Task redistribution as a dual process: Reconfiguring professional boundaries through knowledge development and jurisdictional competition

Abstract

Health care systems globally are redistributing the responsibilities to address workforce shortages, yet task redistribution may create tensions between professional groups. Through this ethnographic study, I examine medication management as a case for exploring how professional boundaries are negotiated and reshaped during the redistribution of tasks. Fieldwork in three Norwegian nursing homes comprised 87 hours of observations and seven semi-structured interviews with nine informants. The data were thematically analysed and interpreted through Wenger’s concepts of participation, reification, negotiation and boundary objects as well as Abbott’s concepts of jurisdiction and workplace assimilation. Certified nursing assistants’ (CNAs) participation in medication management created opportunities for knowledge development, as CNAs approached nurses for support. Medication administration records (MARs) functioned as boundary objects, enabling alignment but often lacking information meaningful to CNAs, leading them to seek clarification from nurses. These interactions facilitated knowledge sharing but simultaneously created tensions, as nurses experienced them as interruptions during high-risk tasks. Due to resource constraints and formal divisions of labour, CNAs’ participation remained a form of peripheral, partial jurisdiction that both blurred and reconfigured boundaries while adding to nurses’ workload. The study demonstrates that task redistribution is not a straightforward transfer of tasks but a dual process of knowledge development and negotiation of jurisdiction. Recognising this duality is crucial for designing policies that support the situated realities of professional work.

Keywords

situated learning theory negotiation meaning jurisdiction boundary object workplace assimilation

Introduction

Health care systems globally are redistributing responsibilities in response to workforce shortages. Task redistribution from specialised health professionals to those with lower formal education has become a central strategy in many countries (World Health Organization, 2008). In Norway, policy initiatives emphasise care at the lowest effective level, including delegation of tasks from nurses to certified nursing assistants (CNAs) to mitigate insufficient nurse staffing (Norwegian Ministry of Health and Care Services, 2023). While task redistribution is often presented as a pragmatic response to resource constraints, research shows that restructuring professional boundaries can create tension, particularly when work traditionally performed by one profession is delegated to another (Ingebrigtsen and Lundvoll Warth, 2025). Studies indicate that nurses may employ defensive strategies, such as demarcating and valuing nurses’ holistic medical knowledge and downplaying CNAs’ contributions (Allen, 2000; Bach et al., 2012). Studies have identified role ambiguity between nurses and CNAs in general (Wong et al., 2025), and in medication management, in particular (Måløy et al., 2016). At the same time, expanding responsibilities may create opportunities, as taking on additional responsibilities can foster learning and boundary blurring (Johannessen, 2018). However, as some professional groups are enabled to do more, others’ roles may become less clear (Randell et al., 2021).

This ethnographic study examines medication management in three Norwegian nursing homes to explore interprofessional relationships and everyday practice during task redistribution. Specifically, I ask: What opportunities and challenges arise when CNAs participate in medication management, and how do tools mediate this work? Rather than viewing task redistribution as a neutral efficiency measure, the study shows how it stimulates knowledge development through negotiation of meaning while simultaneously triggering jurisdictional disputes. To situate the analysis, the following section outlines the nature of medication work: a complex, high-risk activity that requires collaboration but also functions as an arena where knowledge and professional boundaries are negotiated.

Medication management requires a solid knowledge base and the ability to apply theoretical knowledge to real-life situations (Sulosaari et al., 2011). Professionals actively develop knowledge through everyday practice and informal workplace interactions (Billett, 2004; Lave and Wenger, 1991; Wenger, 1998), specifically by seeking solutions to complex problems (Nerland and Jensen, 2012) and by negotiation (Gherardi and Nicolini, 2000). Participation in clinical communities of practice mediates skills, routines, and professional codes of conduct (Young et al., 2018). Accordingly, strategies for safe medication management are largely developed through everyday collaboration and interaction (Hawkins et al., 2017; Jennings et al., 2011).

However, these interactions may also foster tensions. Nurses often compensate for gaps in CNAs’ knowledge by assisting them in problem-solving (Odberg et al., 2019), although this can entail interruptions to the nurses’ own work. Interruptions during medication management have been widely studied as threats to safe practice (Brabcová et al., 2023; Westbrook et al., 2017). However, emerging work suggests that interruptions may also provide opportunities for patient observation (Alteren, 2022) and enable beneficial changes in patient treatment (Odberg et al., 2018).

In nursing homes, these interactions are often mediated by tools such as the medication administration record (MAR), which documents patients’ medication treatment plans. Existing research primarily focuses on the effects of implementing electronic MARs (Stolic et al., 2023; Truitt et al., 2016; Vicente Oliveros et al., 2017), while little is known about their use in nursing homes, where paper-based versions persist. Studies indicate that handwritten notes can make MARs difficult to interpret (Bengtsson et al., 2021).

Building on this background, this article contributes by examining task redistribution through sociocultural perspectives on learning (Lave and Wenger, 1991; Wenger, 1998) and the sociology of professions (Abbott, 1988). It demonstrates how CNAs’ participation in medication management creates simultaneous opportunities for situated knowledge development and jurisdictional tension and how this process triggers the challenging, negotiation, blurring, and reconfiguring of professional boundaries. By examining how MARs mediate these interactions, the study shows that material tools are central components of task redistribution, an aspect that has received little empirical attention.

Negotiation of meaning and jurisdiction in the workplace

Knowledge is developed through (peripheral) participation in the ‘sociocultural practices of a community’ (Lave and Wenger, 1991: 29). These practices include both explicit (e.g. language, tools, documents, roles, procedures) and implicit components (e.g. underlying assumptions, understandings, world views; Wenger, 1998). Over time, practices create boundaries that distinguish participants from non-participants. In healthcare, such boundaries often arise through medical specialisation (Kerosuo, 2008), for example, nurses and CNAs have different educational backgrounds, roles, and responsibilities.

In the workplace, meaning (the experience of a meaningful world: what learning is meant to produce) is negotiated through two key processes: participation and reification (Wenger, 1998). Participation refers to engaging in activities with others, representing the social experience of membership in a practice. Reification involves treating abstract experiences or meanings as something substantial, often resulting in the creation of physical artefacts. When these artefacts bridge practices, they become boundary objects: ‘artefacts, documents, terms, concepts, and other forms of reification around which communities of practice can organise their interconnections’ (Wenger, 1998: 105). These objects facilitate the coordination of different perspectives (Akkerman and Bakker, 2011; Wenger, 1998). In this study, MARs are considered ‘standardised’ boundary objects (Star, 1989; Wenger, 1998), designed to convey information that is usable across different contexts (Star and Griesemer, 1989), facilitating coordination among physicians, nurses, and CNAs.

When functioning as intended, MARs support meaning-making and the coordination of health professionals’ actions. However, boundary objects may also fail to align meaning across practices, mediating knowledge in ways that are insufficient or ambiguous for some professional groups (Wenger, 1998). In such instances, they become subject to negotiation. It is through the interplay of participation and reification that the negotiation of meaning occurs. As members engage with reified tools in practice, they negotiate meaning by accepting, modifying, or challenging both participatory norms and the tools themselves. In these processes, interaction and discourse, that is, a mutually intelligible ‘common language’, are central in mediating negotiation (Wenger, 1998). Through such negotiations, boundary objects may enable health professionals to push boundaries and build both visibility and acknowledgement (Håland et al., 2015), as mastering medical technologies plays a role in boundary configuration (Serra, 2010).

While Wenger’s framework emphasises the co-construction of meaning within practices, it pays limited attention to power and control over work. Where Wenger considers meaning as the main subject of negotiation and learning the outcome, Abbott (1988) considers workplace jurisdiction as the main subject and the division of labour as the outcome. Abbott’s framework highlights how professional control is established and challenged through claims of jurisdiction. Jurisdiction refers to a profession’s full or partial control over a work task, for example, medication management. This control is constantly negotiated, where one profession may claim jurisdiction that belongs to another profession (Abbott, 1988). Jurisdictions are regarded as scarce goods, and interprofessional relationships are consequently characterised by competition (Abbott, 1988). Jurisdiction is negotiated in the workplace, among other arenas, where ‘the basic question is who can control and supervise the work and who is qualified to do which parts of it’ (Abbott, 1988: 64).

Within larger organisations, such as the health care system, negotiated divisions of labour are susceptible to change due to a lack of resources that necessitates the use of ‘paraprofessionals’ or untrained staff (Abbott, 1988: 65). This situation blurs the professional boundaries in the workplace, which Abbott (1988) refers to as workplace assimilation. Workplace assimilation involves a knowledge transfer wherein ‘paraprofessionals’ learn a practical version of the original profession’s knowledge system without the theoretical training that ‘justifies membership in that profession’ (Abbott, 1988: 65). Workplace assimilation necessitates the renegotiation of professional jurisdiction. In this sense, it captures the dynamics of task redistribution, where work moves from one profession to another under resource constraints.

This article combines the two perspectives outlined above, investigating the developmental processes in the workplace where knowledge and skills are developed through negotiation in the context of workplace assimilation, as well as tensions related to jurisdictional competition in the workplace. I draw upon the negotiation of meaning and jurisdiction to conceptualise how knowledge and divisions of labour are negotiated and developed in practice.

Methods

Research setting

The role of the CNA, which was established in 2006 (Norwegian Ministry of Health and Care Services, 2006), requires 2 years of upper secondary school and 2 years of practical training. CNAs’ work tasks mainly revolve around patient care, but they may participate in medication management with authorisation from a doctor if nurse staffing levels are low (Guldal and Tveit, 2007).

In Norway, medication management includes all tasks from the prescription to the administration or discarding of medications (Norwegian Ministry of Health and Care Services, 2008: § 3e). Medication management in the participating nursing homes involved two core tasks: preparation and administration. Preparation is the work involved when readying medications for distribution to a patient and performing double-checks, and administration includes delivering medication to a patient, monitoring intake, and observing potential reactions.

These tasks were carried out in two different locations: the medication room and by the medication trolley in the hallway. In medication rooms, nurses – and occasionally CNAs – collaborated on preparation, including filling pill organisers and preparing medications according to the MAR. By the medication trolley, a small cart used to transport medications between the medication room and patients’ rooms for administration, nurses and CNAs take pills out of pill organisers and count and double-check the number of pills against the MAR, before administering them to patients. Both preparation and administration require sustained concentration to avoid medication errors. CNAs’ participation in medication management varied across sites. In two nursing homes, CNAs mainly administered medications from pill organisers that had already been prepared by two nurses or by assisting in preparation when nursing resources were low. In the third, CNAs routinely participated in preparation and administration.

According to law, health personnel must ensure that the correct medication is given to the correct patient, in the correct dosage, at the correct time and in the correct way, as ordered by a physician (Norwegian Ministry of Health and Care Services, 2008: § 7). While organisations are responsible for ensuring appropriate procedures and staff competence, individual health personnel are legally required to practise in accordance with the standards for professional conduct (Norwegian Ministry of Health and Care Services, 2008: § 4, 7, 8). Breaches of these standards may result in reactions from supervisory authorities, such as formal warnings and withdrawal of authorisation.

Data collection

Fieldwork was conducted in three nursing homes in two different Norwegian municipalities. Over approximately 6 weeks between February and May 2023, I observed 87 hours of medication-related work across five departments, including both long-term and short-term care. The fieldwork was carried out in collaboration with another researcher; some situations were observed jointly and others separately, allowing the collection of extensive data.

Negotiated interactive observations (Wind, 2008) included reports, pre-rounds, and the general care of patients to provide a coherent understanding of the work practice and thoroughly explored preparation and administration of medications. Observations offer insights into ‘the behaviour and activities of informants at the research site’, (Creswell and Creswell, 2018: 186), in this case, their workplace. The observations were recorded as descriptive jottings with analytic notes in separate sections to support rigour and were later expanded into full field notes (Nicholls et al., 2014). I jotted down locations, times, work activity, professions present, and what I saw and heard. Additionally, 1 day allotted to medication preparation was audio-recorded, transcribed, and treated as field notes. In total, the observational data consisted of approximately 18,500 words.

Qualitative interviews supplemented the observational data, as they serve as a valuable method for capturing detailed accounts of informants’ everyday lives (Silverman, 2020). Seven semi-structured interviews, with an average duration of 46 minutes, were conducted with nine informants: one head nurse, five nurses, and three CNAs. Two interviews were carried out with two participants; the remainder were individual. Some interviewees had previously been observed, allowing questions grounded in observations. The informants were asked about medication-related work practices, including the use of tools, collaboration, and interprofessional relationships in the workplace.

Data collection formed as part of a broader doctoral project and was guided by the aim of including sufficient organisational and professional variation and generating in-depth data, consistent with the principle of information power (Malterud et al., 2016). Extensive fieldwork was therefore conducted across multiple nursing homes and departments and included participants from different professional backgrounds. Together, the scope and duration of the field work were considered sufficient to support the analytical focus of this study.

Data analysis

The transcribed interviews and observations were coded in text form in NVivo 14, drawing upon thematic analysis, a method for identifying, organising, and gaining insight into patterns of meaning (‘themes’) in qualitative data (Braun et al., 2012). I first familiarised myself with the data by reading all the field notes and transcripts repeatedly. Coding was inductive and closely tied to the empirical material. However, my interest in work practices, the use of tools and interprofessional relationships influenced the process, as researchers can never be purely inductive (Braun et al., 2012).

I then actively generated initial themes by identifying overlaps and similarities in the codes before I reviewed the potential themes, ensuring that they captured the data in meaningful ways. During this step, I renamed themes, split some into multiple themes, merged others, turned some into subthemes and reverted others into codes. In the fifth step, I defined the themes by clarifying what each theme contributed to the analysis before I produced the report. At this stage, I applied theoretical perspectives based on the empirically driven themes. The six steps were not conducted in a strictly chronological order but interwoven as I moved back and forth between the steps, critically evaluating the analysis throughout. See Table 1 for examples of the coding and thematisation process.

Table 1.

Examples of the coding process.

Text excerpt	First code	Second code	Theme
Another colleague comes over to the medication trolley and asks the nurse a question. Afterwards, the nurse told me that interruptions by the medication trolley are a challenge for safe medication treatment.	Being interrupted by the medication trolley is a challenge for patient safety	Lack of a quiet work environment	Knowledge for some, risk for others
You can say that when we are a bit understaffed, there is often one person responsible for the medications for 16 people. And that is a lot. And we know that errors happen when there is a lot to do.	Nurses experience time pressure as a challenge in their work	Time pressure	Risk, responsibility, and resource constraints in medication management

Through coding and thematisation, I identified four themes: (1) Risk, Responsibility, and Resource Constraints in Medication Management (2) From Questions to Knowledge (3) Knowledge for Some, Risk for Others and (4) Drawing the Line: Nurses’ Resistance to CNAs’ Expansion. The themes explore both opportunities and challenges that arise when CNAs participate in medication management, focussing on interprofessional relationships and the use of tools.

The analysis was built upon data generated through method triangulation (Hammersley and Atkinson, 2019), combining observations of situated interactions with interview accounts of how participants understood and experienced these interactions. Themes were developed through parallel analysis of both data sources. The first theme, Risk, Responsibility, and Resource Constraints in Medication Management, was supported by observational data on time pressured medication work, as well as interview accounts of perceived risk in the context of these resource constraints. The second and third themes, From Questions to Knowledge and Knowledge for Some, Risk for Others, were informed by observed interactions between CNAs and nurses and further elaborated through interview reflections on these encounters. The fourth theme, Drawing the Line: Nurses’ Resistance to CNAs’ Expansion, primarily drew on interview data, as nurses’ perceptions of changes in the division of labour were more explicitly articulated in interviews.

The findings are grounded in data generated within a specific regulatory, organisational, and sociocultural context. While the study does not aim for statistical generalisation, it provides detailed descriptions of the research setting and the practices examined, enabling readers to evaluate the potential transferability of the findings to other settings (Cohen et al., 2018).

Ethical considerations

Ethical approval was obtained from the Norwegian Agency for Shared Services in Education and Research (ID: 117489) on 12 October 2022. The study adhered to the Agency’s ethical standards, including informed consent, confidentiality, and proper data management. Municipal leaders approved the study and facilitated access. All the interview participants provided written consent, and all the observation participants provided verbal consent. All the informants were informed that they could withdraw their consent at any time. All personal data have been anonymised.

Findings and analysis

The findings illustrate how CNAs’ participation in medication management creates both possibilities for knowledge sharing and development and tensions related to workflow interruptions and jurisdiction. The first theme outlines the high-risk and time-pressured nature of medication management, providing essential context for understanding the setting. The subsequent three examine interprofessional interactions as both opportunities for knowledge development and interruptions and investigate nurses’ resistance to CNAs’ expanding responsibilities.

Risk, responsibility, and resource constraints in medication management

Medication management was a high-risk activity that shaped interactions between nurses and CNAs. The informants repeatedly emphasised the need to remain focussed during medication management to avoid errors:

You must respect what you are doing. It is a big responsibility. You can feel it. For example, if you give the wrong medication to the wrong patient. That is the big fear. It would be a complete crisis for me, personally. (CNA 2, interview)

Both the nurses and the CNAs approached medication management with reverence, aware that their actions carried significant risk and professional responsibility. The high stakes of medication management, where even minor errors can have severe consequences for patient safety, created tensions and shaped the interactions in the workplace. Resource constraints further amplified these tensions. The nursing homes faced challenges of low staffing and high sickness absence, creating hectic workdays for both nurses and CNAs. One nurse said:

We are working under time pressure. Absolutely. We are. And with that comes the fear of making mistakes. (Nurse 1, interview)

Nurse staffing levels were especially low. This created additional stress for nurses, particularly in institutions where CNAs had limited responsibilities for medication management. Nurses described the pressure of being the only nurse on duty, responsible for large patient groups and complex medication routines:

I’ve been the only nurse for the whole building in the afternoons and on weekends. And then having to prepare and double-check medications and control them for patients you don’t really know (. . .). It increases the chance of administering the wrong medication at the wrong time. (Nurse 4, interview)

Several informants expressed that the nurse shortage led to the increased involvement of CNAs, accelerating their responsibilities in medication management. The combination of high-risk medication management and nurse shortages created a need for additional staff to relieve the nurses’ workload. Building on Abbott (1988), the nurses struggled to fulfil their workplace jurisdiction, and opportunities emerged for the CNAs, as paraprofessionals, to participate more actively in medication management. This process of workplace assimilation blurred professional boundaries and opened possibilities for the CNAs to negotiate meaning, but also initiated the renegotiation of workplace jurisdiction. These negotiations unfolded through face-to-face interactions between the nurses and the CNAs, where questions, clarifications, and shared problem-solving both transferred knowledge and challenged jurisdictional boundaries.

From questions to knowledge

Both interviews and observations showed that the CNAs frequently approached the nurses to ask questions, gain clarity, and solve problems, especially during medication administration. The CNAs were described by the nurses as committed to ensuring safe medication management:

I think the CNAs with medication authorisation feel some kind of. . . they feel a responsibility. They are good at, I think, asking nurses if they are unsure of something. (Head Nurse 1, interview)

The CNAs confirmed this, emphasising that uncertainty led them to seek support from nurses:

If I am uncertain, because there is a lot of new medications all the time, I must ask (. . .) a nurse. (. . .) My role is to know what I do, why I do it, how I do it. If I am uncertain, I ask. (CNA 2, interview)

These interactions illustrate how the CNAs sought security from the nurses when they were unsure, opening the way for knowledge development across professional boundaries, in line with Wenger’s (1998) view of learning as participation in practice. This played out in various ways. The CNAs often asked the nurses when they were uncertain about the appearance of specific medications or struggled to interpret the information in the MAR. Such uncertainties frequently arose during medication administration:

A nurse is administering medications by the medication trolley. The nurse is approached by a CNA with questions regarding medications. They find an error in a pill organiser together. A medication is missing, and the nurse must help the CNA identify what kind of medication. (Field notes)

In this instance, the CNA was unable to identify the error by herself and approached the nurse for support. This interaction fostered joint problem-solving, negotiations, and the alignment of meaning between the nurse and the CNA. Similar situations occurred when the CNAs struggled to interpret the MAR, which often required knowledge beyond their training. The MAR largely created two types of situations for the CNAs: routine coordination and sites of breakdown, the latter becoming openings for knowledge development. MARs were important resources for the CNAs:

The MAR is like a bible for us. We must pay very close attention to it. (. . .) I read the MAR, look at the medications [in the pill organiser], and count, which is the most important thing, because I don’t always know what medication is for what condition. So, I can’t go into detail. But I count that the number is correct. (CNA 2, interview)

The CNAs depended on the information mediated by the MAR and considered it an important tool in medication management. The MAR provided meaning and enabled coordination between the practices of the medical doctor and the health professionals in the departments, functioning as a boundary object (Wenger, 1998). Despite this, understanding the information in MARs was challenging for the CNAs. For example, MARs often contained handwritten notes, markings, corrections, and attached post-its, making the information unclear. In addition, MARs often lacked information about conditions, accurate times for ingestion, and what generic equivalents had been used during preparation, which, for the CNAs, was vital for their work:

Usually, it’s the original medication that is written up, and it can be challenging if they have used a generic equivalent [during preparation] (. . .). I often must ask the nurse: “Is this a generic drug?”. They usually know because they prepare a lot of pill organisers. (CNA 3, interview)

While the MARs, as mediating boundary objects, aligned the perspectives of medical doctors and nurses, they often failed to do so in meaningful ways for the CNAs. This situation created breaks in the CNAs’ work practices, which led them to approach nurses for support. In this way, the MARs’ shortcomings created not only challenges but also opportunities for knowledge sharing, allowing the CNAs to develop practical knowledge.

These ongoing negotiations enabled broader changes in practice. In one nursing home, the CNAs had discursively negotiated changes in the MAR, where physicians had begun to include information about which medical conditions the medications were intended to treat. In another, the CNAs were increasingly included in medication preparation alongside nurses to deepen their understanding of the medications they administered. One CNA described the learning opportunities this created:

As long as you (. . .) administer medication, you are supposed to have an overview of the [different types of] medications. And joining the nurses [in the medication room] (. . .). You learn a lot in that process about the medications. (. . .). Not only handing out something to some names on a list, but you actually know about the background. Why this patient has this exact medication. What is it, what is it for? (CNA 2, interview)

Over time, the CNAs’ repeated pursuits of meaning reshaped organisational routines. In this way, the CNAs’ negotiations contributed to the construction of new meanings, the reconfiguring of boundary objects, the expansion of work areas, and a further blurring of the professional boundaries between the CNAs and the nurses. Yet, as boundaries blurred, the same interactions that fostered knowledge development also began to challenge established roles and responsibilities.

Knowledge for some, risk for others

While the CNAs experienced their growing involvement as opportunities for knowledge development, the nurses viewed the same situations quite differently. Being approached by CNAs with questions related to medication management was perceived as being interrupted:

A CNA comes over to the medication trolley and asks the nurse a question while she administers medications. The nurse has previously told me that interruptions like these are a threat to safe medication management. She comments on the interruption: ‘As you can see, I am interrupted as I stand here and work’. (Field notes)

The same nurse elaborated:

If you are standing by the medication trolley, checking and counting, and people are talking to you at the same time (. . .) you lose your focus, and then it is easy to make errors. Therefore, we have a rule, that we do not speak to the ones managing the medications, but [it’s not] always easy to follow that rule. (Nurse 1, interview)

The nurses framed interruptions as threats to patient safety rather than as opportunities for knowledge sharing, reinforcing their jurisdiction in medication management. Structural conditions intensified these tensions: the CNAs needed approval from the nurses for as-needed medications, nurses were frequently alone on duty, and the CNAs could not assist with the advanced clinical procedures that placed the most strain on the nurses’ workload. This division of labour created ongoing dependency, in which the CNAs, lacking full jurisdiction, had to approach the nurses even for low-risk tasks. This added to the workload of the few nurses available. From Wenger’s (1998) perspective, the CNAs’ participation can be understood as peripheral – they are invited into the practice but remain removed from certain parts of the pursuit of the joint enterprise, which can be understood as a disempowering position (Lave and Wenger, 1991). Similarly, Abbott (1988) conceptualises this peripheral participation as a form of partial workplace jurisdiction, where the CNAs are subordinate to the nurses and perform work under their supervision. Such partial control kept professional boundaries intact but also made them sites of ongoing negotiation. This simultaneously increased pressure on the few nurses available, who were left to oversee multiple CNAs amid persistent nurse shortages, all while managing their own medication responsibilities:

The department is divided into two sections, where there is supposed to be one responsible nurse available in each section, but the nurse I am observing has the responsibility for the entire department today due to people being off sick. She says that the other section must find her if they need her assistance, and that being the only nurse is both time-consuming and a lot of responsibility. (Field notes)

Where the CNAs were expected to relieve the nurses’ workload, low nurse staffing levels instead meant that even simple questions became burdensome, precisely because the CNAs depended on the nurses. Another nurse described the situation as follows:

I think it’s okay that we have CNAs. That is absolutely fine. But for instance, during evening shifts, I can be the only nurse in the entire department, and then there can be many medications out of the ordinary that must be administered. (. . .). And we have seriously ill patients who need pain pumps, IVs, and other things that take time. So, in these situations, I wish there were more of us nurses. (Nurse 1, interview)

In addition to adding to the nurses’ workload by asking questions, this quote illustrates how nurses were not relieved by the CNAs in the most demanding work tasks and often had to manage these alone because of the formal division of labour. In these instances, the nurses specifically needed additional nurses to ease their workloads, not CNAs. Thus, what represented opportunities for knowledge development for the CNAs simultaneously manifested as jurisdictional claims and perceived risk for the nurses, exemplifying the duality at the core of task redistribution.

Drawing the line: Nurses’ resistance to CNAs’ expansion

The nurses’ response to the CNAs’ participation revealed a tension between collaboration and control. Although the nurses found the CNAs’ continuous questions burdensome, they also articulated limits to how far the CNAs’ involvement should extend. While the nurses valued the CNAs’ thoroughness, their acceptance was conditional:

The CNAs are extremely thorough, which provides a sense of security for us. We know that they don’t (. . .) hand out medications that they are not supposed to hand out. (Nurse 4, interview)

The nurses perceived the CNAs as valuable when they adhered to the established division of labour, stayed within their professional boundaries, and did not interfere with the nurses’ jurisdictions. This provided the nurses with a sense of security, as they could trust that the CNAs would not overstep their responsibilities. However, as the CNAs’ work areas expanded, these assurances weakened, and interprofessional tensions arose. The nurses expressed resistance and a need for clearer boundaries:

I think the collaboration among us colleagues is good. It’s just that there should be a clearer distinction. I mean, we need to collaborate and listen to one another and such because there’s no doubt that the CNAs have a fantastic ability to observe. Because we are more focused on the medical aspects, and they observe how [the medications] affect the patients. (. . .) So, to have one’s place and to know that “This is my work. I should do this, and the CNAs should do that”, and then we should help each other. (Nurse 2, interview)

This nurse expressed a wish for a clearer division of labour and mutually complementary roles between nurses and CNAs. In Abbott’s (1988) terms, these accounts illustrate nurses’ attempts to preserve jurisdiction by reinforcing their professional authority and medical knowledge. The nurse discursively resisted the expansion of the CNAs’ jurisdiction by emphasising differences in competence, defending her own professional terrain, and implicitly delegitimising the CNAs’ contributions. Another nurse voiced a similar concern, arguing that the CNAs lacked the evaluative competence required for safe medication management:

That’s what I feel can disappear, as knowledge, concerning that suddenly (. . .) everyone is allowed to administer medications (. . .). If I have a patient where I suspect active bleeding, I wouldn’t hand out the regular dose of anticoagulant (. . .), but that knowledge disappears if it’s a CNA who administer medications, who don’t have that training and don’t know that one should not just give it because it has been prescribed, and the physician has said so. You must evaluate each specific case. (Transcribed audio file from observations)

Here, too, the nurse defended her profession’s jurisdiction by highlighting the differential medical knowledge and positioning nurses as uniquely capable of clinical evaluation. She also framed expanded CNA responsibility as a patient safety risk, placing the nursing profession as superior. Across accounts, the nurses praised the CNAs’ reliability while simultaneously marking their limits. Task redistribution thus created a space where the CNAs’ knowledge development and jurisdictional expansion triggered the nurses’ defensive efforts to maintain control over the work tasks, revealing attempts to sustain the professional boundaries even as they blurred in practice.

Discussion

The findings show that task redistribution in medication management is not a simple redistribution of work tasks, but a dual process of knowledge development and jurisdictional competition. This duality shapes how CNAs and nurses engage in everyday work, and understanding it is key to interpreting both the opportunities and challenges that arise during task redistribution. CNAs do not simply develop knowledge; they develop knowledge in this specific way because their practices are situated in a social context where risk, resource constraints, and insufficient tools shape their actions. Thereby, their knowledge development is both a consequence of, and an active response to, the situated organisational and material contexts.

Knowledge development and jurisdictional disputes

Workplace assimilation provided the CNAs, as paraprofessionals, with entry into the practice of medication management. Situated learning theory (Lave and Wenger, 1991; Wenger, 1998) provides an analytical lens for understanding how the CNAs developed knowledge through their participation in everyday work practices, particularly by interacting with the nurses, negotiating meaning, and gaining access to the nurses’ medical knowledge. Empirical studies similarly highlight the social dimensions of learning safe medication management (Hawkins et al., 2017; Jennings et al., 2011). However, this study extends previous knowledge by showing how these social practices also constitute negotiations of jurisdiction. The CNAs developed forms of knowledge that overlapped with what the nurses regarded as central to their own professional domain, particularly medical knowledge and clinical evaluation. These findings resonate with those of Bach et al. (2012) and Allen (2000), although separated by context and time, suggesting that tensions across these two professional groups are an embedded part of their relationship, reflecting how competition over workplace jurisdiction is inherent to the system of professions (Abbott, 1988).

A peripheral paradox

Participating in clinical communities of practice (Young et al., 2018) and taking on work tasks at the boundaries of professions may equip health professionals with expanded clinical knowledge and enable them to blur professional boundaries (Johannessen, 2018). In this case, however, the peripheral participation seemed permanent, reflecting a disempowered position for the CNAs (Wenger, 1998), where they held only partial jurisdiction, subordinate to the nurses (Abbott, 1988). Peripheral participation thus functioned as a boundary-maintaining mechanism: it protected the nurses’ authority and jurisdiction in medication management, while easing some of the nurses’ workload. Yet this very subordination made CNAs dependent on nurses, thereby increasing nurses’ workload. This creates a peripheral paradox, where seemingly permanent peripheral participation both stabilises professional boundaries and intensifies the resource pressure that necessitated task redistribution in the first place. This is a dynamic that likely extends beyond health care, to any organisational context characterised by resource constraints combined with hierarchical divides between professional groups.

The ‘Failure’ of boundary objects: Maintenance or reconfiguration?

The MARs largely functioned as mediating boundary objects (Wenger, 1998), connecting treatment plans provided by physicians to the nurses and CNAs and aligning their perspectives. However, they sometimes failed to support the CNAs’ work practices. MARs as boundary objects were created in historical contexts where CNAs were not included: they have been negotiated through the interplay of medical doctors’ and nurses’ participation and reification and tailored to these professions’ needs. In this way, they functioned as a boundary-maintaining mechanism that could reproduce boundaries between the nurses and the CNAs.

Yet, the CNAs did not merely accept the MARs’ limitations but questioned their content. This study shows how MARs’ limitations fostered negotiations of meaning. When the CNAs sought clarification from the nurses, new understandings emerged, and the MAR itself became a source for boundary negotiation. The boundary object thus pushed boundaries (Håland et al., 2015), potentially enabling the CNAs to increase their professional status, as mastering medical technologies may enhance jurisdictional claims (Serra, 2010). The MAR exemplifies a duality of boundary objects: insufficient reification maintains boundaries by impeding CNAs’ independent action, yet the following negotiations can reconfigure the boundary objects, making them useful to CNAs and redistributing jurisdiction.

Implications: Organising with duality in mind

Task redistribution in medication management thus emerges as a process of continuous negotiation. Authorities argue that shifting tasks from nurses to CNAs is necessary to deal with future nurse shortages (Norwegian Ministry of Health and Care Services, 2023). For this to succeed, health institutions must create conditions that support both groups. Professionals need a clear understanding of their jurisdiction, the competence and tools to carry it out, and meaningful work tasks reflecting the situated contexts of health care. CNAs need tools that provide the information they depend on, while nurses need organisational structures that reduce their supervisory burden. One concrete implication concerns the MAR. Digitalising MARs to integrate them with electronic health records might provide CNAs with some of the context they seek from nurses. This could reduce the need for constant verbal communication and thereby ease nurses’ workload.

The findings and analysis show that task redistribution cannot be understood solely as the movement of tasks between professional groups. Instead, it involves both negotiation of meaning and jurisdiction and unfolds as a dual process of knowledge development and jurisdictional competition. Acknowledging this duality is essential for developing policies that support the situated realities of interprofessional work.

Further research may refine this dual process perspective by examining how different organisational structures, divisions of labour, and various levels of resource constraint shape negotiations of meaning and jurisdiction. Investigating how different organisational structures shape these negotiations may contribute to a more diverse understanding of professional boundary reconfiguration under task redistribution.

Limitations

This study examined interprofessional relationships and medication practices at an interactional level within Norwegian nursing homes. The findings are therefore shaped by the specific organisational and regulatory context, including national legislation governing medication management. While this contextual grounding enabled in-depth analysis of situated negotiations of meaning and jurisdiction, the study does not capture how similar processes unfold in other organisations or under different regulatory conditions.

Furthermore, the analysis focussed on the two central professional groups involved in medication preparation and administration. Other actors, such as medical doctors and management, were not included. Including additional professional groups and organisational levels may have provided further insight into how task redistribution is negotiated across broader and more complex contexts.

Footnotes

Acknowledgements

I would like to extend my gratitude to the Norwegian Research Council for funding this study. Additionally, I would like to thank my supervisor, Anonymised, for valuable feedback during the production of this article. Lastly, I am grateful to the participating institutions and health professionals in this study.

ORCID iD

Stine Agnete Ingebrigtsen

Ethical considerations

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Research Council of Norway (Grant Number: 314382).

Declaration of conflicting interests

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

Data availability statement

The data cannot be shared due to restrictions outlined in the approved data management plan and the participant information sheet/informed consent form. Sharing the full dataset could compromise participant confidentiality, even with anonymisation measures in place.

Author biography

Stine Agnete Ingebrigtsen is a PhD candidate at the Norwegian Centre for e-Health Research and UiT The Arctic University of Norway in Tromsø. She has a background from sociology and pedagogy. Her research examines work practices, interprofessional relationships, and the use of digital tools in healthcare.

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