The Creation of the Social Boundaries of Occupation Based on the Example of Physiotherapists in Poland

Wiktor Sokół^*

Univertity of Gdańsk, Poland

Bartosz Mika^*

Univertity of Gdańsk, Poland

Tworzenie społecznych granic zawodu na przykładzie fizjoterapeutów w Polsce

Introduction

A distinctive element of being involved in a certain occupation is the collective validation of activities that categorize it as an independent profession. A set of activities (tasks) becomes an occupation when it fulfils certain socioeconomic conditions. It must be a source of income for a specific group of people; it must be sustainable over time; and it must be distinct from other activities in the social division of labor. The process of defining the social boundaries of a profession is typically complex and protracted. It unfolds simultaneously in many areas, including economics as well as social, legal, and symbolic legitimation. It is also uneven in terms of the technical and social division of labor. Prior to being classified as a profession, a group involved in specific activities must face and overcome many challenges.

The subsequent sections will outline insights related to the advancement of physiotherapy as a profession in Poland. An analysis of the professional status of physiotherapists will focus on the formal integration of their field into legal and social systems, resulting in the establishment of guild-like self-governance that maintains occupational limits (the Polish Chamber of Physiotherapists). While physiotherapy has existed in Poland since World War Two, the formalization of the physiotherapist profession is relatively new and can be easily examined as it lives in the memories of active members of the profession. The Physiotherapy Act was enacted in 2015, regulating the practice of physiotherapy, the acquisition of the right to practice, professional training, and professional liability. In December 2016, the Polish Chamber of Physiotherapists was established to represent the profession and defend the professional rights of its members. Both processes were interlinked and created the formal framework for physical therapy as an independent medical occupation.

From the methodological standpoint, the relatively recent establishment of the profession provides an opportunity to study the process through the narratives of the participants. Furthermore, focusing on a specific country and the evolution of the profession within its institutional structure is crucial, given that the social validation of professions occurs differently in various economic environments. From the point of view of the qualitative research undertaken in our study, this scenario presents a favorable condition, facilitating the recognition of typological features in the professionalization process without the need to claim representativeness. The argument in this paper suggests that the observed social phenomena may take on various forms in alternative economic settings; however, the core theoretical findings ought to be pertinent across multiple national and regional frameworks.

Starting from the classical sociology of Max Weber (1978) and his successor Stanisław Kozyr-Kowalski (1979), supplemented by the economic perspective of Stephen Marglin, we demonstrate that a profession is primarily the ability to effectively defend a certain monopoly on performing a specific activity within the technical division of labor. Using the meta-approach, we will also employ Burawoy’s Extended Case Method. This method provides the opportunity to set and verify pre-existing theories by checking the extent to which they are reflected in the empirical data (Burawoy, 1998). Then, we will expand on the noted deficiencies, if they do appear. This approach will help with capturing the subjective element that a pre-established structural theory may not have involved. If there are any inaccuracies, the theory can be supplemented with new information. Through extensive interviews with notable authorities involved in the 2015 legislative and active members of the aforementioned Polish Chamber of Physiotherapists, we explored the development of professional standards within the field of physiotherapy. These interviews constitute the principal empirical foundation of this paper. They form part of a broader, ongoing study of massage therapists and physiotherapists in Poland. The connection between the two strands of empirical material lies in the fact that the interviews with physiotherapists – conducted from 2023 to this day – revealed that the enactment of the Physiotherapy Act represented a significant turning point in their professional biographies. This, in turn, generated the need to explore the background of that process, which we present in this article. We also draw selectively on statements made by physiotherapists themselves, but only insofar as they directly concerned the role played by the legal legitimization of the profession. The findings presented here should therefore be regarded primarily as the outcome of expert interviews. In sum, our research shows the importance of professional boundaries for the skills and qualifications used by its practitioners.

What constitutes an occupation?

There is a substantial body of literature on physiotherapy. In recent years, global analyses have particularly emphasized research on entering the physiotherapy profession during university studies (Alaca et al., 2024), experiences associated with the implementation of physiotherapy in COVID-19 recovery (Asser, Soundararajan, 2021), as well as the influence of the pandemic on physiotherapists (Saxena, Jangra, 2023) and the expansion of augmented reality within physiotherapy practice (Estebanez-Pérez et al., 2024). In Polish sociological literature, attention has been drawn, among other issues, to physiotherapy as an intervention during moments of bodily crisis (Byczkowska-Owczarek, 2014), to the relations between touch and the body in physiotherapy (Krzesicka, 2019), and to the embodiment of physiotherapists’ skills (Modrzyk, 2020). What remains absent in the literature, however, is a structural account of the physiotherapy profession. In this study, we aim to address this gap by reconstructing the process through which physiotherapy had been formally institutionalized as a medical profession.

At its core, an occupation is a specialized activity carried out by a defined group within society. An occupation is characterized by systematically organized tasks that serve a specific social goal and provide a steady income. The group of people performing a given occupation is differentiated in the process of the division of labor (Durkheim, 1997), which involves the specialization of tasks on the basis of distinct qualifications. These qualifications define the knowledge and skills required to perform the occupation, sometimes leading to the establishment of formal credentials. In Economy and Society, Max Weber (1978: 140) summarized that “the term occupation will be applied to the mode of specialisation, specification, and combination of the functions of an individual so far as it constitutes for him [and her] the basis of a continuous opportunity of income or earnings.”

An important element of the occupation is its social dimension. A socially-recognized set of roles, responsibilities, and activities performed by individuals to earn a living involves a structured form of labor that requires qualifications and is tied to broader systems of economic production, social stratification, and cultural identity. Occupations are not merely economic activities but also social constructs. They often influence an individual’s social status, identity, and relationships within the community.

The latter is significant, acting as a key contributor to social networks and underpinning the occupation’s relevance and place within the societal structure. Max Weber pointed to three different types of the division of labor: a) technical, b) social, and c) economic. The technical aspect is crucial to the argument presented in this paper, since it is associated with the distribution and combination of the services of various cooperating individuals – as well as the non-human means of production – in order to perform the technical operations involved in work (Weber, 1978). The social division of labor is related to the appropriation of specific services, life chances, and means of work. The economic division takes place between different types of economic units with the separation of profit-orientated enterprises from household administration (Weber, 1978: 114).

The technical division of labor is developed by Weber in an interesting way, as the detailed type of the division of labor depends on the type of activity performed by the individual worker and the group of workers. According to Stanisław Kozyr-Kowalski (1979), who refers to Weber, the individual can perform tasks in a combinative way when s/he performs many technically different tasks, which produce different end results (e.g., in small-scale agriculture). In the case of the compensatory division of labour, Stanisław Kozyr-Kowalski points to the division based on the specification of work, when workers perform many different technical tasks necessary to obtain a single final product (the example is artisanal production). Finally, the division of labor can be specialized when an individual performs a specific, technically distinct partial task that constitutes only a part of the final product. Obviously, the specialization typical of industry requires the work of many units performing different tasks, while specification and combined work can be coordinated “in parallel, or […] into a single collective effort” (Weber, 1978: 120).

All this suggests that the aforementioned professional bond and the work process itself take place in a very diverse environment and can take different forms. In the study presented below, we will argue that the distinction of the physiotherapist’s profession is related to the specialization of tasks within the medical professions. Although the individual actions within the profession of physical therapist are characterized by the specification of tasks (massage, mechanical intervention, gymnastics, etc.), we observe the specialization of the profession against the background of other medical professions.

The above indicates that the point of interest in this paper – i.e., the process of professionalization viewed from the social perspective – takes place within the technical division of labor. The fact is important but not at all obvious from the sociological standpoint. As pointed out by Stanisław Kozyr-Kowalski (1979) and Erik O. Wright (1980), sociologists had generally regarded the social and technical division of labor as essentially the same theoretical terrain. More specifically, Wright points out that: “even when classes are not seen as defined simply by a typology of occupations, classes are generally viewed as largely determined by occupations” (Wright, 1980: 177). According to both Marx’s and Weber’s theories regarding social stratification, different classes and occupations qualitatively represent unique standings within the landscape of social inequalities. An occupation is a type of activity actually performed to earn a living, which constitutes an element of the relations of the division of labor and cooperation at work (Kozyr-Kowalski, 1979: 127). On the other hand, classes can only be defined in terms of their location within the social relations of production (Wright, 1980). Classes are related to the social division of labor, which involves not only different roles in the technical division of labor, but also different access to property and location in the relation of production. In this sense, representatives of the same occupation can be members of different classes^[1].

Keeping in mind the distinction between the social and the technical division of labor, we can read inspiring observations made by Stephen A. Marglin (1974; 2008; 2015) in a unorthodox way. The author focused on the role of profitability and class interest as distinct reasons shaping the organization of work at the shop floor in the early industrial period. The traditional vertical structure of craftsmanship – which relied on techne knowledge – has been supplanted by a system of hierarchical oversight in contemporary capitalist organizations that prioritize episteme knowledge (Marglin, 2015). As a result, the capitalist organisation of work designed to specification and specialisation of tasks made capitalists indispensable (Marglin, 1974).

From our point of view, Marglin conflated two different theoretical spaces: the social and the technical division of labor. At the level of the technical division of labor on the shop floor, his argument is convincing and points to the importance of the monopoly of knowledge in defending occupational boundaries. Drawing on Marglin’s (1974; 2008) analysis, it can be argued that occupational control is fundamentally rooted in a group’s capacity to maintain exclusivity over the application of specific skills or knowledge.

The observations derived from Marglin conclude our definition of occupation in this paper. A profession is understood here as a special type of occupation that constitutes the basis of a continuous opportunity for income or earnings for a specific group of people. The group is characterized by the process of the technical division of labor and by its ability to create and protect a monopoly of knowledge and skills. As we will argue below, professionalization can be understood as a process of creating social boundaries or differentiating skills for a particular group of job holders.

Methodology of the study

The research presented in this paper is the outcome of an ongoing project dedicated to the examination of physicians and masseurs in Poland. The primary objective of the research which began in the 2022/2023 academic year was to explore the work dynamics in massage parlors, particularly emphasizing the emotional dimensions of the job. The research is based on IDIs (in-depth interviews) lasting from 40 minutes to over an hour. Throughout our investigation, we uncover a notable differentiation among four types of activities associated with engaging the body, each varying in accessibility and the level of skills needed. These types are: physiotherapy, therapeutic massage, ethnic massage, and spa massage. After two pilot interviews conducted with masseur technicians, the main data consists (at the moment) of 25 interviews – 10 with technicians and 11 with physiotherapists, and only 4 with other types of massagers. The participants were recruited using a variety of recruitment methods. Primarily, purposive snowball sampling was used (Yin, 2013). The unsatisfied goal was to reduce the importance of bias toward physiotherapists and masseuses. Moreover, the Internet and personal contacts were also used. As physiotherapists and masseurs were very keen to take part in the study, it usually took only one visit to the parlor to make contact with the interviewer.

A detailed examination of the above-mentioned categories falls beyond the scope of this paper; however, what emerged as particularly noteworthy was the distinct manner in which the boundaries of each occupation were defined in every case. Among physiotherapists, academic training grounded in highly specialized knowledge was particularly distinctive. The interviewees consistently emphasized that full recognition of this expertise occurred only with the enactment of the Physiotherapy Act in 2015. Below, we cite statements that confirm this observation. In quoting physiotherapists, we anonymized their data by providing the first letter of their first name, gender and randomly assigned digit between 1 and 9. The considerable importance attributed by practitioners to the emergence of the Act prompted the researchers to examine more closely the process by which the bill had been established.

As a result, in addition to the primary subject of the study – namely emotional labor and its relationship to the human body – the collected narratives highlighted the significance of the professionalization process that has occurred among physiotherapists in recent years. The following section will provide a detailed description of this process. What is important here is the fact that during open coding, based on researchers’ intuition, important differences between masseurs and physiotherapists have been revealed (Glaser, Strauss, 2017). Focusing coding that involved classifying codes into categories shows that the process of preparing for the passing of the 2015 bill establishing physiotherapy as a separate medical profession was a cornerstone of the professionalization of this group.

The disparities that emerged during the focus coding of the primary data collected from physiotherapists and masseurs prompted the research team to extend the study. In order to enhance comprehension of the significance of the processes that culminated in the enactment of the law on physiotherapy, it was decided to trace the process of professionalization with the guidance of individuals directly involved in the development of the law. New respondents were invited to participate in the study. The invited experts comprised three senior physiotherapists (marked below as E1, E2, and E3) – two male and one female – representing the profession’s self-governing bodies and involved in the creation and promotion of the Physiotherapy Professionalisation Act. The interviews were conducted live and they were recorded using a special device. Participants were informed about the aims of the study and notified that the interview would be recorded. The interviews with these experts were based on changed questionnaires and lasted over one hour. They covered topics related to the work of physiotherapists, the process of professionalizing, and the boundaries of the profession. The interviews were conducted in the native language of the respondents (i.e., Polish) and then translated into English. The results of the study were then confronted with the pre-assumed theory to determine – in accordance with the Extended Case Method (Burawoy, 1998) – the extent to which the theory is confirmed by empirical evidence. This process also determined the extent to which new cases and their explanations must be added to the theory to develop it iteratively.

The present paper focuses chiefly on the findings from the latter interviews with experts, supplemented by material gathered during interviews with physiotherapists and masseurs. As the interviews with experts were directly inspired by the discoveries made during the interviews with physiotherapists, the analysis commenced with focused coding directed at the process of professionalizing the occupation. The implementation of a variable-orientated analysis was undertaken to facilitate a more profound comprehension of the pivotal variables that are instrumental in establishing symbolic and legal boundaries between physiotherapists and physicians on the one hand and masseurs on the other. The analyses presented below should be understood primarily as derived from expert interviews. Previously collected interviews with physiotherapists were treated here as a source of inspiration for the study and as material enabling the cross-checking of the narratives put forward by the experts.

Physiotherapy in Poland

Physiotherapy as a medical profession has been present in Poland since World War Two and stems from the number of injuries experienced during the conflict. However, today’s physiotherapy as a medical profession is the result of decades of development and struggle for its position and autonomy. The key point for the development of Polish physiotherapy was the establishment of Master’s degree studies in the 1960s, the first studies of this level in Europe. From the very beginning, this programme was a center for the construction of professional standards. In the course of the IDIs, our interviewees strongly emphasized the significance of academic education. One respondent, when asked whether a Bachelor’s degree would suffice to practice the profession, replied categorically: “A Master’s degree. There was the Act on the Profession of Physiotherapist from 2016 – or 2015, if I am not mistaken – which stipulates that a person wishing to practice the profession must hold a Master’s diploma” (AF3). Another physiotherapist confirmed the significance of this educational pathway into the profession: “Two years ago there was a change in the Act. Previously it was a Bachelor’s degree and then a Master’s, but after the amendment it became a single-cycle Master’s degree. In the meantime you are not able to obtain the right to practice, and only after completing the Master’s degree can you submit an application, upon which you are granted that right” (NF4).

As expert E1 said, “We were a profession, always an academic profession, that is, a profession that learnt from the beginning, not only to perform various procedures with the patient, but […] to study before therapy, to study after therapy, to draw conclusions, and to change this therapy.” Generally, as it was noted in the experts’ interviews, the key moment for physiotherapy as such was the establishment of professional independence – first in Australia in 1976, then in the USA in the same year. Across the globe, numerous countries have established professional autonomy for physiotherapists; however, Poland’s reimbursement framework remains unchanged. As E1 pointed out, “We watched the process which took place in Poland in the 1980s then 1990s. Well, we looked at our situation ourselves and we saw that it was not changing, de facto it was becoming more and more absurd, because physiotherapists in Poland have to carry out doctors’ orders, orders from people who often do not even know what physiotherapy is”.

The outlined conditions have resulted in escalating discontent, given that physiotherapists, although equipped with diagnostic expertise, serve primarily as agents carrying out directions. The Polish Society of Physiotherapy (PTF) – a voluntary, science-based association of physiotherapists (Statut Polskiego Towarzystwa Fizjoterapii, 2023) – has been trying for years to get the law to improve the situation of physiotherapists, but without success. In the interviews, there was a visible attempt to place the physiotherapy profession among the medical profession. As E1 said, “The role of the physiotherapist is crucial and this has been recognized by scholars and practitioners of the so-called Public Health in the United States because the physiotherapist is a key medical profession in public health. Why? Because a physiotherapist spends the most time with the patient and can […] use that time to educate the family and patients about various other elements of therapy […]”.

The physicians and other traditional medical professions can then be defined as a positive point of reference for the physiotherapists. Physiotherapy treated itself as a medical profession and framed the changes they faced in the position of the profession as a specialization among medical professions. Moreover, our interviewees clearly pointed out that against social specialization, the specification of tasks takes place within the profession. For example, GF7, a young physiotherapist with 13 months of experience, is searching for her specification: The needs “I most often observe in patients who come to me include myofascial therapy. I handle it using pain-free techniques work […] I also frequently use tools such as wedges or angles […]. These are blunt-ended steel blades […]. I also often work with EMTek […] where I directly address issues like trigger point elimination, meaning I work directly on the muscle to create an effect” (GF7). Another of the interviewed physiotherapists, BF1, described the differences between medical diagnostics and the practice of physiotherapy. “Recently I was talking with a friend who studies dentistry. For her, patients come and say: ‘Good morning, please fix my tooth’, and usually within half an hour or an hour it is done. There, specific technical skills matter, because you can cause harm. In my profession too, of course, one can do real harm, but the set of skills is somewhat different. For instance, much greater attention is given to soft skills […]. Because when someone comes for a massage, that is one thing, but they also need to do something themselves. It is not a matter of someone simply fixing you – you have to work on yourself as well. And part of my role is to convince the person that they should invest time and effort in themselves” (BF1).

Contrary to medical professions, the masseurs were treated by physiotherapists and experts we interviewed as a negative point of reference (in the sociological sense). It was pointed out that they should not be placed in the same line as physiotherapists because of the different competencies and goals of their activity. Interestingly, in accordance with the Act of March 2024, the profession of massage technician also became a regulated medical occupation. The fundamental distinction between physiotherapists and massage technicians lies in their scope of the techniques used during procedures, autonomy within the therapeutic process and the level of education required. While secondary education is sufficient to practice as a massage technician, the profession of physiotherapist requires higher education. Physiotherapists retain full autonomy in planning therapy, and the scope of their activities extends far beyond massage. Massage technicians, by contrast, are limited to direct interventions on the body and providing health-related advice, which they carry out on the basis of recommendations from a rehabilitation physician or a physiotherapist. The legal framework thus positions the two professions in a hierarchical relationship, with massage technicians occupying a subordinate role.

The boundary between physiotherapy and activities accompanying the process of recovery emerges even more clearly. One of our interviewees, BF1, expressed it in the following way: “Physiotherapy and massage are fields that are regulated by the ministries, and they are medical professions. But there are also various other occupations which are medical in character, so to speak, yet are not defined as such by any legal act. Examples include chiropractic, visceral therapy, and similar practices” (BF1). It was pointed out, with visible regret, how often physiotherapy is confused or equated with simple massage. As E2 said, “This is unfortunately the aftermath, first, of the old system present within NFZ [the Polish National Health Fund, equivalent to NHS in the UK – W.S., B.M.]. Secondly – because in the NFZ the most common clinical case is back pain and the most frequently reimbursed treatments are precisely various medical activities, such as manual forms of massage” (E2). Regarding the increasing popularity of relaxation massage, physiotherapists held differing opinions on whether its widespread adoption negatively affected their profession. There is a historically-based bias about confusing massage and physiotherapy. These associations are so strong that: “I was receiving e-mails, threats, from groups involved in massage. These were groups of, let’s say, Thai massage or massage of some kind, that is, people who provide services to date, but don’t have a medical background, as it were, but they saw our action as a threat to their jobs” (E3). The confusion of physiotherapy with much simpler massages was clearly undesirable among physiotherapists.

The Polish Chamber of Physical Therapists took steps to address the confusion described above and commissioned a professional opinion poll. The results were unsatisfactory. As E1 said, “They found that only 50% of Poles know who a physiotherapist is, but that is almost 70% in big cities and […] 25% in rural area”. While massage is only a small part of physiotherapy, the fact is still not recognized by the general public. Physiotherapy uses an extensive variety of techniques such us physical stimuli, electricity, ultrasound, shock waves, temperature, etc. (all of which indicate specification within an occupation).

A problem with massage itself may arise from the fact that anyone who performs massage and charges for it can be called a masseur. Even in the case of educated massage technicians, there is a difference in the level of acquiring competence in comparison with physiotherapists. Physiotherapists gain their competence at the academic level. As marked by E2, “Today, to become a physiotherapist is a five-year unified Master’s degree. […] We have moved away from the Bologna system […]. We are an academic profession. We are an independent medical profession”. Within these studies, as pointed out by E1, “the number of subjects in pre-diploma training does not differ from those in the medical profession or pharmacist, so these are strictly medical subjects that are not present in the massage profession”. Physiotherapists specialized in a chosen field, such as orthopedics, neurosurgery, or pediatrics.

In comparison, according to our interlocutors, masseur technicians must complete 2,5 years of massage school to be able to work in the medical field. Despite the differences in studies, the most important thing in physiotherapy is knowledge, then hard skills and soft skills. The work of a masseur is mainly manual, and it concerns mainly the massage itself. As was noted in the interviews, physiotherapists have an advantage over masseurs, because they have more precise and diverse knowledge. When physiotherapists are finished therapy with their patients, they often send patients to masseurs. Furthermore, the data collected during interviews with massage therapists and physiotherapists also indicates significant differences between these groups. When asked about the purpose of their work, physiotherapists use terms such as ‘treatment’ and ‘recovery’, while massage therapists talk about relief and the improvement of well-being.

Following expert interviews, an important difference between the above-mentioned occupations is also the fact that physiotherapy is an independent profession (they diagnose and plan), and the main goal of physiotherapy is to restore the patient’s normal state of functioning, regardless of whether the problem is congenital or acquired. These boundaries were strongly highlighted during the interviews.

At the social level, masseurs also do not have self-government, which can cause problems in attempts to join a medical group. At this point, they are regulated like other peri-medical professions. In spite of the fact that there are masseurs with two years of schooling who can perform medical massage, there are also people who call themselves masseurs and who – after sometimes very short courses – are not necessarily competent for this kind of work, or at least do not have sufficient knowledge of anatomy, which can cause harm. But even if the masseur has the status of a technician, the level of a technician or a bachelor is lower than that of a master or specialist in physiotherapy, and is associated with lower competencies.

The 2015 legislation enabled physiotherapists to be recognized as an equal and independent profession in terms of competence within the broader healthcare framework. On the other hand, as will be shown later in this paper, not all of the doctors were happy about it because of the lack of control over the work of physiotherapists. However, physicians and physiotherapists can still complement each other, i.e., rehabilitation doctors in their medical study do not acquire knowledge of patient impact or exercise physiology, whereas this is involved in physiotherapists’ studies. The same does not apply to masseurs. It can thus be concluded that the social construction of the boundaries of the physiotherapy profession has taken place and continues to take place through reference – on the one hand – to a specialization that clearly distinguishes this profession from other forms of manual intervention on the body. On the other hand, this happens through specialisation within medical professions focused on treating patients.

The fight for legislation and games of interest

A point worth emphasizing is the fact that the attempt to position physiotherapy as a medical profession disrupted the existing constellations of interest. As a result of several unsuccessful attempts to formally professionalize the physiotherapy – and in the face of a plan to even deregulate it in the early 2010s (as mentioned by E3) – a group of physiotherapists got organized with the purpose of introducing the obtaining of a law that will enable the aforementioned professionalization to be put into practice. They founded the Polish Society of Physiotherapy, the purpose of which was, as explained by E3, “[…] to introduce a law on the profession of physiotherapist.” The Society was formed from the start by a small group of physiotherapists interested in changing the status quo. As E1 said: “We were graduates of several universities that were at a very high level, and we had extremely enlightened lecturers who, well, they were present in the world of physiotherapy rehabilitation in countries that were more developed than Poland […]”. The Society established a high contribution fee. As E3 said, “It was to serve the purpose that if there will be, I don’t know, 100, 200 people in Poland who will pay this contribution, we will be able to cover legal services”. The Society compiled a report incorporating interviews and information from patients who sustained injuries due to the lack of professional physiotherapy care and accessibility, as well as the presence of an unregulated market. The report also addressed training courses that granted certifications without ensuring the necessary competencies. As respondent E3 pointed out, “On the one hand, we collected from all over Poland information about how people were not guided by physiotherapists […]. It was a report that was dozens of pages long, but to this report, in addition to these patient statements, we also added such information about [underground – W.S., B.M.] trainings […]”.

The Society was not alone in this process; they had meritocratic support from abroad. As E3 pointed out, “We created the provisions of the law, which of course required contact with lawyers. Our law was created on the basis of the Law on the Medical and Nursing Profession, but we also had such a preparation regarding discernment in the world and how it looks like, so we contacted various physiotherapy organizations around the world”. Physiotherapists also collected above 100,000 signatures on the citizens’ project of the new law. Support also came from groups that have long relied on physiotherapy, such as athletes. As noted in the interviews, there were also actions involving patients sending letters to the president. As E3 said, “We came here to the president’s office with more than 4,000 letters written by patients […]”. As E2 claims, “Undoubtedly, this period of the last 15 years is the most dynamic period of development, that is, just including the moment when the law came into force, the process of arriving at this law and then the creation of self-government, this is really […] the most, such a turning point, as far as modern history is concerned […]”.

Attempts to professionalize physiotherapy are framed in this paper as the final stage of professionalization. Our interlocutors strongly highlighted that professionalization in the form of an emancipation of the profession, among other medical professions, had been perceived by some as a threat to their interests. One of the groups considered as a threat was about 2,000 physicians specializing in rehabilitation. Rehabilitation doctors had a strong position to the date; they were responsible for commissioning physiotherapy care, which was associated with financial benefits much higher than physiotherapy care itself. As E3 stressed, “It was also a bit of a fear that the moment we regain some independence, […] at that point this commissioning will simply change in our favor.” Also E1 claims that: “The doctors of rehabilitation continue as if here they are still trying to do something there with us, if I may so colloquially say, a war of competence, well this is money; simply we directly affected the limitation of the income of physicians of rehabilitation”.

This group of physicians actively lobbied against physiotherapists, using their contacts in politics and the medical community, creating a vision that the independence of physiotherapists can bring a threat to the life and health of patients. During debate around the 2015 Act, rehabilitation physicians used their influence on the Polish Supreme Medical Chamber (NIL) to organize a press conference about how the physiotherapy Act is a threat to the health and life of patients. Objections also arose among politicians. It was feared that physiotherapists may not have sufficient knowledge to practice independently, and that the law would allow physiotherapists to admit patients without consulting a doctor, which could be a source of harm. To answer these concerns, physiotherapists augmented that they were competent enough to practice independently. They pointed out that their education was advanced and sufficient for the competencies that the law was supposed to give them. However, there are still places – as it was noted in the interviews – where physiotherapists are still dependent on doctors. As E3 noticed, “On the other hand, in many hospitals, especially in those that do not operate in large cities […], there is such a situation when medical orders are still in force and physiotherapists do not even know that they have the right to discuss with a doctor about what the orders are and what they relate to […]”.

To sum up, the Physiotherapy Act has been described as the most important turning point in the development of Polish physiotherapy. As was stated by E2, “The entry of the law itself, well they were such a bit you could say symbolic point, a bit like entering the [European – W.S., B.M.] Union [by Poland – W.S., B.M.]”. The law has allowed physiotherapists to increase their professional standing, including in relation to other medical professions, and has enabled them to gain greater control over their work process. It gave autonomy to physiotherapists and caused the formation of their self-government. It also sanctioned educational standards for physiotherapy courses. However, there were also legal obligations: there was a need to keep medical records, an obligation to have liability insurance, and an obligation to work according to evidence-based medicine.

Conclusions

The picture that emerges from interviews with experts is one of a success story in the construction of the social boundaries of the profession. The experts involved in setting up the Polish Physiotherapy Association and preparing and lobbying for the 2015 law are particularly proud of what they have achieved. Recognizing physiotherapy as a legitimate medical field and ensuring the profession’s autonomy was particularly strongly stressed. If we define procession as a special type of occupation that constitutes the basis of a continuous opportunity for income or earnings for a specific group of people, we can point out that these opportunities had existed even before 2015. Of course, physiotherapy as an occupation had existed, and it was fine before the Act of 2015. Yet, it is this statute that has generated and is currently maintaining a unique dominance of skills and knowledge for physiotherapists. We consider it here as a final stage of professionalization understood as creating the social boundaries of occupation. Based on the definition developed in the theoretical section, it is precisely the capacity to construct and defend the boundaries of professional competence that stands out as the most significant feature of professionalization.

As was pointed out in the paper, the process was complex and long-lasting. It started in Poland just after Second World War, when the rehabilitation of war veterans and civilians injured during the war created an extended need for help. Then it was rooted in the training procedures based on Master’s degree programs taken in higher education facilities. This fact builds strong fundamentals for the occupation’s professionalization, placing strong obligations on future physiotherapists to acquire extensive knowledge and skills. It is worth emphasizing once again that the level of the education of Polish physiotherapy specialists stood out globally. Despite this, the period of transformation after 1989 and the underfunding of the healthcare system froze the development of physiotherapy, at least in the sense that public healthcare utilized it in an insufficient and often selective manner. In the years following accession to the European Union in 2004, the condition of the healthcare system improved and physiotherapy services gained importance, although they were still not implemented to a sufficient degree. This fact was widely known among specialists, decision-makers, and the general public alike. In seeking a way out of this impasse, various concepts for change clashed. Proposals for deregulation competed with ideas for a stricter protection of specialist competencies. Moreover, doctors specializing in rehabilitation defended their monopoly on autonomous diagnosis connected with physiotherapy. Under these conditions, the final act of the professionalization of the physiotherapist occupation took place. Owing to the efforts described in this article, physiotherapists have obtained the legally protected monopoly on their qualifications, clearly distinguishing themselves from other medical and paramedical professions.

What we want to emphasize here is the fact that this was not an obvious or the only possible scenario. It required physiotherapists to take specific actions. It was, therefore, a social process of building the boundaries of the profession and establishing the continuity of income opportunities (in the Weberian sense) as well as the monopoly of qualifications. Physiotherapists have proven that they understand well what a profession is – namely the ability to defend a monopoly on qualifications.

The empirical data we obtained regarding the formation of professional boundaries and professionalization does not deviate from our initial assumptions. Based on the data, there is currently no need to expand the theory with new cases and their explanations (Burawoy, 1998).

For closing remarks, it is also worth noting the limitations of the presented study. We began this summary by stating that it represents a success story. This, however, raises intriguing interpretative questions that we have not been able to address on the basis of the material at hand. How is this process perceived by rehabilitation doctors? What is the view of physiotherapists who envisaged a different trajectory for the profession’s development?

The material presented here also does not provide answers regarding the boundaries and stages of professionalization. Are occupations that fail to establish such clearly defined boundaries of competence to be considered non-professional? Such a claim would undoubtedly be an oversimplification. As we have also seen in this article, massage technicians have likewise succeeded in securing a certain, albeit narrower, professional monopoly within medical professions. Does the fact that they occupy a subordinate position vis-à-vis physiotherapists and rehabilitation doctors invalidate their achievement? Certainly not – it merely points to a different position within the social division of labor. In other words, future research on professionalization should also take into account the broader social context and consider the relations of complementarity between different professions.

Acknowledgements

The authors would like to thank the Polish physiotherapy community for their participation in the study. We are particularly grateful for their openness and for sharing valuable insights into the history and everyday practice of the profession.