On the Interplay Between Boundary Work and Organizational Context

2.1 Boundaries and Boundary Work

The concept of boundary work was originally coined by Gieryn (1983) to illustrate the demarcation of science from non-science. It can be studied by examining how professionals socially construct professional or disciplinary boundaries individually and collectively through discursive, cognitive, material, and embodied practices (Langley et al. 2019). A great deal of boundary work literature employs the notion of professional boundaries to understand professions, professional identities and projects, and how these professional interests influence interprofessional collaboration (Bucher et al. 2016; Bos-de Vos, Lieftink, and Lauche 2019; Järvinen and Kessing 2021; van Bochove et al. 2018). Making, negotiating, or maintaining boundaries can be significant for a professional’s claim of a practice domain. Embedded in the sociology of professions (Abbott 1988), the notion of boundary work typically refers to fights for jurisdictions among professional groups who strive to demarcate exclusive rights to specialized knowledge and jurisdictional control (Liu 2018; Feyereisen and Goodrick 2019). The ongoing construction and negotiation of boundaries marks who belongs to a professional group and who does not. Negotiating boundaries can thus be used to stress the differences between “us” and “them” in interprofessional collaborations as an exclusion mechanism or to use references to difference as occasion for including members of other disciplines or professions into collaboration (Meier 2015). Hence, interprofessional collaboration implicitly involves boundary work, which in turn has consequences for establishing and reproducing professions and professional projects (Bucher et al. 2016; Fournier 2000; Järvinen and Kessing 2021).

Boundary work has therefore often been applied to study professionals’ responses to organizational change or new interprofessional collaboration initiatives (Lindberg, Raviola, and Walter 2017; Weber et al. 2022). For example, Liberati, Gorli, and Scaratti (2016) found that interprofessional collaboration in a hospital setting remained challenging even after reorganizing from functional units to multidisciplinary teams. The professionals sought to maintain their occupational identity, making it challenging to bridge professional boundaries. Consequently, disputes over boundaries stood in the way of improving integrated care. And Eliassen and Moholt (2023) studied boundary work between therapists and home trainers in reablement teams within a municipal home care set-up. They found that reablement teams were either hierarchical (drawing on demarcation strategies) or symbiotic (drawing on collaborative strategies).

Although professionals often collaborate towards achieving a common goal for their citizens, they also have their own distinctive professional goals and are thus in competition with each other (Wackerhausen 2009) which influence their boundary work (Comeau-Vallée and Langley 2020). Bucher et al. (2016) studied how field-level professionals responded to a proposal for interprofessional collaboration that would potentially change their jurisdictional boundaries and professional practices. The study found that the professionals used different discursive boundary work strategies that reflected the status of their professions. The higher-status professions engaged in “generic naturalistic framing” in that they emphasized maintaining the status quo and did not question current boundaries, presenting other professions as being less important. Professions with lower status engaged in “targeted evidence-based framing” of other professions to explicitly renegotiate boundaries to deconstruct the generic naturalistic framing of the higher-status professions based on evidential and experiential resources.

In another study, Bos-de Vos, Lieftink, and Lauche (2019) showed how architects in inter-organizational settings responded to threats of marginalization and increasingly unstable role structures by engaging in different types of boundary work: reinstating, bending, and pioneering role boundaries. These strategies enabled the professionals to reconcile project demands with their professional values and beliefs (Bos-de Vos, Lieftink, and Lauche 2019). Building on this work, Taminiau and Heusinkveld (2020) explored how professional groups with different statuses in accounting firms responded to institutional pressures. They found that the higher-status professionals (accountants) applied competitive boundary work strategies, which in turn spurred competitive strategies from the lower-status professionals (tax advisors).

An important insight from this line of research is the theorization of a relationship between social position and boundary work at the meso and micro level of organizations and how this relationship impacts boundary negotiations. Higher-status professionals tend to make efforts to naturalize clear boundaries, while lower-status groups tend to blur boundaries to advance their position (Comeau-Vallée and Langley 2020; Langley et al. 2019). The body of literature on boundary work shows that despite the intention to dismantle organizational and hierarchical boundaries to deliver holistic and coordinated care, existing power dynamics and status struggles may be reproduced in interprofessional settings (Finn 2008; Järvinen and Kessing 2021; Liberati, Gorli, and Scaratti 2016; Nugus et al. 2010; Wackerhausen 2009). Accordingly, the ongoing negotiation of boundaries means reorganizing for more coherent care does not necessarily imply the integration of work across disciplines (Liberati, Gorli, and Scaratti 2016).

2.2 Boundary Work and Organizational Context

Recently, boundary- work research has emphasized the importance of understanding the different contexts and conditions surrounding the professionals being studied (Langley et al. 2019; Liberati 2017; Lindberg, Raviola, and Walter 2017; Weber et al. 2022). Professionals’ boundary work is increasingly understood as shaped not only by elements found at the professional level (e.g., identities) but also by elements found at the organizational level (e.g., contextual constraints). Considering different ways of organizing, Stjerne and Svejenova (2016) investigated permanent and temporary organizational structures in a Danish film production company. These authors drew on boundary work to reveal how tensions were resolved at different levels to shape a complex and dynamic connection between temporary and permanent organizational structures. In their study, Lindberg, Walter, and Raviola (2017) emphasized changes in the organizational context for boundary work following the introduction of new practices in a hybrid operating room in a hospital. Specifically, they found that new technologies and material artifacts conditioned the performance of boundary work. However, to our knowledge, only a few empirical studies have focused explicitly on how the context within which boundaries, groups, tasks or collaboration unfold matters for professionals’ boundary work. When the literature does include context as relevant, this is primarily articulated as a relatively stable, rather general and often disembedded background to the professionals’ everyday boundary work.

Increasingly, however, researchers recognize that context is much more dynamic and interlinked with phenomena than previously theorized (Meier and Dopson 2021; Murdoch et al. 2023) and this may also apply to the relationship between boundary work and organizational context. Carmel (2006), for example, found that the efforts of doctors and nurses to obscure their professional boundaries ended up reinforcing the organizational boundaries. Boundaries are “an intrinsic element of organizing”, as Stjerne and Svejenova (2016: 1773) state and we should not assume a simple, one-directional relationship. Considering ‘context’, Meier’s (2015) study of collaboration in hospital wards found that a range of conditions related to the nature and organization of healthcare work, e.g., the degree of urgency, input uncertainty, and severity of the patient’s illness, influenced the professionals’ boundary work. Similar results were described by Liberati (2017) in a study of how context influences the regulation of the medical-nursing boundary in three hospital wards. This author found three types of context factors: patients’ state of awareness, the type of clinical approach adopted by nurses and doctors, and the level of acuity on the ward.

Such knowledge of the interplay between context and boundary work is important because it nuances our understanding of how and why professionals draw boundaries in certain ways and with which effects. These studies highlight an important, and so far, underexplored point in the literature on boundary work: a link can be made between organizational context and professionals’ boundary work and as Liberati (2017) argues, the current literature fails to sufficiently examine and theorize the “negotiation context” in which professionals draw boundaries.

3.1 Research Context

In Denmark, municipal authorities provide care-needing older adults with publicly funded home care and home healthcare. The Danish Social Services Act regulates home care (personal care and domestic help), while the Danish Health Act regulates home healthcare. The eldercare workforce consists of nurses (approx. 14 %), social and healthcare assistants (approx. 32 %), social and healthcare helpers (approx. 37 %), and unskilled labor (approx. 10 %) (Vinge and Topholm 2021).

Based on educational level, clinical decision making and autonomy over work, nurses are the higher-status group with a minimum education at the Bachelor level, corresponding to level 6 on the international EQF scale (Kjellberg et al. 2022). In Danish eldercare, nurses perform healthcare tasks that cannot be delegated to care workers with lower competence levels and are responsible for managing complex care pathways, such as those of terminally ill citizens. Non-complex tasks such as stable wound care, simple medicine dosages, injections, medicine administration, and compression socks are typically delegated to care workers (Vinge and Topholm 2021). Care workers, which include social and healthcare assistants and social and healthcare helpers, also provide personal care and domestic help, such as bathing, dressing, and nutrition, for which the needs are assessed and allocated by administrative personnel (typically with a background in nursing, physiotherapy, or occupational therapy). Social and healthcare assistants have a vocational education corresponding to level 4 on the international EQF scale, while social and healthcare helpers are trained at level 3 on the same scale (Kjellberg et al. 2022). For the analysis, we were interested in the boundary between health care and home care and therefore grouped social and health care assistants and helpers under the term ‘care workers’. These care workers form the lower-status group based on lower education levels, clinical competence, and reduced autonomy over work compared to nurses.

The need for interprofessional collaboration (i.e., working together) between nurses and care workers is substantial in this sector (Hald et al. 2024a). For example, if a citizen receives both complex wound care from a nurse and help with bathing and dressing from care workers, the nurse and care workers must coordinate when each carries out their tasks and keep each other informed about the citizen’s health progress regarding the wound. Another example is when a nurse has been performing complex care tasks that have stabilized, e.g. medication dosages, in which case the nurse would delegate the task to the care workers and supervise the care pathway, necessitating continual communication. This makes interprofessional collaboration between nurses and care workers, regardless of its form, an ongoing process of coordination, communication, and delegation (Hald et al. 2024b).

This ongoing process is structured through formal documentation systems (electronic patient records), where professionals can record observations, agreements, and tasks for one another, and can be supplemened with weekly or bi-weekly in-person meetings to facilitate coordination, communication, and discuss potential challenges or difficult tasks. Moreover, interprofessional collaboration can also occur informally, with professionals coordinating and communicating via text, phone calls, or casual conversations when they meet at the office or at the citizen’s home (Hald et al. 2024a). However, it is important to note that while this interprofessional collaboration is greatly needed and the municipalities have different ways of organizing for it, it does not always occur as expected. Despite the formal systems and expectations for interprofessional collaboration, the findings illustrate that it is not always enacted in practice, meaning professionals do not always collaborate across boundaries as intended.

In the case of functional units, nurses are organized in healthcare units with nursing managers, and care workers are organized in home care units with home care managers. These units are usually not co-located, with professionals working from different offices and sometimes not even sharing the same citizen base. This means that the functional units are viewed as separate entities with interprofessional collaboration occurring across the organizational boundaries between the two types of units. In contrast, in the integrated units, nurses and care workers report to the same manager, work from the same location and office space, and share the same citizens. These integrated units are typically organized in smaller interprofessional ‘groups’ or ‘teams’ and the interprofessional collaboration thus happens within the unit.

Consequently, although the expectations towards interprofessional collaboration are the same in both cases, the organizational context differs significantly. In this study, we explore possible connections between these different organizational contexts and the boundary work strategies of nurses and care workers.

3.2 Case Selection

To examine how and why different organizational contexts are connected to different forms of boundary work, we chose two cases for comparison: A case of boundary work articulations in functionally organized units (three research sites) and a case of boundary work articulations within integrated units (two research sites). The two cases of boundary work articulations were chosen to vary on how the organizational boundaries are drawn, serving as polar cases (Eisenhardt 2021). We were able to recruit five municipalities as research sites to participate in the study. Three municipalities were recruited serving as cases of functionally organized units, and two municipalities were recruited as cases of organizing in integrated units. The participating municipalities differed in size and geographical location because they were only sampled on this aspect of the organizational context. However, they were otherwise similar in terms of how the nurses and care workers were expected to work together in the care pathways.

3.3 Data Collection Through Interviews

We conducted in-depth semistructured group interviews with members of each professional group. This method produced knowledge on how the professionals articulated their own and the other group’s collaborative efforts and their experiences of how their practices were related to the organizational context they worked within. The purpose of interviewing each professional group individually was to gain insight into their experience and perceptions of working together across professional groups and to ensure openness among each group (see e.g. Bach, Kessler, and Heron 2012).

Access to interview participants was obtained through the local managers in each municipality. In total, 12 nurses and 19 care workers participated in the study. Table 1 presents an overview of the number of participants within the two professional groups from each municipality. Data consisted of a total of 15 qualitative group interviews conducted by the first author in October and November 2021. Interviews were held in the municipalities or online if requested by the municipalities due to the risk of COVID-19. Each group interview lasted between 90 and 120 minutes.

The interviews were structured around a thematic interview guide which was tailored to each of the three professional groups but centered around the following themes: 1) perceived advantages and disadvantages of the organizational context, 2) the professional role and task domains of each professional group, 3) task allocation practices, and 4) ways of collaborating across professional and/or organizational boundaries. The interview participants discussed the functioning of working together, coordination and communiation, how it was organized for in their local context, and how this impacted their professional interests. The interviews gained insights into each professional group’s articulated practices and experiences of whether and how they worked together across professional boundaries, and thus, into how they articulated boundary work efforts.

3.4 Data Analysis

The interviews were audio recorded and subsequently transcribed. As a first step, we wrote up brief case narratives (Miles and Huberman 1994) to understand the local organizational context of the professionals and how interprofessional collaboration was organized for, e.g. mutual meetings, phone contact or informal interactions. The coding progressed in three steps drawing on an abductive analysis strategy (Thompson 2022). The aim was first to characterize how the two professional groups discursively constructed boundary work strategies and to compare these articulations across the two cases to investigate whether and how there was a relation between boundary work and organizational context. For this, the transscribed inteview data was pooled into each case to allow for within-case analysis of boundary work articulations in functional units and integrated units respectively. In this second reading of the material, data were coded following the theoretical concepts of collaborative and competitive boundary work, as shown in Table A1 in the appendix. These overall concepts guided an initial open coding. We then analyzed the coded paragraphs to identify specific micro-strategies concerning the two professional groups. We also coded instances where these strategies were connected to the organizational context. In this step, we were guided by the micro-strategies already identified in the literature while remaining open to additional or contrasting findings. For example, we interpreted it as competitive boundary work when nurses talked about how much they valued being organized in their own unit and what this meant for their professionalism (“defending”). Or, when care workers, rather than resisting or trying to create new boundaries, made excuses for why nurses often did not attend mutual case conferences, we interpreted this as collaborative boundary work (“accommodation”). The majority of the most salient micro-strategies we identified corresponded with the literature (e.g., “differentiation”), while a few appeared to us to suggest new formulations (e.g., “withdrawal”). The outcome of the analysis is illustrated in Table A2 in the appendix.

Then, we conducted a cross-case analysis by 1) juxtaposing the articulated boundary-work strategies of each professional group in the two cases and 2) juxtaposing the strategies connected to nurses and care workers, respectively, between cases. We did this to examine the differences and similarities in articulated strategies across the two organizational contexts to draw out the important elements for boundary work. Additionally, we wanted to examine the differences and similarities in boundary work across the two professional groups to draw out their relations to hierarchical status. We saw that care workers drew on similar types of boundary work in the two cases. In contrast, the articulations of the nurses’ boundary work varied with each case. Our case analyses are illustrated in Table 2.

4.1 A Competitive Boundary Work Mode in the Functional Units

4.2 A Collaborative Boundary Work Mode in the Integrated Units