and how much should I know? – Care Guide Group Interview, 010
Other care guides experienced stress because they worried that the role of care guide duplicated other psychosocial roles that already existed, especially in the places where it overlapped with social work. During one care guide group interview, a participant expressed that social workers would do this work if they had time, but they usually spent all of their time doing discharge planning. At the conclusion of this comment, others chimed in to say:
Care Guide 011: You have to be licensed to be a social worker, and this role—like you said—is entry level. To understand where that boundary is and say we are talking about deep things, very difficult things that people don’t necessarily want to talk about with other people. How do we take care of that really special concept when we’re expected to also expand in all these other areas? Obviously, I think everyone in this room has really good qualities in certain ways. I don’t see anything that I’m like, oh, this, this and this, but just understanding that we’re taking on something that’s very touchy in terms of the role that we’re creating is, essentially – I hate to say it – that are already there [within social workers].

Care Guide 009: Right, only it’s less pay.

Care Guide 007: And it’s not licensed. – Care Guide Group Interview
Importantly, not being licensed meant that care guides also were not expected to understand or follow professional ethical codes and did not have the same levels of protection or obligations as licensed clinicians. Care guides understood that part of their work was to push at professional boundaries, but because they had not received professional training, they did not understand the ways in which pushing professional boundaries could potentially make them vulnerable:
[I’m] laying this out today is because I do really hope I can continue this work and right now it feels like some of it is being built on the shoulders of these people around the table today. Since many of us are saying we’re not getting it, we’re not getting what we need, we’re not understanding, and yet we’re being held accountable now, more and more, it feels like it’s being built on our backs and I don’t know if we’re going to be crushed. – Care Guide Group Interview, 001
Some also linked these risks to potential harms to patients, expressing that they were concerned about the ethics of withdrawing the level of support previously given by care guides. This level of support was being dialed back as clinicians’ concerns about professional role jurisdictions ramped up:
There’s an ethical piece to this that I think we rarely discuss, but we do have an ethical and moral obligation to these patients and their families. To me they’re not rats in the lab; they’re not just, oh, this didn’t work. The idea of harm, which we know we’ve seen, it’s painful to me to see patients that we harmed, potentially, one for sure we harmed. (You know what I’m talking about.) It was extremely painful for the person who had to go through it. – Care Guide Group Interview, 004
Making reference to a specific patient who had had a reduction in time with the assigned care guide, this participant thought it was unethical to withdraw this level of care. But, the clinicians involved were concerned that the level of care guide involvement may create ethical issues, including psychological dependencies, conflicts of interest, and disruption to relationships with other care providers. Mental health clinicians, especially, were trained to recognize and work through these dynamics of relational work, but some feared that care guides did not have the knowledge or skills for that kind of reflexivity. According to these professionals, when the care guides were “in over their heads,” patients could be harmed (Clinician Group Interview, 014).

As care guides realized the risks of pushing at professional jurisdictions, they increasingly were upset at their low levels of compensation and professional status. These conversations left many care guides feeling frustrated with their designation as “entry-level.” The entry-level labeling combined with the low pay grade reinforced the long-standing symbolic boundaries among healthcare professions that grants licensed medical clinicians dominance and esteem within the healthcare hierarchy. Those without credentials were relegated to the bottom of the hierarchy, where they received little pay and often little respect. They took these concerns to management, but felt further frustrated that changes were not made:
And compensation is tied to that as well, but just the development of the job description. We were told pretty darn clearly, “Can it! We will address this, but it’s not our priority right now; we will deal with it.” This is really important to the people here around this table. It has been increasingly frustrating for me that the things that are really important to us are put on the back burner by the people that aren’t on the front lines. – Care Guide Group Interview, 002
Care guides worked as part of the larger Care Group team, but it was not always clear how they should divide up jurisdictions of care. Clinicians worried that care guides were susceptible to violations of professional standards because of their lack of professional training, especially when care guide work intersected with the jurisdictions of the psychosocial support team members (therapist, social worker, chaplain). Care guides came to understand that there was a problem with them doing complex relational work, but unlike clinicians, characterized this as a problem because they were not given respect or compensation to match the requirements of the work.

Working Outside the Care Team: “Trying to Push the Boundary”

Because care guides were meant to help fill gaps in care, managers encouraged them to try to collaborate with healthcare providers outside of their Care Group. This collaboration was supposed to take the form of attending appointments with patients, bringing up issues with providers when patients needed support, sending messages with updated information on patient concerns and issues, and coordinating care between providers. Care guides’ frustration only magnified as outside providers also started pushing back on their perceived jurisdictional transgressions. These interactions outside the team made professional boundaries even more salient and uncovered a new risk:
We don’t have clinician licensing to support the activities we’re doing … Everything we do is against what the system is saying is supposed to be. That’s why we have such lengthy in-depth conversations on professional versus unprofessional relationships, because we are trying to redefine and push the boundary of unprofessional being professional. It feels unsafe. – Care Guide Group Interview, 004
Another care guide (007) linked their entry-level status to other providers’ reactions to them: “There are implications of calling us entry level. If [the health system] thinks of us as entry level, our partners will think of us as entry level” (Care Guide Group Interview).

Care guides continually felt like they had to sell their value to other providers, many of whom seemed disinterested in collaboration. One care guide (006) explained: “For the time I’ve been here, I’ve not had a clear way to sell who I am, what I’m doing, what my job is, even basically describe what I do” (Care Guide Group Interview). Some care guides were met with “blank stares” when they encountered other healthcare providers. Care guides found that because clinical visits were already very busy, providers were reluctant to spend a great deal of time trying to understand their new role. Providers’ lack of knowledge about the intervention sometimes meant they made assumptions about the clinical training of care guides. One Care Team clinician explained that some providers expected care guides to have clinical skills, which put care guides in difficult positions:
I think that therapist didn’t have the recognition that she wasn’t speaking to a person on the same clinical level, so she said more than she should have, in support of the person, and then what does the care guide do with that? It’s really tricky. – Clinician Group Interview, 013
Because the care guide and the therapist did not share a clinical background, the care guide perhaps did not have the skills necessary to act on the information appropriately.

The lack of clarity surrounding their role within the greater medical system eventually led some care guides to stop attempting to create collaborative relationships with clinicians beyond their immediate Care Group team. One noted, “They’re not good about working with us; that’s just the truth. I have better things to do than chase them and then let them beat up on me” (Care Guide Group Interview, 003). Others placed blame on management for not helping to pave the way for collaboration. One care guide said, “I think what we’re discovering is that you really cannot mandate collaboration” (Care Guide Individual Interview, 002). Problems collaborating with providers outside the Care Team mostly stemmed from providers ignoring or dismissing care guides. Occasionally, an event arose that made it clear that clinicians’ concerns about jurisdictional violations were reflected in the larger healthcare environment. These are discussed in the next section.

Consequences: “It Does Seem Very Toxic.”

When an issue was escalated beyond the Care Group, it frequently caused more intervention from team managers. For example, when conflicts with other healthcare teams arose, team managers began to correct role boundary violations and set expectations for more structured work. As pressures from outside increased, team managers largely focused on nailing down the documentation and processes around the role, even though care guides felt that it was still too early. The care guides expressed that they were still testing the feasibility of the innovation and that their collaborations with other healthcare professionals were not yet strong enough to warrant expansion. This eventually produced an environment many thought of as toxic.

Some care guides tried to deal with this uncertainty by engaging in more emotional labor with outside providers. Their hope was that through better working relationships, they could rebuild the role to complement existing care services:
So I've learned to communicate in a more humble fashion the things that I know about people. [To] their primary care providers, I often say, 'You probably already know this, but this is what they told me today.' A lot of times I try to reflect to the provider what the person has said to me about them, if they've had a positive relationship. I say, 'I had my first meeting. They brought up their relationship with you as a really strong source of comfort in receiving care' or 'they want you in the lead.' – Care Guide Group Interview, 002
Others expressed that management had a greater responsibility for fixing problems in role definition and collaboration. Some were doubtful that management was willing to engage in these conversations, however. This frustration was heightened by pressures to create a guidebook that outlined the role and scripted the care guide’s work—even before care guides felt like they personally could define the role:
And over the last year, I would say, there has grown a huge gap, a huge disconnect, [with the] massive playbook and these other work groups continuing to go on, and then documents come down. And, we're between leadership and operations people and those of us on the ground doing the work … It feels really strange and disingenuous to have this huge team working on this . – Care Guide Group Interview, 008
Until this point, the gap between what the care guides thought was best and what management was pushing was often explained as a breakdown in communication. Team members often stated that they believed leadership had good intentions, but just did not understand their experiences.

However, two events caused many care guides (and some clinicians) to become much more critical of management. In the first event, a clinician from another healthcare team expressed concerns about one of the care guides. Several team members felt like management had “thrown [the care guide] under the bus” and were wary that they could also be put in a difficult position. One lamented:
People can throw us under the bus at any point, because we do not have a defined role, we’re exploring these boundaries through trial and error, and here we are. I guess I think this is highly predictable … We are all going to be in these positions where we can be thrown under the bus. Honestly, I think that’s what they’re doing. I don’t think they’re necessarily trying to do that, but in some ways they’re being supportive. I’m not saying it’s an entire shove you, but it’s the reality of the impact, because care guides really don’t have any kind of professional definition to fall back on. – Care Guide Group Interview, 003
Only one care guide was directly impacted by this dispute, but several others also expressed concern that they could be next.

The second event happened when leadership brought the team together to discuss upcoming changes to operations. In addition to describing more structured roles, they took a hard line on care guides’ growing dissent. Leaders brought up several specific examples of care guides critiquing the model and/or management. Care guides perceived that they were “being punished for the way they had behaved” in expressing their critiques, and that “[managers] don’t care; they don’t want to know … It’s just stop it and move on” (Care Guide Group Interview, 004). The care guides came to call this meeting the “Perfect Storm” meeting in that it was a product of many different forces coming together, while leadership was “failing to take into consideration climate change” (Care Guide Group Interview, 010). Some care guides referred to the meeting as “destructive,” while at least one expressed that they thought the intention was right in that it aired existing tensions, but that the delivery was poor. In all cases, care guides were visibly shaken by the meeting and in subsequent weeks, the entire Care Group referred to the “Perfect Storm” in our group interviews.

These two interrelated events led to several team members feeling burned out and one care guide (003) responding to a team member who characterized the team as “toxic”:
I can only imagine what it’s been like to come into this, because I’m sure it does seem very toxic and all those kinds of things. Here you are in a new job. I appreciate that a lot. But I think that sometimes when things feel toxic like that, we have to understand why, what’s behind that. Where’s that coming from? What’s that about? Yeah, your perspective is really helpful, because it does feel toxic to me; it does. I guess I agree with that word and I don’t like it. – Full Team Group Interview
As the groups progressed, this level of toxicity eventually led to several care guides discussing ways that they changed their relationship to the work. One said, “For the first time over the last couple of months, I find myself pulling back a little bit” (Care Guide Group Interview, 007) while others said they were “detached,” “burned out,” and “disengaged.” Still others left the team altogether. As data collection for this project came to a close, turnover increasingly became a concern for team members, and some reported that over half of the team was actively looking for other work. While the hope was that the creation of a new role would fill gaps in the existing healthcare system, the lack of role definition and problems in collaboration created an untenable work environment for many of the lay healthcare workers.

Discussion

Lay healthcare workers are part of a larger trend of creating consumer-facing roles in healthcare as it attempts to achieve two countervailing goals: to cut costs by offloading low-skilled work from licensed professionals to lay workers; and, to orient care to the needs and preferences of patients. In this paper, we use almost three years of qualitative data to examine the experiences of one group of lay healthcare workers as they attempted to develop their role and figure out how to work with existing clinicians and the larger hierarchical medical system. These new roles should be thought of as part of a larger growth of consumer-oriented service work in healthcare and beyond. Unlike many studies of consumer-oriented services, however, this study takes place in the highly bureaucratic and increasingly rationalized institution of medicine. As such, lay healthcare workers represent the experience of trying to balance the variable and personal needs of consumers while simultaneously meeting the financial and professional goals of the larger organization. This puts them in a “risky” position organizationally, professionally, and personally.

Analyses of these workers’ experiences reveal that lay healthcare workers disproportionately absorbed the risk of the workplace innovation. There were two issues in the design of this new role that produced the disproportionate risk. First, management asked care guides to push against professional jurisdictions and consider ways that they could pick up some of the work of clinically trained professionals. But, healthcare is highly bureaucratic, and built around clinically trained professionals, so the policies, rules, and license requirements make jurisdictional changes challenging. In this case, care guides were seen as dangerously transgressing their appropriate role. Care guides viewed these transgressions as warranted, but the larger healthcare system did not agree. Early on, this meant that care guides spent much of their time thinking about their identities as care workers, what was valuable about their role, and how they might add something complementary to existing health services. In thinking through these issues, they often formed and discussed discursive boundaries between what they did and what other healthcare providers did. They presented their value of coming from having “no agenda” in their relationships with patients.

Second, as care guides experienced resistance, team managers did not provide the kinds of coverage and support necessary for mitigating personal and professional consequences of risk. Supervisors first did not seem to understand the issues care guides brought to them, but eventually responded to concerns with antagonism. Not only did this antagonism increase dissatisfaction with work, but it also reduced the likelihood that care guides could use their experiences to help improve the innovation. They were increasingly pushed out of contributing to the redesign of the work.

Ultimately, the poor role definition, resistance from other providers, and lack of management support caused care guides to become more critical of their managers, who they thought could have done more to pave the way for interactions with other providers. As time went on, the work environment became very difficult for some care guides. While many said that that still enjoyed time with patients and their family members, some said that they were withdrawing from collaborative attempts. Toward the end of the study, some even said that they were withdrawing from their interactions with patients and feeling burned out. Disengagement and turnover meant that even if there was initially some “magic” in the role, the pressures ultimately stripped away what the care guides thought was most valuable about the intervention.

As our study was coming to an end, the project continued to shift away from the undefined, open roles that care guides found so valuable in the beginning. The remaining care guides were integrated into the larger healthcare system, where they helped patients and their family members navigate specific care settings. Because the team as we knew it did not exist beyond the study, it is hard to know if the tensions discussed here would have continued or if they were a temporary byproduct of any attempt at change. Regardless, our findings do clearly show that the attempt to create a new, innovative lay role put disproportionate risk on the lowest level workers, potentially reducing the positive impact of the attempt to innovate.

Conclusion

Our analysis of this progression of events builds upon several areas in the sociology of work. Our findings speak to boundary work within highly bureaucratized organizations as they try to create new and innovative roles. Generally, previous studies of boundary work within healthcare show how members of prestigious professions try to distinguish their roles from lower-status professions; this effort is well documented in research focusing on physicians and nurses (Allen, 2000; Martin et al., 2009; Norris, 2001; Timmons & Tanner, 2004). Unlike these studies, we show how the lower-status workers may also try to create boundaries that they can use to their own advantage. Despite their active boundary work, care guides still had to navigate a traditional medical model that favored clinical credentialing and licensing over nonclinical work (Manners, 2017). This left care guides in a precarious position; they knew the importance of their work, yet had to defend it to the broader healthcare system.

Our study also illustrates how boundary violations produce resistance. As care guides took on more, clinicians expressed and acted on concerns about unlicensed lay people tackling issues that required higher training. Care guides were expected to navigate their own undefined roles, while also knowing when and how their roles blurred with professionals, all without explicit training on interdisciplinary collaboration (Michalec & Hafferty, 2015). While professional workers deal with diagnostic and treatment ambiguity on a daily basis, the lack of professional training meant that care guides approached the ambiguity without the controls, supports, and oversight common within professional work (Abbott, 1988). Not only was the care guide role ambiguous, but at times, management expected care guides to deal with diagnostic and treatment ambiguity with little oversight.

Importantly, care guides were more likely to challenge the boundaries of psychosocial clinicians (therapist, social worker, chaplain) than medical clinicians (nurses, pharmacist), illustrating that the high value put on medical knowledge and credentialing offers medically-focused clinicians some protection against jurisdictional disputes. Psychosocial support clinicians were relegated to a lower status, as shown in other medical settings (Cain, 2019; Carey, 2007). The medical hierarchy shapes boundary work possibilities for less powerful actors, such as lay healthcare workers. Given this, our findings show that concerns that new healthcare roles and organizational practices may reduce the authority of medicine (McKinlay & Marceau, 2002; 2008) are not realized, at least in the case of lay healthcare workers. More research is needed on how higher skilled new roles may challenge the authority and jurisdictions of physicians.

These experiences also reveal the complex dynamics between de- and up-skilling in healthcare environments. If the larger healthcare institution allows lay people to pick up some “lower-level” tasks, it may be considered evidence of continued deskilling of medicine, especially in terms of psychosocial support services (Krachler & Greer, 2015). On the other hand, attempts to increase value by giving clinicians more time to work at the “top of their license” may be a form of upskilling, or increasing the skill demands for clinically trained workers. We find that attempts to upskill medical clinicians reduced clinicians’ meaningful time with patients, but did not challenge their jurisdictions. Upskilling attempts operated differently with non-medical clinicians. Without full understanding of the skills and ethics taught to relational professionals, the relegation of relational skills to lay workers may have resulted in the transfer of work that required high-level clinical skills from clinicians to lay workers. These findings provide mixed evidence for the de-skilling and up-skilling of medicine by using lay healthcare workers. Future studies should consider how the medical hierarchy and different types of licenses affect skilling processes as well.

Our findings may be applicable to other settings where lay healthcare workers are used to collaborate with existing healthcare providers. These include settings with community health workers, navigators, volunteers, and other lay people meant to fill holes in the care delivery system and reduce costs of care. Beyond healthcare, our findings about risk, jurisdictions, and boundary work may be applicable to other highly bureaucratic workplaces that attempt to increase efficiency through the creation of new low-skill work roles. When new roles create new vulnerabilities for workers, they are unlikely to be integrated into highly bureaucratic workplaces.

Our analysis is enriched by our longitudinal qualitative approach and rich data on care guides’ experiences. However, limitations of our approach do exist. We analyzed data over a long period of time, but it is a single team that we trace through time. If we were to study a range of teams attempting to innovate similarly, we may find more variation in the experiences discussed (Michalec et al., 2015). Our findings may not be applicable in settings where workers in the new role do not work as a team, are not asked to help shape the role, or do not work within a bureaucratic, hierarchical organization. Future research may benefit from a focus on the perspectives of managers and professionals, who likely view the creation of the new roles quite differently (Vermeerbergen et al., 2020). Additionally, we use interview data to understand the experiences of working within this new role. While interview data is ideal for studies of actors’ meanings and social processes that shape those meanings, interviews can be subject to a number of biases, including recall and desirability (Tavory, 2020). Ethnographic data on how workers engage with one another would be a beneficial complement to interview studies.

As healthcare, and all service workplaces, continue to shift to meet the needs of consumers and efficiency, the creation of new roles will be essential. But, the success of these new roles is contingent on how the roles are integrated and supported within the existing systems. The more we understand how to support collaboration with new roles, the better prepared we will be for new models of work and care (Vogus et al., 2020).

Footnotes

Acknowledgment

This article was greatly improved through the comments from the anonymous reviewers and editorial team. We are grateful to the Care Group Team for sharing their experiences.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Robina Foundation.

ORCID iD

Cindy L. Cain

Author Biographies

Cindy L. Cain is an assistant professor of Sociology at the University of Alabama at Birmingham. Her research interests include healthcare, end of life care, and organizational change. Recent publications have appeared in Journal of Health and Social Behavior, Sociology of Health and Illness, Poetics, and Gender, Work and Organization.

Caty Taborda is a PhD candidate in Sociology at the University of Minnesota and a Ford Foundation fellow. Her research focuses on medical marketplaces and health inequalities, and her work has most recently appeared in The Journal of Interprofessional Care.

Monica Frazer is a senior researcher in HEOR at Optum, implementing research related to mental health. Her research interests include family health, mental health, primary care, complex illness, and chronic illness care. Recent publications have appeared in Human Relations and Journal of Health and Quality of Life Outcomes.

References

Abbott

(1988). The system of professions: An essay on the division of expert labor. University of Chicago Press.

Allen

(2000). Doing occupational demarcation: The “boundary-work” of nurse managers in a district general hospital. Journal of Contemporary Ethnography, 29(3), 326–356.

Allen

Pilnick

(2005). Making connections: Healthcare as a case study in the social organisation of work. Sociology of Health & Illness, 27(6), 683–700.

Avgar

A. C.

Eaton

A. E.

Givan

R. K.

Litwin

A. S.

(2020). Paying the price for a broken healthcare system: Rethinking employment, labor, and work in a. Work and Occupations, 47(3), 267–279.

Berwick

D. M.

Nolan

T. W.

Whittington

(2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759–769.

Braverman

(1974/1998). Labor and monopoly Capital: The degradation of work in the twentieth century. NYU Press.

Broom

(2006). Reflections on the centrality of power in medical sociology: An empirical test and theoretical elaboration. Health Sociology Review, 15(5), 496–505.

Brown

Korczynski

(2010). When caring and surveillance technology meet: Organizational commitment and discretionary effort in home care work. Work and Occupations, 37(3), 404–432.

Cain

C. L.

(2019). Agency and change in healthcare organizations: Workers’ attempts to navigate multiple logics in hospice care. Journal of Health and Social Behavior, 60(1), 3–17.

10.

Cain

C. L.

Frazer

Kilaberia

T. R.

(2019). Identity work within attempts to transform healthcare: Invisible team processes. Human Relations, 72(2), 370–396.

11.

Cain

C. L.

Taborda-Whitt

Frazer

Schellinger

White

K. M.

Kaasovic

Nelson

Chant

(2017). A mixed methods study of emotional exhaustion: Energizing and depleting work within an innovative healthcare team. Journal of Interprofessional Care, 31(6), 714–724.

12.

Cappelli

(1993). Are skill requirements rising? Evidence from production and clerical jobs. ILR Review, 46(3), 515–530.

13.

Carey

(2007). White-collar proletariat? Braverman, the deskilling/upskilling of social work and the paradoxical life of the agency care manager. Journal of Social Work, 7(1), 93–114.

14.

Conrad

(2005). The shifting engines of medicalization. Journal of Health and Social Behavior, 46(1), 3–14.

15.

Cottingham

M. D.

Erickson

R. J.

(2020). The promise of emotion practice: At the bedside and beyond. Work and Occupations, 47(2), 173–199.

16.

Daykin

Clarke

(2000). They’ll still get the bodily care’. Discourses of care and relationships between nurses and health care assistants in the NHS. Sociology of Health & Illness, 22(3), 349–363.

17.

DiCicco-Bloom

(2019). Secondary emotional labor: Supervisors withholding support and guidance in interdisciplinary group meetings in a community hospice program. Work and Occupations, 46(3), 339–368.

18.

Dodson

Zincavage

R. M.

(2007). “ It's like a family”: Caring labor, exploitation, and race in nursing homes. Gender & Society, 21(6), 905–928.

19.

Fayard

A.-L.

Stigliani

Bechky

B. A.

(2017). How nascent occupations construct a mandate: The case of service designers’ ethos. Administrative Science Quarterly, 62(2), 270–303.

20.

Findlay

Lindsay

McQuarrie

Bennie

Corcoran

E. D.

Van Der Meer

(2017). Employer choice and job quality. Work and Occupations, 44(1), 113–136.

21.

Freidson

(1988). Profession of medicine: A study of the sociology of applied knowledge. University of Chicago Press.

22.

Gale

N. K.

Kenyon

MacArthur

Jolly

Hope

(2018). Synthetic social support: Theorizing lay health worker interventions. Social Science & Medicine (1982), 196, 96–105.

23.

Gallie

(1991). Patterns of skill change: Upskilling, deskilling or the polarization of skills? Work, Employment and Society, 5(3), 319–351.

24.

George

(2008). Interactions in expert service work: Demonstrating professionalism in personal training. Journal of Contemporary Ethnography, 37(1), 108–131.

25.

George

(2013). Seeking legitimacy: The professionalization of life coaching. Sociological Inquiry, 83(2), 179–208.

26.

Goodrick

Gorman

E. H.

Sandefur

R. L.

Reay

(2011). Constellations of institutional logics. Work and Occupations, 38(3), 372–416.

27.

Granter

Wankhade

McCann

Hassard

Hyde

(2019). Multiple dimensions of work intensity: Ambulance work as edgework. Work, Employment and Society, 33(2), 280–297.

28.

Hage

(1998/2018). Organizational innovation. Routledge.

29.

Heisig

(2009). The deskilling and upskilling debate. International handbook of education for the changing world of work (pp. 1639–1651). Springer.

30.

Hendley

(2016). Seeking self-verification: Motives for private and personal chefs’ boundary work. Cultural Sociology, 10(4), 466–482.

31.

Kash

B. A.

May

M. L.

Tai-Seale

(2007). Community health worker training and certification programs in the United States: Findings from a national survey. Health Policy (Amsterdam, Netherlands), 80(1), 32–42.

32.

Kellogg

K. C.

(2014). Brokerage professions and implementing reform in an age of experts. American Sociological Review, 79(5), 912–941.

33.

Khessina

O. M.

Goncalo

J. A.

Krause

(2018). It’s time to sober up: The direct costs, side effects and long-term consequences of creativity and innovation. Research in Organizational Behavior, 38, 107–135.

34.

Krachler

Greer

(2015). When does marketisation lead to privatisation? Profit-making in English health services after the 2012 health and social care act. Social Science & Medicine (Medicine), 124, 215–223.

35.

Lamont

Molnár

(2002). The study of boundaries in the social sciences. Annual Review of Sociology, 28(1), 167–195.

36.

Lee

Y. S. H.

Nembhard

I. M.

Cleary

P. D.

(2020). Dissatisfied creators: Generating creative ideas amid negative emotion in health care. Work and Occupations, 47(2), 200–227.

37.

Leidner

(1993). Fast food, fast talk: Service work and the routinization of everyday life. University of California Press.

38.

Leigh

D. E.

Gifford

K. D.

(1999). Workplace transformation and worker upskilling: The perspective of individual workers. Industrial Relations: A Journal of Economy and Society, 38(2), 174–191.

39.

Light

D. W.

(2007). Professional dominance in medicine. The Blackwell Encyclopedia of Sociology, 1–5.

40.

Light

D. W.

(2010). Health-Care professions, market, and countervailing powers. In C. E. Bird, P. Conrad, A. M. Fremont, & S. Timmermans (Eds.), Handbook of medical sociology (6th ed., pp. 270–289). Vanderbilt University Press.

41.

Lindblad

Hallman

E.-B.

Gillsjö

Lindblad

Fagerström

(2010). Experiences of the new role of advanced practice nurses in Swedish primary health care—A qualitative study. International Journal of Nursing Practice, 16(1), 69–74.

42.

Lopez

S. H.

(2006). Emotional labor and organized emotional care: Conceptualizing nursing home care work. Work and Occupations, 33(2), 133–160.

43.

Lopez

S. H.

(2010). Workers, managers, and customers. Work and Occupations, 37(3), 251–271.

44.

Manners

R. A.

(2017). Professional dominance: The social structure of medical care. Routledge.

45.

Martin

G. P.

Currie

Finn

(2009). Reconfiguring or reproducing intra-professional boundaries? Specialist expertise, generalist knowledge and the 'modernization' of the medical workforce. Social Science & Medicine (1982), 68(7), 1191–1198.

46.

May

M. L.

Bowman

G. J.

Ramos

K. S.

Rincones

Rebollar

M. G.

Rosa

M. L.

Saldana

Sanchez

A. P.

Serna

Viega

Villegas

G. S.

Zamorano

M. G.

Ramos

I. N.

(2003). Embracing the local: Enriching scientific research, education, and outreach on the Texas-Mexico border through a participatory action research partnership. Environmental Health Perspectives, 111(13), 1571–1576.

47.

McKinlay

J. B.

Arches

(1985). Towards the proletarianization of physicians. International Journal of Health Services: Planning, Administration, Evaluation, 15(2), 161–195.

48.

McKinlay

J. B.

Marceau

L. D.

(2002). The end of the golden age of doctoring. International Journal of Health Services: Planning, Administration, Evaluation, 32(2), 379–416.

49.

McKinlay

Marceau

(2008). When there is no doctor: Reasons for the disappearance of primary care physicians in the US during the early 21st century. Social Science & Medicine (1982), 67(10), 1481–1491.

50.

Micelotta

Lounsbury

Greenwood

(2017). Pathways of institutional change: An integrative review and research agenda. Journal of Management, 43(6), 1885–1910.

51.

Michalec

Hafferty

F. W.

(2015). Role theory and the practice of interprofessional education: A critical appraisal and a call to sociologists. Social Theory & Health, 13(2), 180–201.

52.

Michalec

Reinhold

Dressler

Laskowski-Jones

Adarve

Elliott

(2015). Barriers to and facilitators of interprofessional-interdepartmental interventions: Unearthing departmental culture. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality, 30(2), 126–134.

53.

Mitchell

Boyle

(2021). Understanding the role of profession in multidisciplinary team innovation: Professional identity, minority dissent and team innovation. British Journal of Management. 32(2), 512–528.

54.

Murphy

C. B.

(2014). Facing the void: Identity and legitimacy in emerging professions (PhD Thesis). The Pennsylvania State University.

55.

Nancarrow

S. A.

Borthwick

A. M.

(2005). Dynamic professional boundaries in the healthcare workforce. Sociology of Health & Illness, 27(7), 897–919.

56.

Norris

(2001). How ‘we’ are different from ‘them’: Occupational boundary maintenance in the treatment of musculo‐skeletal problems. Sociology of Health & Illness, 23(1), 24–43.

57.

O'Brien

(2007). Overseas nurses in the national health service: A process of deskilling. Journal of Clinical Nursing, 16(12), 2229–2236.

58.

O'Brien

M. J.

Squires

A. P.

Bixby

R. A.

Larson

S. C.

(2009). Role development of community health workers: An examination of selection and training processes in the intervention literature. American Journal of Preventive Medicine, 37(6), S262–S269.

59.

Paradis

Leslie

Puntillo

Gropper

Aboumatar

H. J.

Kitto

Reeves

(2014). Delivering interprofessional care in intensive care: A scoping review of ethnographic studies. American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses, 23(3), 230–238.

60.

Peng

Wang

Han

(2018). Information technology and employment: The impact of job tasks and worker skills. Journal of Industrial Relations, 60(2), 201–223.

61.

Powell

(2016). Reforming a health care system in a big way? The case of change in the British NHS. Social Policy & Administration, 50(2), 183–200.

62.

Rees

G. H.

Gauld

(2017). Can LEAN contribute to work intensification in healthcare? Journal of Health Organization and Management, 31(3), 369–384.

63.

Ritzer

Walczak

(1988). Rationalization and the deprofessionalization of physicians. Social Forces, 67(1), 1–22.

64.

M. J.

Treadwell

H. M.

Northridge

(2003). Community health workers and community voices: Promoting good health. Community Voices.

65.

Russell-Babin

Wurmser

(2016). Transforming care through top-of-license practice. Nursing Management, 47(5), 24–28.

66.

San Martín-Rodríguez

Beaulieu

M.-D.

D'Amour

Ferrada-Videla

(2005). The determinants of successful collaboration: A review of theoretical and empirical studies. Journal of Interprofessional Care, 19(Suppl. 1), 132–147.

67.

Schwartz

(2018). Embedded in the crowd: Creative freelancers, crowdsourced work, and occupational community. Work and Occupations, 45(3), 247–282.

68.

Scott

W. R.

Ruef

Mendel

P. J.

Caronna

C. A.

(2000). Institutional change and healthcare organizations: From professional dominance to managed care. University of Chicago Press.

69.

Sherman

(2010). “ Time is our commodity”: Gender and the struggle for occupational legitimacy among personal concierges. Work and Occupations, 37(1), 81–114.

70.

Sherman

(2011). The production of distinctions: Class, gender, and taste work in the lifestyle management industry. Qualitative Sociology, 34(1), 201–219.

71.

Singh

Sachs

J. D.

(2013). 1 Million community health workers in Sub-Saharan Africa by 2015. The Lancet, 382(9889), 363–365.

72.

Smith

D. E.

(2005). Institutional ethnography: A sociology for people. Rowman Altamira.

73.

Smith

(1994). Braverman's legacy: The labor process tradition at 20. Work and Occupations, 21(4), 403–421.

74.

Subramanian

Suquet

J. B.

(2018). Unpacking the service triangle: Arranging power relations between frontline occupations. Work and Occupations, 45(1), 38–81.

75.

Tavory

(2020). Interviews and inference: Making sense of interview data in qualitative research. Qualitative Sociology, 43(4), 449–465.

76.

Timmermans

(2020). The engaged patient: The relevance of patient–physician communication for twenty-first-century health. Journal of Health and Social Behavior, 61(3), 259–273.

77.

Timmermans

Tavory

(2012). Theory construction in qualitative research: From grounded theory to abductive analysis. Sociological Theory, 30(3), 167–186.

78.

Timmons

Tanner

(2004). A disputed occupational boundary: Operating theatre nurses and operating department practitioners. Sociology of Health & Illness, 26(5), 645–666.

79.

Vallor

(2015). Moral deskilling and upskilling in a new machine age: Reflections on the ambiguous future of character. Philosophy & Technology, 28(1), 107–124.

80.

van de Ruit

Bosk

C. L.

(2021). Surgical patient safety officers in the United States: Negotiating contradictions between compliance and workplace transformation. Work and Occupations. 48(1), 3–39.

81.

VanHeuvelen Jane

(2020). Professional engagement in articulation work: Implications for experiences of clinical and workplace autonomy. In H. G. Elizabeth & P. V. Steven (Eds.), Professional work: Knowledge, power and social inequalities (Vol. 34, pp. 11–31). Emerald Publishing Limited.

82.

VanHeuvelen

J. S.

Grace

M. K.

(2020). Occupational heterogeneity in healthcare workers’ misgivings about organizational change. Work and Occupations, 47(3), 280–313.

83.

Vermeerbergen

McDermott

A. M.

Benders

(2021). Managers shaping the service triangle: Navigating resident and worker interests through work design in nursing homes. Work and Occupations. 48(1), 70–98.

84.

Vogus

T. J.

Gabriel

A. S.

McClelland

L. E.

(2020). The social context of caregiving work in health care: Pushing conceptual and methodological frontiers. Work and Occupations, 47(2), 123–143.

85.

Zetka

J. R.

(2008). The making of the “women's physician” in American Obstetrics and Gynecology: Re-forging an occupational identity and a division of labor. Journal of Health and Social Behavior, 49(3), 335–351.