Institutional Work to Maintain Professional Power: Recreating the Model of Medical Professionalism

The creation of new roles commonly threatens the power and status of elite professionals through the substitution of their labour. In this paper we examine the institutional work carried out by elite professionals to maintain their professional dominance when threatened. Drawing on 11 case sites from the English National Health Service (NHS) where new nursing or medical roles have been introduced, threatening the power and status of specialist doctors, we observed the following. First, the professional elite respond through institutional work to supplant threat of substitution with the opportunity for them to delegate routine tasks to other actors and maintain existing resource and control arrangements over the delivery of services in a way that enhances elite professionals' status. Second, other professionals outside the professional elite, but relatively powerful within their own professional group, are co-opted by the professional elite to engage in institutional work to maintain existing arrangements. Our work extends Lawrence and Suddaby's typology of institutional work in three ways. First, we reveal how different types of institutional work interact, and how different types of institutional work cross categories of creating or maintaining institutions. Second, we show how an actor's social position or status, both intra-professionally as well as inter-professionally, in the institutional field frame the institutional work they engage in. Third, the institutional work of 'theorizing' by professional elites appears particularly significant, specifically the focus of the institutional work to invoke the concept of 'risk' associated with any change in service delivery, which maintains the model of medical professionalism.