Over the past twenty years, healthcare systems in Western Europe and North America have developed national or state-level policies to ensure safe nurse staffing levels. Whilst a diversity of formal methodologies has emerged there is little evidence to recommend any model. This paper contributes to this evidence base through a qualitative cross-case comparative analysis of nurse staffing systems in England and Wales. Whereas previous research has focused on the reliability and validity of a measures, outcomes, costs, and/or implementation processes, this study is distinctive in deploying a socio-material perspective to examine the network of relations in nursing staffing systems, their mechanisms of action and effects. We describe and explain the impact of organisational and knowledge hierarchies and external constraints in diluting policy intent and how these create spiralling effects that further militate system effectiveness. Recommendations for improvement are made.

The shortage of medical professionals in peripheral areas is an international challenge, not only in the developing world, but also in developed countries, which jeopardizes the quality and equity of care provision (WHO,2021; AHEAD,2022). Scholarship in the field of health policy has analyzed the causes that determine the phenomenon. For instance, Weinhold and Gurtner (2014) propose a framework of the factors that influence the choice to work in remote contexts, listing: infrastructural, professional, educational, socio-cultural, economic and political factors. However, the multiple facets of the professional determinants of shortages remain underexplored.

We bridge this approach with the perspective of the research on medical professionalism. Traditional professional work is characterized by treating complex cases with autonomy and in relative isolation. However, this traditional model has changed, as complex conditions, new treatments and technologies determined stronger specialization, needs for new work interdependencies, as well as the requirements of continuous professional updates (Noordegraaf,2015; Martin et al.,2015). Therefore, it is crucial to understand how contemporary doctors perceive the professional work in rural areas, in order to make sense of the staff shortages and identify intervention strategies.

We explore this issue with a qualitative approach, by performing four case studies in Italian LHAs managing small/medium hospitals in peripheral areas. We performed a total of 24 in-depth interviews with managers, cardiologists, and orthopedic surgeons.

Our findings show that the picture is multifaceted. Different professional drivers emerged as relevant for doctors, including complexity of the case-mix, opportunities for learning, availability of technologies, educational pathways, autonomy, opportunities for professional entrepreneurialism, quality of the working environment, status in the local community, relationships with patients. While peripheral contexts appear poorly positioned regarding some of these elements, in other cases they may offer interesting work opportunities for doctors.

In the discussion we draw theoretical implications and practical implications for policy makers, health managers as well as medical hybrids called to organize professional work.

We examine new doctors’ and nurses’ experiences of transitioning from training to practising as health professionals, drawing on the concept of liminality. Liminality is a stage of ‘in-betweenness’, involving uncertainty and ambiguity as people leave one social context and reintegrate into a new one. Surprisingly little research has explored new health professionals’ experiences of liminality during role and career transitions, particularly in precarious and resource-constrained settings. Drawing on 146 qualitative interviews and seven focus groups, involving 121 new graduate medical doctors and nurses transitioning through internship training in Kenya, we describe three aspects of liminality. First, liminal professional practice, where interns realise that best practices learned during medical and nursing schools are often impossible to implement in resource constrained health care settings; instead they learn workarounds and practical norms. Second, liminal inter- and intra-professional relationships, where interns leave behind being students and adopt identities and responsibilities as qualified professionals within pre-existing professional hierarchies of status and expertise. We explain how these new doctors and graduate nurses negotiate their liminal status in relation to more experienced but less qualified professional colleagues. We also discuss how interns cope with liminality due to disappointing and inadequate supervision and role modelling from senior colleagues but then find peer support and their place within their own professions. Finally, we discuss how new doctors and nurses come to terms with the precarity of working in resource constrained health systems, abandon expectations of secure, permanent employment and careers, and accept permanently liminal health professional careers. We explain how all three forms of liminality influence professionals’ developing practices, identities, and careers. We call for further studies with a specific liminality lens to explore this critical period in health workers’ careers, to inform policy and practice responing to global transformations in healthcare professions and practice.