The division of labour in vision care - Wiley Online Library

Sociology of Health & Illness Vol. 22 No. 4 2000 ISSN 0141±9889, pp. 431±452

The division of labour in vision care: professional competence in a system of professions Fred Stevens,1 Frans van der Horst,2 Frans Nijhuis 3 and Silvia Bours 2 1

Department of Health Care Sciences, Section of Medical Sociology, University of Maastricht 2 Department of General Practice, University of Maastricht 3 Department of Health Organisation, Policy and Economics, University of Maastricht

Abstract

The provision of vision care services by ophthalmologists, general practitioners, orthoptists, optometrists and opticians in the Netherlands was investigated. We assessed their division of labour, task boundary conflicts, and consensus on professional domains. Analysis of six patient cases indicated considerable overlap in the services provided by these professions. Only general practitioners and orthoptists were content with their current role. Ophthalmologists preferred to delegate cases, optometrists and opticians to expand their services. The results revealed important differences in inter-professional status, more or less fixed-status hierarchies and dissatisfaction with the existing division of labour. Preferences of the professions did not point to increased inter-professional co-ordination; this could probably only be achieved by means of external intervention.

Keywords: professions, health occupations, division of labour, interprofessional co-ordination, domain consensus, ophthalmology, vision care Introduction This paper examines the division of labour among professions involved in the provision of vision care services in the Netherlands. An important issue in the organisation of health care services is how the activities of autonomous occupational groups can be co-ordinated, so that overlap of activities can be reduced and medical care can be provided at the best level possible. In theory, the relationship between different eye care professionals should be mutually beneficial, based on consensus about their respective functional # Blackwell Publishers Ltd/Editorial Board 2000. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden MA 02148, USA.

432 Fred Stevens, Frans van der Horst, Frans Nijhuis and Silvia Bours

territories or work domains. In practice, however, this is rarely the case. Studies have shown that occupations compete and dispute each other's claims about which occupation performs, or should be allowed to perform, specific work tasks (Abbott 1988, Begun and Lippincott 1987, Bucher 1988, Hughes 1958). Workplace activities are seldom so complex or unamenable to differentiation that occupational domains cannot be contested (Aiken and Sloane 1997, Jamous and Peloille 1970). In addition, because successful professionalisation is strongly influenced by technological developments, new claims are likely, which will intrude into the existing division of labour (Barley 1986, Blum et al. 1988, Gritzer and Arluke 1985, Light 1995). In the sociology of the professions a long research tradition has focused on the division of labour between professions. Two perspectives have dominated this line of research. In the first, emphasis has been on the professional arena, with professions being seen as more or less autonomous àctors' who negotiate tasks in the workplace in order to settle, maintain or expand their respective domains (Hughes 1958, 1963). Examples are found in studies on negotiations between doctors and nurses in hospital wards (Allen 1997, Strauss et al. 1964, Svensson 1996). In the second, more `macro'-oriented perspective, emphasis is on medical dominance in the division of labour visaÁ-vis other health occupations. Studies have, for instance, shown how powerful professions (e.g. medicine) are able to set the terms for their work and how, in the division of labour, `dirty work' is passed on to subordinate groups like nurses and other allied professions (Brannon 1994, Freidson 1970, 1988). Because of the growing popularity of the power approach during the last two decades, with dominance and autonomy as hallmarks of professionalisation, the sociological study of professions has shifted more and more from the workplace to macro-oriented studies (Abbott 1993). This also applies to approaches in which professions are conceived as operating in a field of countervailing powers of economics, organisation of services, governmental policies, and consumer/patient demand (Johnson 1972, Larson 1977, Light 1993, 1995). As a consequence, analyses of the workplace have been marginalised in the literature. Several authors have expressed their uneasiness with this state of affairs. As Hall over a decade ago stated: Ìt is time to return to the research fields and find out what is going on within the professions and the contexts in which they work' (Hall 1988: 275). Abbott has suggested that we put the workplace at the centre, and that, instead of focusing on one profession, we should study systems of professions: complex, dynamic networks of occupations, involving interrelated struggles over the workplace (Abbott 1988, 1993). Abbott emphasises the link between a profession and its work, which he calls its jurisdiction. Dynamics in professional relations are not only dependent on the activities of individual professions, but also on the behaviour of other professions in the context of technological and social changes in their environment. Sometimes this results in the dominance of one group over the others; at other times it leads to changes in the division # Blackwell Publishers Ltd/Editorial Board 2000

The division of labour in vision care 433

of labour. Consequently, developments in one occupation affect directly or indirectly all the other occupations in the same system. In this process, occupations try to gain the support of the state and the general public. Although Abbott has been criticised for putting too much weight on the systems concept, and on the struggle between professions to the neglect of power relationships (Macdonald 1995, Krause 1996), the significance of his work lies in his attempt to bring workplace studies back into the centre of sociological analysis. A limitation of his approach, however, is that, in the main, he focuses on the historical development of systems of professions. His pure Chicago School approach, which stresses `what do professions do', is confined to the historical, interacting development of systems of professions. There are few `middle range' studies that examine the way in which contemporary occupations as interacting collective entities actually organise their work and perform specific tasks within specific work domains (Walby et al. 1994, Wicks 1998). In the present study we assessed the actual and preferred occupational domains of health professionals providing vision care services. We investigated the division of labour, specific task boundary conflicts, and domain consensus of these professions and then used this information as the basis for a discussion of professional status and identity. There are several sociological arguments to support our choice of this particular occupational domain. First, occupations providing vision care services have system characteristics. They share a common goal, the delivery of vision care services, and in this they are mutually dependent in order to function properly and are to a certain degree dependent on the same material and social environment (clients, the government, the insurance system, practice settings). Secondly, the domain of vision care is a `classic' example of technology-induced segmentation and of horizontal and vertical task differentiation in and around medicine: horizontally between ophthalmologists and general practitioners and between opticians and optometrists; vertically between medical and non-medical occupations (Begun and Lippincott 1980, Van der Horst 1996, Wardwell 1972). Ophthalmic services in the Netherlands Task areas In the Netherlands, five independent professions provide vision care services: ophthalmologists, general practitioners, orthoptists, optometrists and opticians. Ophthalmology was officially recognised as a medical speciality in 1936 and there are about 450 registered ophthalmologists. Most work in hospitals or in ophthalmic clinics (Van der Horst 1996, Van der Kwartel 1997). There are about 6,650 general practitioners in the Netherlands. The general practitioner has a special position vis-aÁ-vis ophthalmic services. On the one hand, he or she is professionally qualified to carry out specific ophthalmic examinations and treatments and, on the other, as the medical gatekeeper in # Blackwell Publishers Ltd/Editorial Board 2000


primary health care, he or she also governs access to other, mainly hospitalbased, services (Imhof 1997). There are about 240 orthoptists in the Netherlands. These allied health professionals are specialised in the treatment of children and deliver refractive services and give vision training. The profession was introduced to the Dutch health care system in 1956, when its practitioners were called `ladies for training children with crossed eyes' (De Vries 1983). In 1975, orthoptists gained the status of a paramedical profession; a formal educational programme was introduced and the occupation was protected by law. Now, orthoptists have an autonomous work position, although patients have to be referred to them by general practitioners or ophthalmologists. While ophthalmologists, general practitioners and orthoptists are all professionals in the medical domain, this is not the case for optometrists and opticians. Optometrists specialise in the `healthy eye'. They supply contact lenses, examine the eye for defects and faults of refraction (subjective and objective 1) and prescribe corrective lenses or exercises, but not drugs or surgery. In this, even more than with opticians, their work overlaps that of general practitioners and ophthalmologists. In 1989, optometrists started a full-time educational programme at bachelor's level. From 2000 on, optometrists, as a paramedical profession, will officially be included in the health care system. The Dutch optometrist will then be allowed to perform activities that were, until recently, the exclusive domain of ophthalmologists and general practitioners (Van der Kwartel 1997). In fact, the Dutch optometrists can then be compared to their British counterparts, who were introduced into the National Health Service in 1948, and whose degree of Bachelor of Science (BSc) was acknowledged in the Opticians' Act of 1958. Opticians, who number about 330 in the Netherlands, make up spectacles in accordance with optical prescriptions. Because optics has traditionally been considered a craft, the training of opticians took place in a `guild-like' fashion (Krause 1996). In 1936, a special course was started to train opticians, with successful completion of the course being recognised in the title `master optician'. Later, because of technological advances, opticians could specialise in optometrics and in contact lenses. These specialised opticians call themselves optometrists, but will no longer be allowed to do so with the official recognition in 2000 of the professional training for optometrists (similar to the UK optometrists). Opticians also measure defects of refraction (subjective). With this, their task domain overlaps with that of ophthalmologists and general practitioners and optometrists. Ophthalmologists and orthoptists mainly work in hospitals. The ophthalmologist, however, has taken over the primary health care role of the general practitioner, although a patient can usually visit him or her only after a referral from a general practitioner. Most opticians and optometrists are self-employed in optical retail outlets. Serving as a low-threshold facility, they have a non-official primary care function, because people can come to them with their vision problems before going to a physician. A summary of the main characteristics of the occupations under study can be found in Table 1. # Blackwell Publishers Ltd/Editorial Board 2000

Table 1. Characteristics of occupations in vision care in the Netherlands General Practitioners

Optometrists

Orthoptists

Opticians

Occupation

Medical

Medical

Non-medical1

Paramedical

Non-medical

Total number of practitioners (1996)

450

6650

805

260

330

% part-time employed1

28

18

5

100

1

% women1

24

15

12

98

18

Training

6 years medical training+4 years internship ophthalmology

6 years medical training+3 years internship general practice

4 years optician+ 4 years day release courses2

3 years orthoptist

4 years, full time or day release courses

Task domains

Specialized medical care

General medical care; screening for pathology

The `healthy eye', objective and subjective refraction, dispensing of all optical appliances

Refractive services and vision training

Subjective refraction, dispensing of spectacles and contact lenses

Practice setting

Hospital

General practice

Optometric practice/ optical retail outlet

Hospital

Optical retail outlet

Referral necessary

Yes, from general practitioner

No

No

Yes, from general practitioner or ophthalmologist

No

1 2

Based on the study sample. From 2000 on the optometrist will have an official and exclusive paramedical status, based on a bachelor's degree.


# Blackwell Publishers Ltd/Editorial Board 2000

Ophthalmologists


Shortage problems and sources of conflict As Abbott states: `Normally differentiation appears when demand suddenly outstrips available professional numbers' (Abbott 1988: 77). This seems to apply to vision care services in the Netherlands. There is one ophthalmologist for every 36,400 inhabitants in the Netherlands. Comparing this with other countries shows that the ophthalmologist density in the Netherlands is not very high (E.C.O.O. 1996, N.O.G. 1992). In Belgium there is one ophthalmologist for every 11,900 inhabitants, in Germany one per 16,300 and in Italy one per 9,500. Great Britain has very few ophthalmologists (one per 77,200), but this is outweighed by the large number of well-trained optometrists who have a pivotal position in British primary health care. Optometrists have a similar position in the U.S. (Wardwell 1972, Begun and Lippincott 1987). A consequence of the small number of ophthalmologists in the Netherlands is long waiting lists for their services (F.O.Z. 1994). Shortage problems are aggravated by the fact that general practitioners are providing fewer vision care services (Van der Velden et al. 1991), mainly because nowadays they lack specific knowledge and skills. Their main task is one of referral. Shortage problems and a declining role of the general practitioner in ophthalmology coincides with the growing popularity of the optician. In 1983, 63 per cent of people with vision problems went first to an ophthalmologist; in 1995 only 26 per cent did so. In 1995, 65 per cent of people with visual problems visited an optician/optometrist first, instead of an ophthalmologist. In the 1970s the government suggested, unsuccessfully, that opticians should be given a formal role in health care in recognition of the long waiting lists for ophthalmologists and the easy accessibility of opticians (Trompen 1970, Kaan 1979). The relationships between optometrists, elsewhere characterised as an èncroaching occupation' (Begun and Lippincott 1980), and ophthalmologists have not been resolved to the full satisfaction of both parties. In the early 1980s, the Dutch Ophthalmic Association advised that better trained paramedical optometrists should be introduced as a `bridge' between ophthalmologists and opticians (N.O.G. 1980). Orthoptists anticipate that vision care services will become streamlined when doctors other than ophthalmologists and general practitioners (e.g. paediatricians, neurologists) are allowed to refer patients directly to them. A complication is that primary health care workers have little knowledge of the work of orthoptists. The current problems of inter-occupational co-operation and sources of conflict in vision care in the Netherlands can be summarised as follows: .

People with visual problems have a choice between many facilities and occupations: opticians, general practices, eye clinics, outpatient clinics, etc. The domain, however, lacks co-ordination and formal co-operation. The scarcity of health care resources makes it necessary to co-ordinate tasks and activities.


The division of labour in vision care 437 .

.

.

There is a shortage of ophthalmologists. Waiting lists are long for nonurgent patients. For the majority, it can take 6 to 26 weeks before they can go to the ophthalmologist. The general practitioner seems to be losing his or her professional ophthalmic competence, and now needs extra training. This, however, is complicated by the fact that there is no consensus on what should be the core tasks of the general practitioner in vision care. The division of labour between opticians, optometrists and orthoptists is not clear. Indeed, the overlap of activities and functions is increasing with further training opportunities, legalisation and extension of task domains. It is important to determine formally which profession is responsible for certain tasks.

Research questions While professional groups recognise the need for a more effective division of labour and better co-ordination of vision care services, they also try to keep and even to extend their respective domains (Abbott 1988). Most occupations try to acquire status and prestige that can be used to claim and to protect a work domain, generate income and capital, and legitimate power (Larson 1977, Macdonald 1995). This makes it unlikely that an acceptable, non-overlapping division of labour will easily be realised. This paper illustrates the professional division of labour by addressing the following research questions: first, how do different professions perceive problem areas in vision care? Secondly, how do professions perceive their own competence and task domain in relation to those of others? Thirdly, how much consensus exists about task domains? Fourthly, to what extent are preferred task domains amenable to a more effective division of labour? In this paper we deliberately use the terms `professions' and òccupations' interchangeably. This is because we are not concerned with the problem of professionalisation, what constitutes a profession, or how a specific occupation becomes one. Research design The data for this study were collected in 1996 by means of a mailed questionnaire (Van der Horst 1996). A stratified random sample of 800 general practitioners was drawn, based on province, urbanisation grade (urban±rural), practice setting (solo practice±group practice), age of practice (new vs. long-existing practice), sex and age of the GP. Within the group of optometrists, a 50 per cent sample was drawn. Because the number of practising ophthalmologists, orthoptists and opticians in the Netherlands is relatively small, all practitioners were approached to participate in the # Blackwell Publishers Ltd/Editorial Board 2000


study. After correction for respondents who were not accessible (address unknown, retired, deceased, etc.), the following response rates were obtained: 397 general practitioners (51 per cent response), 296 ophthalmologists (71 per cent), 187 orthoptists (78 per cent), 562 optometrists (71 per cent) and 185 opticians (65 per cent). With 1825 persons participating in the study, a total response rate of 65 per cent was obtained. All subjects received the same questionnaire. Data Problem areas Respondents were given a list of statements about issues that could be considered problematic. These had to be checked as being (a) a `pressing problem'; (b) a `less pressing problem' or (c) `no problem at all'. The list consisted of items concerning the shortage of ophthalmologists, work load, practice organisation, perceived professional autonomy, co-ordination of tasks and perceived professional recognition from the other vision care professionals. Items were derived from an instrument developed to measure the occupational image of nurses (Birnbaum and Somers 1989), supplemented by specific questions on shortage, professionalisation and practice organisation (Stevens et al. 1992a, 1992b). Factor analysis (Principal Component Analysis with varimax rotation) was conducted on all items, resulting in four components. Within each component, items with highest loadings (4.60) were summed, resulting in four variables. Internal consistency was calculated by means of Cronbach's alpha. The four variables, indicating different problem areas, were labelled as (problems with) (a) Workload and practice organisation (six items, e.g. `Time available for patients', Àvailability of supporting personnel'; alpha=.83), (b) Inter-professional coordination and recognition (four items, e.g. `Co-ordination of occupations in vision care', `Recognition by other vision care professionals'; alpha=.78), (c) Waiting lists and shortage of ophthalmologists (four items, e.g. `Waiting lists for first visits with an ophthalmologist', `Shortage of ophthalmologists'; alpha=.74), and (d) Professional autonomy (three items, e.g. Àutonomy in making decisions', Àutonomy to treat patients as preferred'; alpha=.81). A complete list of items for each problem area, including the item-total correlations can be found in Appendix 1. Cases To investigate perceived professional competence in different task domains of vision care, six hypothetical cases were presented to the respondents. These cases, developed in close collaboration with the professional associations for the occupations under consideration, satisfied the following criteria: (a) the cases were `recognisable' for all occupations involved; (b) the cases had relatively high levels of incidence and prevalence; and (c) the cases # Blackwell Publishers Ltd/Editorial Board 2000


represented the major overlapping task areas in vision care. Based on these criteria, the following cases were presented to the respondents: Case 1 `Red eye': Case 2 `Child': Case 3 `Spots': Case 4 `40+': Case 5 `50+': Case 6 `Diabetes':

A patient has had a painful red eye for two days; possible diagnoses: (a) bacterial conjunctivitis (inflammation) and (b) kerititis dendritica. A child under eight has one bad eye. Possible diagnoses: (a) refraction deviations, (b) strabismus (crossed eyes), (c) amblyopia (lazy eye). A patient has seen spots for two weeks. Possible diagnosis: fundus bleeding. A 40-year-old patient has irritated eyes but no visual problems or redness. Possible diagnoses: (a) refraction disturbances and (b) glaucoma. A 50-year-old patient has had visual problems for six months. Possible diagnosis: cataract (loss of transparency in the lens of the eye). A patient with diabetes type 2 (for 10 years) has not had his eyes examined for five years. Possible diagnosis: diabetic retinopathy/retinal bleeding.

For each case, the following questions were posed on actual (present) and preferred (future) professional competence or professional domains: 1. Present professional competence: Do you consider (`yes'/`no'/`don't know'): (a) your occupation professionally qualified to examine a patient with this complaint? (b) other occupations professionally qualified to examine a patient with this complaint? 2. Preferred future professional competence: In the future, who should be the first to examine a patient with this complaint (case 1 to 6) in order to decide whether something is wrong (`yes'/`no'/`don't know') and whether further action is necessary: (a) the general practitioner?, (b) the ophthalmologist?, (c) the orthoptist?, (d) the optometrist?, or (e) the optician? Results Perceived problems in vision care For all occupations, Figure 1 graphically presents average scores of perceived problems concerning workload, co-ordination and recognition, shortage of ophthalmologists and professional autonomy. Means, standard deviations and F-scores are presented in Appendix 2. On average, waiting lists and the shortage of ophthalmologists was considered as the most pressing problem affecting the division of labour in vision care. Opticians, followed # Blackwell Publishers Ltd/Editorial Board 2000


by optometrists and general practitioners considered this a pressing problem. For ophthalmologists and orthoptists this was less the case. Problems regarding work load and practice organisation were felt most by ophthalmologists, and much less by the other professionals.

Figure 1. Perceived problem areas in vision care (mean scores of different occupations; 1=minimum; 3=maximum).

Inter-professional co-ordination and recognition appeared to be more of a problem for optometrists and, although to a somewhat lesser extent, for opticians than for the other professionals. The same pattern was found with regard to professional autonomy. Again, opticians and, especially, optometrists had higher scores than the other professionals, which indicates that they considered themselves to be less autonomous in their work than the other professionals. Relatively speaking, however, professional autonomy was not a very pressing problem for orthoptists, ophthalmologists and general practitioners. The results suggested that inter-professional recognition, co-ordination and professional autonomy were more of an issue for the non-medical professionals (optometrists, opticians) than for the medical professionals (ophthalmologists, general practitioners). # Blackwell Publishers Ltd/Editorial Board 2000


Professional competence The left-hand columns in Figure 2 show the percentages of respondents who considered their occupation professionally qualified to examine a patient who presented with the case characteristics and to decide upon that whether further action was necessary. Not surprisingly, virtually all ophthalmologists considered themselves competent to examine the patients as described. This was also true for general practitioners, except for case 6, `diabetes'.

Case 1 `Red Eye'

100 80 %

60 40 20 0

%

Ophthalm.

60 40 20 0

60 40 20 0

Ophthalm.

G.P.

60 40 20 0

Ophthalm.

G.P.

Orthopt. Optomet. Optician

Case 6 `Diabetes'

60 40 20 0

Ophthalm.

G.P.


`Total'

100 80 %



Case 4 `40+'

100 80 %

G.P.

60 40 20 0


Case 5 `50+'

100 80 %

G.P.

Ophthalm.

100 80 %

Ophthalm.

60 40 20 0


Case 3 `Spots'

100 80 %

G.P.

Case 2 `Child'

100 80

Legenda Ophthalm.

G.P.


Present Task Domains

&

Preferred Task Domains

Figure 2. Present (left column) and preferred (right column) task domains of vision care occupations in percentages. # Blackwell Publishers Ltd/Editorial Board 2000


Thus, eye problems associated with diabetes mellitus appear to be the exclusive domain of the ophthalmologist. Orthoptists considered themselves least competent in five of six cases. The only exception was case 2 `child' (strabismus). In five of six cases, more than 70 per cent of the optometrists considered themselves qualified to examine the case as presented. In the final graph of Figure 2 headed `total', the mean percentages for the six cases together are presented. This shows that orthoptists considered themselves the least, and ophthalmologists and general practitioners the most, qualified to assess a range of task areas in vision care. Preferred professional competence The preferred professional competence is presented in Figure 2 (right-hand columns). Compared to the present situation, ophthalmologists considered that they should not be the first professionals to assess patients with certain problems, which suggests that they would prefer to specialise by `delegating' activities (cases) to other occupations. Secondly, the optometrists and the opticians considered that, in the future, they should be the first professionals to assess patients with certain problems, which might imply that they want to expand their scope of work. Thirdly, the smallest differences between present and preferred functions were found among general practitioners and orthoptists. In other words, these professionals do not envisage their task as changing in the future. Compared to the present situation, optometrists considered that, in the future, they should be the first professionals to assess patients with certain symptoms. For five out of six cases, optometrists considered themselves as qualified as doctors, and their mean score was even higher than that of ophthalmologists and general practitioners. Domain consensus To examine the division of labour and to assess whether there are conflicts concerning task domains, difference scores were calculated, based on which of the six referred cases were considered to belong to the respondent's own occupational competence, and whether this was consistent with the opinions of respondents from the other occupations. This agreement, referred to as `domain consensus', indicates the acceptance of each other's domain in the inter-professional field. Domain consensus is defined here as the agreement among participants in the system of professions regarding the appropriate role and scope in inference, diagnosis, and taking further action of an occupation (Benson 1975, Braito et al. 1972, Levine and White 1961). Domain consensus was assessed by calculating the percentage of respondents who considered a case to be in their own sphere of competence, and subtracting from that the percentage of respondents from all other occupations who agreed with this. In Figure 3 the degree of domain consensus is presented for all six cases combined. Left-hand bars indicate domain consensus/lack of consensus for the current division of labour, and right-hand bars indicate domain consensus/lack of consensus for the preferred division of labour. # Blackwell Publishers Ltd/Editorial Board 2000


A low bar implies much domain consensus (much agreement between the professions), a high bar indicates lack of domain consensus (much disagreement between the professions).

Figure 3. Mean degree of domain consensus concerning present tasks and preferred tasks, based on difference percentages. (Low column: much agreement/domain consensus; high column: little agreeement/domain consensus).

Most domain consensus was found for the role and function of orthoptists and ophthalmologists, while most lack of consensus was found for the role and function of optometrists and opticians (left-hand bars in Figure 3). Thus, there was much disagreement on how optometrists and opticians see their profession and how other professionals perceive it. The data also indicate a clear split between medical and non-medical professions: ophthalmologists and general practitioners versus the others. Ophthalmologists were ascribed the largest task domain, and orthoptists the smallest. General practitioners and opticians were in between. When comparing the present and the preferred situation, as indicated by the differences between the left and right hand bars, a decrease in domain consensus can be observed for optometrists, opticians and ophthalmologists. In other words, the disagreement about future tasks domains is likely to increase. More domain consensus can only be expected for general practitioners and orthoptists. The `negative' score of orthoptists indicates the remarkable situation that they considered their professional role and function as being less than that ascribed to them by the other professionals. The preferred division of labour A final analysis of the division of labour in vision care can be found in Figure 4. For each case, the claimed and ascribed professional competence is # Blackwell Publishers Ltd/Editorial Board 2000

444 Fred Stevens, Frans van der Horst, Frans Nijhuis and Silvia Bours Case 1: `Red Eye'

Case 2: `Child'

Case 3: `Spots'

Case 5: `50+'

Case 6: `Diabetes'

`Total' (mean of all cases)

Case 4: `40+'

Figure 4. Preferred division of labour in vision care. Grey background: more than 50% of respondents within an occupation considers the case the occupation's own task. Arrow: more than 50% of respondents within an occupation considers the case (also) another occupation's task. # Blackwell Publishers Ltd/Editorial Board 2000


graphically presented. An arrow indicates that at least 50 per cent of respondents with a given profession were of the opinion that another specific profession should take care of a particular case in the first instance. If a profession is set against a grey background, then at least 50 per cent of the respondents with that profession considered their own profession qualified to deal with the case. Only data on the preferred division of labour are presented. As Figure 4 shows, ophthalmologists and general practitioners considered that they should examine a diabetic patient (case 6). However, the other professionals considered that only ophthalmologists should examine such a patient. In contrast, all professions considered themselves competent to examine a child (case 2); however, only ophthalmologists and orthoptists were considered by all other professionals to be qualified to examine such patients. Comparing the different cases also shows that the `competence claims' of ophthalmologists were always supported by opticians and orthoptists. However, the claims of opticians were never supported by the other occupational groups. The claims of general practitioners were supported by ophthalmologists in five of six cases, indicating the willingness of ophthalmologists to give general practitioners a more substantial role in vision care. Further, in five of six cases, optometrists supported the claims of ophthalmologists, but this was not mutual. Indeed, ophthalmologists considered optometrists to be the appropriate first examiner in only one case. In sum, there is consensus on the primary roles of ophthalmologists and orthoptists in dealing with children (case 2), of general practitioners in examining people older than 40 (case 4), and of ophthalmologists in examining patients who see spots (case 3) and patients older than 50 (case 5). Except for case 6, `diabetes', which was recognised by all parties as being the exclusive domain of ophthalmologists, no occupation was considered to have the exclusive right to examine a specific case. Discussion We examined the division of labour of five occupations providing vision care services in the Netherlands. We first assessed problem areas with regard to the professional work and the division of labour and then compared the actual and preferred work domains of the professions on the basis of six patient cases. The findings confirmed that waiting lists and the shortage of ophthalmologists are significant problems for the delivery of vision care services. Although the ophthalmologists themselves did not see this to be a serious issue, they complained more than the other occupational groups about their work load and practice organisation. The higher perceived workload of ophthalmologists coincides with their wish to reduce tasks, by delegating certain activities to other professionals. For example, the patients described in cases 4 and 5 (irritated eyes but without problems of vision or # Blackwell Publishers Ltd/Editorial Board 2000


redness; patients with visual problems for 6 months) represent two of the largest patient categories seen by ophthalmologists. The majority of these patients, however, can be routinely helped without intervention by ophthalmologists, which would decrease their workload substantially. Thus, specialisation (client differentiation) and the delegation of routine activities to other professions seems to be the preferred strategy for reducing work load rather than increasing the number of ophthalmologists. Professions compete by taking over each other's tasks (Abbott 1988: 33). This implies that when one profession intends to delegate certain activities, it is likely that other professions will claim these activities. Comparison of the actual division of labour in vision care with the preferred future one suggests that this is indeed happening. While ophthalmologists were inclined to give up specific activities, it was the optometrists and opticians who made most claims on these activities, suggesting that the evolution of professional networks is characterised by alternating patterns of expansion and contraction, as has been suggested in ecological approaches of both professions and organisations (Abbott 1988, Hannan and Freeman 1988). However, the other professional groups did not consider optometrists and opticians to be suited to take on these activities. This confirms that the attitude of organised medicine and the authorisation of professional relationships with optometrists is still a wavering one (Wardwell 1972). Our findings also suggest that there is a clear hierarchy of professional competence. The opinions about the competence of one's own profession showed a `gap' between medical and non-medical occupations; with the medical ones being considered as most qualified. More generally, the task domains of allied professions were more disputed than those of medical professions. As Abbott has noted, ìnternal status differences combine with differences in clients and in work organisations to create wide disparities of income, power and prestige within professions. At the same time, the various professions involved in a task area generally fall into a stable status hierarchy' (Abbott 1988: 120). The data for perceived inter-professional recognition, professional autonomy and domain consensus made this very clear. Domain consensus, defined as the agreement among all professions on the tasks and scope of a particular profession, was highest for the medical professions (ophthalmologists, followed by general practitioners) and lowest for the allied occupations (optometrists and opticians). Moreover, optometrists and opticians not only made the most unsupported claims of professional competence to do certain activities, they also reported serious problems with their (lack of) autonomy, inter-professional coordination and recognition. This probably also explains why higher status groups, in this case ophthalmologists, are willing, or can afford, to give up specific activities, while lower status groups try to acquire them. The problems that optometrists have with regard to inter-professional coordination and recognition are consistent with the high discrepancy between opinions about their own tasks versus those perceived by others. This holds # Blackwell Publishers Ltd/Editorial Board 2000


for present competence as well as for preferred future competence. General practitioners and orthoptists are in a different position, because they have more limited, or different, interests. Orthoptists do have an independent status, but even so their work is still closely related to that of the ophthalmologist. For general practitioners, vision care is only a very small part of their work. Their professional position will never be contested in the strongly primary care-oriented Dutch health care system. Another comment concerns the preferred division of labour in the interprofessional field. Our analysis showed that, with the exception of orthoptists all occupations considered themselves qualified to deal with the cases presented. However, the other occupations only recognised the claims made by ophthalmologists and general practitioners. Because this again points to a difference in the position of medical and allied professions, it confirms that the division of labour in vision care will continue along more-or-less fixed professional status hierarchies (Abbott 1988). One conclusion that can be drawn from these results is that the dissatisfaction with the actual division of labour, as expressed by all participating occupations, is unlikely to lead to a more co-ordinated and synchronised division of labour. Indeed, analysis of the preferred future division of labour in vision care did not suggest a `natural' development towards more domain consensus and increased co-ordination. This confirms that the preferences of individual professions may be inspired more by their own interests than by the professional system in vision care as a whole. Consequently, if the complex organisation of health care delivery, combined with the increased specialisation of physicians and allied health professionals, necessitates innovative institutional arrangements, these may be difficult to realise without external intervention, for instance, by the state or institutional payers (Light 1995). Health care planning cannot afford to ignore the importance of a well-coordinated system of professions, because of the effects it may have on the quality of care. Unnecessary referrals of patients with visual problems by general practitioners, for instance, may result in long waiting lists, a high work load for ophthalmologists and unnecessary costs. As a consequence, the ophthalmologists may not have enough time to spend on serious cases, and patients may not be willing to accept the long waiting lists for a visit to the ophthalmologist and may try the alternative of the optical retail outlet. However, if they have serious eye problems that require medical intervention this is not necessarily the right choice. This underlines that vision care services would benefit from systemlevel planning, domain consensus and integration. The results of our study should be evaluated in the context of the research method. Because we restricted the analyses and interpretations to aggregate data, we did not analyse how opinions on cases and problems were influenced by practice setting or individual characteristics like age, sex, experience, level of training or expertise. Nor did we consider processes of segmentation within a profession along these characteristics (Begun and # Blackwell Publishers Ltd/Editorial Board 2000


Lippincott 1980, Bucher and Strauss 1961, Richardson 1987). Also, because the data were based on self-reports, it is not clear how they reflect actual professional behaviour. Notwithstanding this, the present study has provided an insight into the professional division of labour in vision care, a relatively neglected area of practice. We have focused on the dynamics of occupations, the interrelations among them, and the shifting arena in which they operate. We believe that research like this not only contributes to a more empirically-based sociology of the professions, but also provides more insight into how professions organise their work and negotiate about their work domains. Address for correspondence: Fred Stevens, Department of Health Care Sciences, Section of Medical Sociology, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands e-mail: [email protected] Appendix 1 Perceived problems in present professional practice (n=1825):

Corrected item-total correlation

Work load and practice organisation (alpha=.83) ± ± ± ± ± ±

Available time for each patient Work load Availability of supporting personnel Coming up to the expectations of the patient Availability of budgets Imposed tasks

.69 .67 .58 .57 .56 .52

Interprofessional recognition and coordination (alpha=.78) ± ± ± ±

coordination of occupations in vision care definition of domains between the occupations communication with other occupations in vision care recognition by other professions in vision care

.66 .60 .56 .52

Waiting lists and shortage of ophthalmologists (alpha=.74) ± ± ± ±

waiting lists for first visits of non-urgent patients waiting lists for follow-up visits waiting lists for non-urgent surgery shortage of ophthalmologists

.63 .57 .48 .46

Professional autonomy (alpha=.81) ± autonomy to treat clients/patients as preferred ± autonomy to make important decisions ± autonomy to introduce new methods of treatment # Blackwell Publishers Ltd/Editorial Board 2000

.73 .67 .56

Appendix 2. Problem areas as perceived by vision care occupations (1=no problem; 2=less pressing problem; 3=pressing problem). Ophthalm. n=296

Gen. Pract. n=397

Orthoptist n=187

Optometrist n=562

Optician n=185

Total n=1825

F-value*

(s.d.)

Mean

(s.d.)

Mean

(s.d.)

Mean

(s.d.)

Mean

(s.d.)

Mean

(s.d.)

Work load/practice organisation

2.13

(.47)

1.52

(.40)

1.50

(.47)

1.39

(.37)

1.30

(.34)

1.61

(.51)

152.52

Interprofessional recognition/coordination

1.59

(.46)

1.67

(.48)

1.76

(.49)

2.11

(.55)

1.88

(.56)

1.84

(.56)

61.17

Waiting lists/Shortage of ophthalmologists

1.84

(.52)

2.06

(.56)

1.84

(.56)

2.05

(.54)

2.17

(.56)

1.99

(.56)

13.14

Professional autonomy

1.20

(.36)

1.14

(.35)

1.22

(.35)

1.51

(.56)

1.37

(.52)

1.30

(.46)

31.77

* All F-values significant at p5.001



Mean


Note 1

Subjective refraction measures the optimum optical correction and visual acuity of the eye by means of trial lenses and letter charts. Objective refraction measures the refractive status of the eye by means of instruments without enlisting the patient's responses.

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