The objective of this review was to identify factors (barriers and enablers) that influenced scope of practice of the five largest regulated health care professions in Australia. Eight factors were identified across three professions (nursing & midwifery, pharmacy, and physiotherapy): education, competency, professional identity, role confusion, legislation and regulatory policies, organisational structure, financial factors, and professional and personal factors. There is substantial crossover in the scope of practice of many of the AHPRA registered health care professions, e.g. occupational therapy and physiotherapy. While this review was restricted to the five largest professions in Australia, subsequent research could examine the scope of practice crossover amongst AHPRA regulated professions.
The lack of literature on the factors influencing scope of practice of medical practice in Australia is in contrast to international jurisdictions. For example, Russell et al.  discovered that four categories of influencers on scope of practice of medical practice exist within the US context: personal (e.g. training, work/life balance, mentoring); workplace (e.g. population, type of work, training); environment (e.g. proximity to hospital, isolation, health care regulations); and population (e.g. age demographics, bias toward speciality care, cultural norms regarding care). Additionally, Reitz  found that the broader health care landscape, local factors, and personal factors influenced scope of practice of medicine.
Within the Canadian context, Myhre et al.  identified that geographic factors (e.g. rural location, community size, distance to a large hospital), personal physician characteristics, professional education, and patient factors influenced scope of practice, while Kabir et al.  discovered that training, organisational structure, inadequate remuneration, workload, professional satisfaction, and the amount of patient care required per treatment influenced scope of practice. Additionally, Myles et al.  reported that geography, the practice environment, the needs of those within communities, and regional and jurisdictional variations in healthcare delivery were key elements in determining scope of practice of family physicians in Ontario, Canada. One influencing factor that was not discovered in the literature search that should be acknowledged is that of intra- and inter-professional issues.
The importance of education in health care
Several Australian studies reported that pre- and post-professional education influenced scope of practice [15, 37, 42, 43, 46, 47, 53, 58] and facilitated the continuing development of the country’s healthcare system [40, 69, 70]. Studies from Canada offer further insight into the importance of education in health care, particularly ‘continued professional development’ (CPD). For example, Myles  and Horsley et al.  assert that scope of practice and CPD are inextricably linked, while Kam et al.  contend that education not only determines and maintains scope of practice over time, it is essentially the curriculum for CPD. In other words, education links scope of practice with CPD.
These findings suggest that health care professionals need to be well-educated and knowledgeable regarding advances in research and treatment modalities in order to practice in a competent manner . This approach has been shown to assist in the discovery and application of health care approaches that help prevent disease and promote well-being [75, 76]. Importantly, the current pre- and post-professional education in Australia is reported as giving individual health care professionals the confidence needed to deliver quality health care within a full scope of practice [77, 78].
The importance of competency
The core element of competency in Australian health care is the ability to practice in a manner that utilises critical thinking and accurate practice skills . Any operational definition of competency must be straightforward and easy to understand as health professionals are required to adapt to changing clinical circumstances . This approach is echoed in other jurisdictions . Several papers identified competency as an influencing factor on scope of practice in Australian health care [15, 36,37,38, 41,42,43,44, 46, 47, 50], while international studies such as that from Kam et al.  highlighted that competency may be negatively impacted if a health care professional acts outside of their scope of practice. Several other influencing factors were reported including years of practice, age, certifications, and a workplace with a clear vision .
Other studies reported that competency acts as a quality assurance measure and reflects the appropriate application of sound knowledge and skills within a particular vocational context [42, 43]. These findings are congruent with the fundamental role of competency in health care, i.e. to execute care in a manner that generates a desirable outcome in the safest possible way . This description suggests that competence is dynamic and changes over time . In other words, a health care professional should be able to develop the ability to employ knowledge, skills, and abilities effectively to new settings, as well as to common tasks for which specified standards exist .
The need for professional identity
The development of professional identity is a critical outcome of work-readiness programmes in health care (e.g. medical internships) . It is a multifactorial phenomenon shaped by several factors including clinical and non-clinical experiences, motives, expectations, individual values, and beliefs and obligations . Due to the influence of professional identity on scope of practice, interest in the topic has increased . The term ‘professional identity’ appears regularly in the literature, but is typically ill-defined [85, 87]. To establish identity, health care professions often look for what is unique and different about their services in order to clarify identity and separate themselves from other professions .
Within the Australian health care setting, confusion around professional identity has led to the absence of a clearly defined scope of practice [51, 52, 89, 90]. Similarly, within the global context, scope and what constitutes professional identity appears to vary, despite extensive discussion on the subject . For example, some researchers have defined scope of practice as a dynamic personal concept that develops from the commencement of pre-professional education, through to the health professional’s working life [91,92,93,94,95]. Others assert that professional identity comprises an integration of personal and professional values that must be internalised and committed to [96,97,98].
A clearly defined professional identity is important as it prevents scope of practice becoming more focused on roles that ‘fill gaps’, rather than retaining a paradigm-specific focus . At the same time, it can reduce inconsistent and unsupported definitions of professional identity that often lead to misunderstandings and confusion amongst health care professionals , help prevent burnout, reduce loss of confidence in a profession, decrease role confusion [100,101,102], and more importantly develop a safe and effective scope of practice [15, 37, 51, 86, 103]. Therefore, it is imperative for a health care profession to have a strong professional identity otherwise the profession may have difficulty when considering its values and how they relate to the behaviours expected by the profession, colleagues, and the general public . If the lack of clarity around professional identity is not ameliorated, patient safety may be jeopardised .
Issues surrounding role confusion
Role clarity is crucial as poorly defined roles can become a source of conflict within clinical teams and reduce the effectiveness of care and services delivered to the population . Several studies identified the existence of role confusion within Australian health care [15, 37, 39, 42, 44]. These studies suggested that a high level of standardisation of scope of practice [15, 37] combined with limiting role expansion can reduce role confusion . The existence of role confusion causes concern to many health care professionals as it can potentially cause frustration, impede collaboration, create conflict, and constrain the improvement of knowledge and skills within a health care setting . International studies assert that a well-defined professional identity, particularly within multidisciplinary settings , as well as a working knowledge of other health care professions’ roles, can help alleviate role confusion [39, 45, 107].
Contributing to these challenges are: legislative and regulatory frameworks that result in overlapping or encourage expanded scopes of practice; lack of clarity in workers' objectives; co-workers' expectations; the overall scope of responsibilities of their job; starting in a new organisation; a new supervisor or manager; a change in the structure of a work unit; and when a health care professional is required to perform a role that goes against their personal values . A key challenge for all health care professions, not only in Australia but also globally, is to better define, differentiate, and demarcate the roles of each profession [42, 109,110,111].
The influence of legislation on scope of practice
Specific principles outlined in legislation within the current Australian healthcare system can influence the scope of practice health care practitioners. Legislation aims to ensure that the highest quality of protection and care are afforded to the public , expedite access to services provided by health practitioners in harmony with the public interest and facilitate the continuous development of a flexible, receptive health care workforce . These can be achieved, in part, by controlling what health care practitioners do through legislation .
Even though legislation is accepted as the “foundation of authority relevant to scope of practice” in Australia [50, 54], current legislation restricts scope of practice . Moreover, jurisdictional, regulatory, and legislative changes that influence scope of practice often occur without broad consultation with the health care professionals delivering services. This scenario can lead to confusion around scope of practice [43, 47]. A recent US report highlights that the introduction of new regulations that seek to alter scope of practice are frequently costly, time-consuming and adversarial, due to an element of self-interest within the profession . Conversely, legislation can be an enabler to scope of practice by providing role clarity for the profession .
The influence of organisational structures on scope of practice
A healthcare structure is a place where patients needing a similar area of expertise are arranged into autonomously managed departments. Historically, the use of discrete healthcare structures was considered appropriate to support and foster the knowledge development necessary by medical science. More recently though, this framework has displayed considerable weaknesses including economic and organisational inefficiencies .
Australian studies shed light on this subject, highlighting that organisational structure can influence scope of practice [15, 42, 47, 116]. For example, the so-called ‘internal culture’ or ‘long-held traditions’ within an organisation can act as a barrier to scope of practice and limit improvement in health care access for the community [44, 46, 113, 117]. This attitude appears to disregard the fundamental purpose of a healthcare structure, to attain objectives that are outside the capacity of any single individual . Similar results were reported in the US, where an entrenched ‘culture’ or ‘tradition’ within a structure may be a substantial barrier to scope of practice [119, 120].
Several Australian articles indicate that scope of practice of health care professions is influenced by financial factors from two main areas: government funding [41, 48, 121, 122], and insufficient personal remuneration for services rendered [15, 36, 56]. The Medical Benefits Scheme (MBS), (a key component of Medicare Australia), can act as a barrier to scope of practice if MBS item numbers are limited for specific health services [41, 121, 122].
Halcomb et al.  found that as some government funding programmes operated on an ad hoc basis, subsequent opportunities for further development of scope of practice were limited. Moreover, insufficient personal remuneration (whether real or perceived) for services rendered can act as a barrier to scope of practice of health professionals in Australia [15, 36, 37, 56]. Two international reports support this view indicating that financial factors influence scope of practice of health care professionals [123, 124].
The influence of professional and personal factors
Birks et al.  and Exercise & Sports Science Australia  highlight that scope of practice for health care professionals in Australia is influenced by professional and personal factors. Professional factors include practice environment, the need for a supportive working setting, personalised roles that are regularly revised and clarified, limited access to wider networks and geographic location [15, 56, 126]. Poor quality practice environments are a barrier to scope of practice as they typically engender unrealistic workloads, have poorly equipped facilities, and create unsafe working conditions. This makes it more difficult to entice, inspire and retain staff. Moreover, this setting reduces an organisation’s ability to meet performance targets .
Access to wider networks refers to the availability of other health professionals to refer to, while geographic location, in the context of these studies, refers to rural and remote settings. In the Australian context, legislative and regulatory provisions are in place across State, Territory and Federal governments to support the expanded scope of practice of novice and advanced health care professionals in rural and remote areas. For example, it is recognised that registered nurses need to be adequately prepared for the broader scope of practice necessary for rural and remote practice. Thus, educational programmes need to be flexible, accessible and affordable. Educational pathways should be structured to enable health care workers to expand their scope of practice according to the context in which they work and the needs of the community. A regular review of health legislation is needed to ensure there are no impediments to supporting advanced nursing practice within those settings [128, 129].
Rural and remote settings can be a barrier to scope of practice of some health care professionals because a lack of access to medical and/or specialised allied health staff can pressure some health professionals to work outside their normal scope of practice [15, 45, 49, 56, 126]. In other words, they perform tasks for which they have little or no training. This scenario is associated with higher levels of job dissatisfaction amongst Australian health care professionals  as individuals feel inadequately prepared for the extra responsibilities and experiential or technical challenges associated with an increased scope of practice . In the global context, this is reflected in reduced role clarity which can jeopardise patient safety .
While professional and personal scope of practice are inextricably linked, it should be acknowledged that the scope of practice of an individual practitioner is distinct to the scope of practice of a profession. Personal factors that may influence scope of practice include being unable to undertake professional development, inexperience, stress, individual personality, motivation, and time constraints [56, 132]. Similarly, international studies demonstrate that personal circumstances such as time constraints, financial restrictions, and limited learning resources can influence scope of practice [133, 134]. Fundamentally, when workplace settings are optimised for a practitioner, health professionals tend to perform at peak scope of practice , leading to better health outcomes for patients.
Strengths and limitations
A key strength of this review was the breadth of the literature search, which included multiple research databases and grey literature sources. Additionally, we compared scope of practice across multiple professions which, to our knowledge, has not been undertaken before in a single study. This is in contrast to other studies that typically focus on a single profession. A limitation of the review is that some articles may have been overlooked due to the constraints in our search strategy. For example, we used the terms ‘medical practice’ and ‘psychology’, but we did not look at the various sub-specialities within medical practice (e.g. plastic surgery and general surgery), or psychology (e.g. clinical psychology and forensic psychology). In addition, the paucity of Australian-based literature meant we were unable to systematically compare our findings across the five professions with other literature. Furthermore, the majority of studies included in this review related to nursing, which may limit the generalisability of our findings.
The results from this review may serve to underpin future studies that investigate scope of practice for the remaining regulated health care professions in an attempt to identify if similar factors exist in those professions. Such studies may also help to determine if it is beneficial to have a common scope of practice across professions and whether this would assist in increasing competency and patient safety. Future research could also address several issues within the Australian context including: whether the regulated professions function equally well without a legislated scope of practice, or whether a formal, defined scope of practice is more acceptable for a profession and its patients. Furthermore, using the COVID-19 pandemic as a backdrop, future research could explore if the scope of practice of the largest health professions in Australia changed because of pandemic response measures and whether the pandemic impacted education, competence, and other factors identified in this study.