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Health care services experienced remarkable growth in the latter half of the twentieth century in industrialized countries. Advances in medical science and technology, the expansion of health insurance, the aging of the population, increased public expectations and disposable income, and expanding social deﬁnitions of the boundaries of medical care all contributed to increased utilization of health services and changing patterns of care. These changes fostered the development of an expanded division of medical labor in which allied health professionals emerged to complement and compete with physicians in the provision of a broader array of health services. Globalization of health care has fostered renewed interest in strengthening the roles of allied health providers in developing countries and in the post-Soviet states in order to increase access to primary medical care and improve population health.
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1. The Changing Context Of Health Care
Health and medical services have undergone dramatic change since the mid-twentieth century. Medical care has become more specialized while also expanding in scope. At the beginning of the twentieth century, physicians accounted for about one in three healthcare workers; by the 1980s the comparable ratio was about 1 in 16 (Mechanic 1983). Health care occupations are highly sex-segregated with most nonphysician occupations dominated by women. Indeed, in many parts of the world physicians are also predominantly women reﬂecting societal sex role links between women and caring health functions.
1.1 Changing Disease Patterns
Advances in medical science including antibiotics and vaccines as well as improved standards of living contributed to shifting the burden of illness from acute, infectious illnesses to chronic conditions. While advances in modern medicine have produced important treatments for chronic illnesses, most have resulted in ‘halfway’ technologies that extend life but do not cure the underlying disease (Thomas 1977). Examples include long-term renal dialysis for the treatment of kidney failure and, more recently, antiretroviral drugs that extend the lives of people with acquired immunodeﬁciency syndrome (AIDS). Chronic conditions are accompanied by a myriad of functional limitations and social support needs that fall outside the conventional deﬁnition of medical practice. Nurses, social workers, occupational therapists, physical therapists, and other nonphysician health professionals have demonstrated interest and expertise in helping the chronically ill and frail elderly manage the sequella of chronic conditions and medical treatments, thus creating new roles for themselves in the medical division of labor.
1.2 Medicalization Of Problems Of Everyday Living
The successes of modern medicine in treating life-threatening illnesses have resulted over time in the redeﬁnition of a range of health-related issues and problems of everyday life as medical concerns. The boundaries of medicine have expanded to encompass health promotion, diet and exercise, child rearing, school performance, occupational health, and a wide array of personal and social problems. Medicalization of problems of everyday living lend legitimacy to social interventions (such as behavior control of disruptive school children), allow those seeking help to adopt a socially sanctioned sick role (Parsons 1951), and provide access to health insurance funds for ﬁnancing treatment. Physicians are not well suited by interests or training to providing quasimedical social services, thus opening up new roles for allied health professions including social workers, psychologists, and chiropractors, as well as a myriad of new occupations such as personal exercise trainers and weight loss consultants.
Indeed, physicians have continued to pursue more specialized medical training and practice as help seeking patterns in the general population have redeﬁned the boundaries of medical care to encompass a much broader array of health concerns. Thus, in addition to the expanded opportunities aﬀorded the allied health professions, alternative and complementary health practitioners such as naturopaths, acupuncturists, and herbalists have grown in number and availability. In 1997, American consumers paid an estimated $27 billion for unconventional therapies, which is roughly comparable to out-of-pocket expenditures for physician services (Eisenberg et al. 1998). Increasingly, conventional physician-dominated settings, including prestigious teaching hospitals, are establishing alternative and complementary health clinics employing nonphysician providers.
1.3 Organizational Changes Conducive To Expansion Of Nonphysician Professions
Professions routinely aspire for full control over welldocumented jurisdictions in which workplace authority is secured formally through legislation or courts of law and validated by public opinion (Abbott 1988). Physicians have successfully defended their dominance over the medical division of labor through legislative and legal actions, controlling referral patterns, and by limiting direct access to health services payments (Sage and Aiken 1997). Yet, nonphysician health professions are constantly seeking to deﬁne themselves, grow, survive, and contest with medicine within an organizational environment that is continually subject to change due to exogenous social and technological trends.
The organizational context of medical practice changed substantially in the latter third of the twentieth century. The corporatization and consolidation of health services resulted in loss of autonomy for physicians (Starr 1982), but new opportunities and a more favorable environment for the allied health professions. Managerial priorities on cost containment gave allied health professions their ﬁrst opportunity to compete with physicians on the basis of price and client satisfaction, and they have been successful on both.
1.4 Rapid Growth Of Nonphysician Clinicians
The changing nature of health care and its organization has resulted in the rapid growth of allied health professions even in a context of a rapidly increasing physician supply. An analysis of growth of nonphysician clinicians in the USA revealed that the aggregate number of nonphysician clinicians in 10 disciplines (nurse practitioners, physician assistants, nurse-midwives, chiropractors, acupuncturists, naturopaths, optometrists, podiatrists, nurse anesthetists, and clinical nurse specialists) doubled between 1992 and 1997, and was expected to increase by two-thirds more by 2005 (Cooper et al. 1998). These 10 occupations were selected for study because they most overlap the scope of medical and surgical services provided by physicians. The growth of allied health professions is not unique to the USA, and evidence of expansion of nonphysician clinicians can be found in many industrialized countries and also in the developing world as health care becomes an increasingly global enterprise.
1.5 Globalization Of Health Services
Global trade and business interests have increasingly impacted upon health services and health care personnel through cross-national commercial ventures, trade agreements aﬀecting the movement of workers across national boundaries, and international aid activities. The North American Free Trade Agreement (NAFTA), linking Mexico, the USA, and Canada, and the European Union (EU) created the impetus to begin reconciling the training and practice of health professions across countries (Freeman et al. 1995). Health services is a major vehicle for transforming economic markets in the now independent states of the former Soviet Union, and many Western concepts of organization and ﬁnancing of health services, and education of medical personnel are being introduced (Mossialos and McKee 1998/99). The growing threat of new emerging infectious diseases in parts of the developing world has attracted international attention and focus on strengthening public health and primary care in poor countries (Institute for the Future 2000). Since the health workforce is the infrastructure upon which health services initiatives are built, global initiatives inevitably impact on the education and composition of the medical workforce.
Nursing is the largest of the health professions. Nursing historically has been closely tied to the profession of medicine, and the boundaries between the two have blurred over time in interesting ways. Nurses now participate in activities that in the past were the sole domain of physicians, such as physical examinations, diagnosis, treating illness, and prescribing drugs. The obverse is also true. Physicians have claimed jurisdiction over some types of services provided routinely in the past by nurses, as in the case of attending at normal births (Fagin 1990), and provision of anesthesia for surgery which only since the 1980s has become a physician specialty (Bankert 1989).
Expanded roles for nurses is a global phenomenon. The USA has led in developing expanded roles for nurses in care exploiting high technology (Fairman and Lynaugh 1998) and in independent practice roles in ambulatory care with the development of advanced practice nurses (Mezey and McGivern 1999). Other countries are now following similar patterns. British nurses have been granted wider authority by the National Health Service to prescribe drugs (Norman 2000). Canada is training nurse practitioners based on the US model of advanced practice nursing. Role expansion for nurses is occurring in a context of suﬃcient or excess supply of physicians, suggesting that nurses are not substituting for physicians as much as they are responding to a broader deﬁnition of health and medical care and market forces that provide new opportunities for role expansion for nonphysicians.
2.1 Historical Perspectives
Modern nursing dates back to mid-nineteenth century England when hospitals were disorganized, unsanitary, staﬀed by unskilled and undisciplined workers, and were generally held in low esteem. Only the destitute sought help in hospitals, except in times of war. Florence Nightingale, a wealthy and educated English woman, accepted the challenge of bringing order to military hospitals during the Crimean War and in doing so began a social experiment that would change the nature of hospitals around the world. Nightingale identiﬁed trained nurses as the vehicle for transforming hospitals but she recognized that nurses capable of skilled work and responsible ward management would have to be recruited from the better educated classes. To legitimize the work of nursing to more highly educated women, she drew on the well-respected traditions of religious education and military-style authority. Young nurses motivated by a sense of dedication and service to mankind worked long hours for few economic rewards under strict discipline with total obedience expected (Abel-Smith 1960).
Nightingale combined her vision of order and management led by trained nurses, with the opportunity created by the Crimean War and her social position and statistical prowess to forge a new future for hospitals. Florence Nightingale, while well known as the founder of modern nursing, was also among the ﬁrst to use proportional statistics (Cohen 1984). By tracking deaths by cause in military hospitals in Crimea she demonstrated that more soldiers died of hospital environmental causes than of injuries received in battle. Her volume, Notes on Hospitals, has been reissued in several versions as an example of one of the ﬁrst medical outcomes studies (Rosenberg 1989).
2.2 Vestiges Of History In Contemporary Nursing Roles
Nursing’s history leaves a legacy that gives contemporary professional nurses special legitimacy in the medical division of labor, and a high level of public trust. However, that same legacy creates substantial barriers to the continued evolution of the profession of nursing in contemporary health care. Nursing developed as an ancillary occupation supportive to physicians. Nurses gained much of their professional status and public legitimacy from their close association with physicians. The subordinate status of nursing relative to medicine in the medical labor hierarchy, however, has hindered their quest for greater autonomy (Friedson 1970). The dominance of medicine over nursing is often cited as the archetype of settlement of competing occupational jurisdictional claims by subordination (Abbott 1988). Medical dominance over nurses is linked to the organizational frame of the modern hospital where the majority of nurses practice and where physicians exercise considerable professional authority. Indeed, nursing’s quest for professional autonomy was not realized to any great extent until they began to practice in larger numbers and in a broader array of roles outside the hospital.
The association of early nurse training with religious orders has reinforced a continuing expectation of service and charity. These attributes are no longer valued as highly in Western culture, and no longer serve as suﬃcient motivating forces to recruit and retain professional nurses in today’s world. Despite a shift from caring and nurturing functions to more technological responsibilities akin to those associated with male roles in other occupations, nursing has retained a feminine image and is thus subject to sex-role stereotyping and sex discrimination in professional relationships and labor practices. The large-scale entry of women into the labor force and into higher education has facilitated the advancement of nursing by increasing the absolute number of nurses, raising overall educational levels, and broadening scope of practice. However, women now have many more career options than in years past and nursing is attracting a smaller share of new career aspirants as suggested by a steady rise in the average age of practicing nurses (Buerhaus et al. 2000). Prospects for attracting enough qualiﬁed nurses to meet projected future demands for health care are uncertain, which poses a threat to the professional advancement of nursing. In the past when the supply of nurses has been insuﬃcient to meet market demand, nursing has been vulnerable to the substitution of less-educated personnel and pressures to lower educational standards.
2.3 Nursing Education
The education of professional nurses has undergone a dramatic transformation since the 1970s that is still underway world-wide (Lynaugh and Brush 1996). Nursing education developed in hospital apprentice like programs with a large service component. Indeed, until the Great Depression forced many graduate nurses into hospital employment, hospital nursing care was supplied largely by students in training. Leaders in American nursing advocated early in the twentieth century the standardization of nursing education within institutions of higher education. The Flexner Report of 1910 had brought about similar reform in medical education in the USA. The analogue of the Flexner Report for nursing, known as the Goldmark Report, was published in 1923 and recommended the baccalaureate degree as the minimum entry-level educational requirement for professional nursing. Subsequent reports and commissions supported the recommendation culminating in the American Nurses Association in the late 1970s setting 1985 as the target year for requiring the baccalaureate degree. While progress has been made toward the goal of baccalaureate education for nurses, the new century dawned without this goal having been achieved in the USA, although other countries including Australia, New Zealand, Iceland, Chile, and United Kingdom have implemented an academic degree requirement for new entrants into nursing.
Freidson (1970) described nursing as an incompletely closed profession because of its inability to set a minimum educational requirement. Three generic types of education programs prepare professional nurses: three-year hospital diploma programs, twoyear associate degree programs, and four-year college university programs. Neither employers nor legal practice acts distinguish between professional nurses by type of education. The proportion of US nurses trained in hospital diploma programs declined from over 80 percent in 1960 to less than 8 percent in 1996. Community college programs instead of baccalaureate education replaced the diploma programs and now train over 60 percent of US nurses (Aiken and Gwyther 1995). By 1996, only about 40 percent of US nurses held a baccalaureate or higher degree, and 10 percent held master’s or doctoral degrees (Moses 1997).
3. Nurse Practitioners And Physician Assistants
Nurse practitioners, also known as advanced practice nurses, and physician assistants are two relatively new additions to the medical division of labor, both originating in the USA in the 1960s. Nurse practitioners represent more of an evolution in the profession of nursing than a distinct new occupation while physician assistants constitute a new allied health profession.
Nurse practitioners (NPs) are registered nurses with advanced clinical training (Mezey and McGivern 1999). In the USA a master’s degree is required for certiﬁcation in advanced practice nursing. Nurse practitioners provide generalist care including routine physical assessment, treatment of uncomplicated episodic illness, continuing care for persons with stable chronic conditions, and acute care in hospital settings. Nurse midwives, a type of advanced practice nurse, provide routine obstetrical care including normal deliveries as well as routine health care for women. Nurse practitioners have successfully deﬁned a legal scope of autonomous practice although attempts by physicians to exert control over their practice and remuneration is a continuing source of conﬂict (Sage and Aiken 1997).
Physician assistant (PA) education is generally 24 months in length. Programs exist in four diﬀerent academic pathways: certiﬁcate programs, associate degree programs, bachelor’s degree programs, and master’s degree programs although the PA component is the same regardless of degree level (Hooker and Cawley 1997). A major diﬀerence between physician assistants and nurse practitioners is that physician assistants have accepted a legally dependent role working under the direction of a physician while nurse practitioners have fought for and obtained a legal scope of practice that does not require physician supervision (Sage and Aiken 1997).
3.1 Historical Context
While nursing’s history and evolution is strongly tied to the development of the modern hospital, nurses have a long and distinguished history in public health and home care, settings in which they exercised considerable autonomy and professional leadership. Lillian Wald invented the term ‘public health nurse’ in 1893 to describe a role for nurses that was a combination of health promotion, illness care, and social reform (Buhler-Wilkerson 1993). Public health nursing and public health in general underwent substantial erosion in the USA with the rise of health insurance after World War II. However, the foundation for the emergence of nurse practitioners was the legacy of public health nursing.
The evolution of expanded roles for nurses and the development of physician assistants is often linked to a perceived shortage of generalist physicians in the USA in the 1960s and the market demand for physician substitutes. In the case of nurse practitioners, however, these factors created a favorable environment for expanding the scope of nursing practice that had long been advocated by nursing’s leaders and that was exempliﬁed by the early public health nurses. Thus, nurse practitioners, while often considered new allied health professionals, are really not new at all but nurses with legally sanctioned expanded scope of practice including some domains formerly controlled solely by physicians, such as drug prescription authority (Lynaugh and Brush 1996, Mezey and McGivern 1999). While educational and legal requirements for advanced nursing practice vary across countries, there is a global trend to replicate the successful US model (Fagin 1990, British Medical Journal 2000).
The origins of the new occupation of physician assistants in the USA stem from the return to the civilian workforce of military medical corps personnel in the 1960s at a time of a perceived domestic physician shortage. Most initial recruits to physician assistant programs were experienced medical corps personnel and the initial training programs were short-term onthe-job training. While the profession was predominantly male in its inception, it is now almost equally male and female, and the most recent graduating classes are over 60 percent female (Hooker and Cawley 1997). The early programs were located at medical schools but did not have academic standing or lead to degrees. Over time, degree-granting programs have been incorporated into schools of allied health.
Nurse practitioner education was rapidly incorporated into the large existing university-based infrastructure of schools of nursing. Enrollments in nurse practitioner programs grew steadily and by 1996 over 70,000 nurses in the USA had formal preparation as nurse practitioners, primarily at the master’s level (Moses 1997). There was no comparable existing educational infrastructure for physician assistant education, and thus their numbers have grown more slowly than those of nurse practitioners, reaching 29,000 in 1997 (Cooper et al. 1998).
3.2 Practice Issues
A large research literature has developed on the safety and eﬀectiveness of care provided by nurse practitioners and physician assistants. The Oﬃce of Technology Assessment of the US Congress conducted a synthesis of research published through 1985 and concluded that nurse practitioners and physician assistants working within their areas of competence provided comparable care to that provided by physicians, and in some aspects of care, such as patient satisfaction, nurse practitioners and physician assistants had better outcomes than physicians (Oﬃce of Technology Assessment [OTA] 1986). A special issue of the British Medical Journal (2000) reports similar ﬁndings from four randomized clinical trials evaluating care provided by nurse practitioners in the UK. Competing jurisdictional claims between professions are unlikely to be solved by scientiﬁc evidence. Indeed, no matter how many studies have been undertaken including randomized controlled trials (Mundinger et al. 2000), many physicians have not accepted nurse practitioners (Kassrer 1994, Sox 2000). The opposition of physicians notwithstanding, the market demand for nurse practitioners has grown steadily in the USA, a trend that appears to be spreading to other countries (Norman 2000).
4. Other Allied Health Professionals
Over 200 diﬀerent occupations and professions comprise the allied and auxiliary health care workforce. In the USA, this broad category accounts for 60 percent of the nation’s 10.5 million health care workers and includes personnel who provide therapeutic, diagnostic, informational, and environmental services across the full array of health care delivery settings (Ruzek et al. 1999). The non-nursing allied health occupations are diverse in roles, functions, and education (Hamburg 1975). Many of these occupations are products of the twentieth century, having evolved in response to demands created by new technologies and niche roles created by changing patterns of medical care. Some of the alternative and complementary medicine occupations such as acupuncturists have roots in cultures that predate the development of modern Western medicine but are nevertheless considered newcomers within the Western division of medical labor (Eisenberg et al. 1998).
Education, work setting, and license regulatory requirements vary vastly across the allied health occupations. Some ﬁelds require six months to one year training and are institutional on-the-job training programs, while others are university based. Physical therapy (PT) and occupational therapy (OT) are illustrative of the allied health professions that emerged primarily in the twentieth century.
4.1 Roles And Work Settings
Physical therapists plan and administer treatment to relieve pain, improve functional mobility, maintain cardiopulmonary functioning, and limit the disability of people suﬀering from physically disabling injury or disease. Approximately one-third are employed in hospitals; other major employers include rehabilitation facilities, home health agencies, nursing homes, school systems, and clinics. About 20 percent of physical therapists are in private practice.
Occupational therapists promote learning of skills necessary to perform daily tasks, diminish or correct pathology, and promote and maintain health. Occupational therapy focuses on both mental and physical disabilities. About 60 percent of occupational therapists work with people with physical disabilities. Some specialize in particular age groups such as the elderly or children. Occupational therapists working with the mentally ill or disabled in institutional and community-based settings typically provide activities that help mentally ill and disabled people learn to cope with daily stresses and manage their work and leisure time more eﬃciently (Institute of Medicine 1989). Most occupational therapists are employed by healthcare organizations and private practice is not common.
4.2 Evolution Of Occupational And Physical Therapy
Occupational therapy traces its origins back 200 years to a French physician’s observation that mental patients given menial tasks to perform improved in functional capacity faster than those who were idle. In the USA at the end of the eighteenth century, physician Benjamin Rush introduced work as a treatment for mentally ill patients at Philadelphia’s Pennsylvania Hospital, and in 1906 the ﬁrst training course for occupational therapists was established in Boston (Institute of Medicine 1989). World War I created a demand for rehabilitation of large numbers of injured soldiers, which served as a major impetus for expanding the scope of practice of occupational therapy to physically as well as mentally disabled persons, and for establishing the new occupation of physical therapy.
4.3 Education And Characteristics
Not surprisingly, given the growth impetus for physical and occupational therapists associated with the two World Wars, the early recruits to both occupations were predominately women. Over time both have remained predominately female occupations, although 25 percent of physical therapists are men compared with 5 percent of occupational therapists and 6 percent of nurses. The ﬁrst training program in physical therapy in the USA began in 1917 as a short course for women aides. The success of these aides in the aftermath of World War I resulted in federal funding to increase the supply of therapists during World War II through accelerated programs to train college graduates in related ﬁelds such as physical education for roles in therapy. University-based degree-granting programs in physical therapy were established concurrently. Physical therapy has thus been a university-based educational program almost from its inception.
Since 1979, the American Physical Therapy Association has advocated graduate level preparation for the profession. As of 2002, the Association will no longer accredit baccalaureate professional programs and is moving to master’s and doctoral level professional education. While practitioners with a baccalaureate degree may still practice, the purpose of the change in accreditation is to shift the educational patterns for future cohorts. Physical therapy does not support career mobility from the physical therapy aide category to the professional category and has established non-overlapping educational requirements for the two groups thus avoiding the problem nursing has faced. Physical therapy has also developed viable options for private practice, which allows the occupation to continue to evolve independently, to some extent, from institutional managerial control of salaried practice. Physical therapy is considered to be more visible and autonomous than occupational therapy for these reasons (Institute of Medicine 1989).
Occupational therapy in many ways more closely resembles nursing in its composition and education than physical therapy, perhaps because its roots are in the nineteenth century with nursing and its knowledge and intervention domains are less discrete than physical therapy. The ﬁrst formal ‘professional’ standards for education in occupational therapy were established in 1923 as 12-month training programs for high school graduates, in contrast to physical therapy, which moved directly to university-based education. There are presently two educational levels for practice: technical training at the two-year associate degree level and professional education at the baccalaureate degree for registered occupational therapists.
Occupational therapy has had diﬃculty attracting students reportedly because of its focus on mental health services, which are highly stigmatized, and poorer remuneration opportunities than alternative ﬁelds such as physical therapy. In 1995, there were 54,000 registered occupational therapists compared to 102,000 physical therapists in the USA (Bureau of Labor Statistics 1996).
5. Global Perspectives
Developing countries, which contain 84 percent of the world’s population, account for only 11 percent of the world’s health professionals (Schieber and Maeda 1999). Physicians, the most expensive category of health personnel, are often in relatively generous supply compared to nurses and allied health personnel in countries with modest annual health expenditures. An imbalance in the ratio of physicians to allied health workers has a number of consequences including excess expenditures on secondary and tertiary care leaving inadequate resources for primary care and public health as well as geographic imbalances in health care because physicians tend to locate in urban areas. The range in the ratio of nurses to doctors is enormous across countries: from one doctor to three or four nurses in northern European countries, to one doctor to 1.5 nurses in south-eastern Europe, and from one nurse to two doctors in Argentina, to one nurse to ﬁve doctors in Pakistan (Bankowski and Fulop 1987).
Allied health workers provide much of the medical care in poor countries but are in short supply and often poorly trained. The potential of nurses and nurse midwives to improve access to and quality of health care in developing countries is well recognized. However, many countries have insuﬃcient resources to create employment opportunities for qualiﬁed nurses (Bankowski and Fulop 1986). Thus, nurses trained in developing countries migrate in substantial numbers to more aﬄuent countries. Additionally allied health workers with some medical training such as feldshers in Russia are also in short supply because of the practice of admitting experienced health care workers to physician training programs (Ryan and Thomas 1996).
Developing countries tend to emulate the medical care systems in industrialized countries by building hospitals, purchasing technology, and training large numbers of physicians. Ultimately the prospects for improving health in the developing world are in investments in frontline allied health workers, primary care, and public health and safety.
Thus, nursing and other allied health occupations have good prospects for future growth in developing countries as well as in the sophisticated and highly technological health systems of industrialized countries.
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