Layout 1 [Qualitative Research in Medicine & Healthcare 2018; 2:7376] [page 121] Introduction In January 2012, the Academy of Nutrition and Di- etetics – the leading professional association for registered dietitians (RDs) – did something it had never done before in its 95-year history: it changed its name. Once the Amer- ican Dietetic Association, its new name, the Academy of Nutrition and Dietetics, was chosen to better communi- cate its mission while promoting the strong science back- ground and academic expertise of [its] members.1 A year later, the Academy announced that dietitians could now choose their preferred title, Registered Dietitian or Reg- istered Dietitian Nutritionist (RDNs). Both the RD and the RDN titles require the same education requirements, certification processes, scope of work, and regulation. The Academy reinforced the importance of choosing a title in their 2014 Media Guide, saying, All registered dietitians are nutritionists, but not all nutritionists are registered di- etitians. This is a distinction that can matter a great deal to people’s health.1 RDs and RDNs are empowered to se- lect the title that best fits their work and perceived audi- ence’s preferences. These title changes are more than simple changes in semantics. They hint at deeper tensions and ongoing con- flicts regarding who gets to be the gatekeeper of nutri- tional knowledge – registered dietitians or nutritionists. The Academy’s name change and adoption of the RDN title suggest that, despite being a regulated profession, the Academy is actively and purposefully engaging in pro- fessionalization, which includes the discursive processes that workers, as individuals and collectives, use to attain and maintain professional legitimacy for their occupation or profession.2 Positioning RDs as the nutritional experts in the United States gives RDs the exclusive right to pro- vide nutritional advice and services. It limits the rights of nutritionists and other health care professionals. This study examines the professionalization practices used by RDs and their professional association. Specifi- cally, we examine how RDs strategically frame and or- ganize their identities to establish themselves as the nutritional professionals. We also seek to understand RDs’ perceptions of how their professionalization discourses affect their profession and other professions. We argue that the Academy and its members established a discur- sive turf war between RDs and nutritionists as a way to Waging a professional turf war: an examination of professionalization as a strategic communication practice used by registered dietitians Sarah N. Heiss,1 Kristin K. Smith,2 Heather J. Carmack3 1Department of Community Development and Applied Economics, University of Vermont; 2Department of Earth Sciences, Montana State University; 3Department of Communication Studies, University of Alabama, USA ABSTRACT In 2012, the American Dietetic Association changed its name to the Academy of Nutrition and Dietetics. The following year, the association allowed their members to select between two titles: registered dietitian (RD) or registered dietitian nutritionist. Based on interviews with dietitians, we argue that these semantic changes added fuel to a pre-existing discursive struggle for professional legit- imacy. As of June 2017, there were over 100,000 registered dietetic practitioners, globally. Approximately 74% of RDs are members of the Academy, a notably high percent of representation, suggesting the influence of this professional organization on the occupation. Academy members work in a variety of occupational settings and fields, including hospitals, nonprofit organizations, and the food in- dustry, and as such make significant contributions to patient health and public health outcomes. The Academy and its members have es- tablished a discursive turf war to strategically establish and defend boundaries within the field of nutrition and dietetics. Their discursive turf war has implications on the day-to-day work life of registered dietitians and other nutritional professionals as well as perceptions of professionalism made by audiences outside the field. Correspondence: Sarah N. Heiss, Department of Community De- velopment and Applied Economics, University of Vermont, USA. E-mail: sarah.heiss@uvm.edu Key words: Professionalization; Professional boundaries; Health communication; Organizational communication. Funding: grants from Vermont Agricultural Experimentation Sta- tion Competitive Hatch, during the conduct of the study. Received for publication: 23 February 2018. Revision received: 20 August 2018. Accepted for publication: 26 August 2018. This work is licensed under a Creative Commons Attribution Non- Commercial 4.0 License (CC BY-NC 4.0). ©Copyright S.N. Heiss et al., 2018 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2018; 2:121-131 doi:10.4081/qrmh.2018.7376 Qualitative Research in Medicine & Healthcare 2018; volume 2:121-131 No n- co mm er cia l u se on ly increase their profession’s legitimacy and economic se- curity. Our analysis of the RD’s turf war examines the boundary dynamics within nutritional healthcare provi- sion and has valuable implications for RDs and nutrition- ists alike. Nutritional healthcare providers Dietetics grew out of the field of home economics, a history that has enabled and constrained the profession’s identity and legitimacy in healthcare contexts.3,4 While di- etitians first organized themselves as part of the American Home Economics Association (AHEA), they broke off from this group and formed the American Dietetic Asso- ciation (ADA) in 1917.5 The ADA was exclusively for in- dividuals who were officially trained and educated in home economics and/or dietetics.5 The ADA attempted to leverage the exclusivity of its membership to create legit- imacy in health care contexts, which dismissed or dimin- ished the value of nutritional health care: “the true dietitian when properly trained and experienced is a spe- cialist and deserves that recognition in the hospital.”3 To bolster the legitimacy of RDs further, the Academy point- edly used positivist and scientific language to frame its purpose and goals. In 1955 the president of the Academy explained its mission was “to improve the nutrition of human beings, to advance the science of dietetics and nu- trition, and to advance education in these allied areas.”3 The Academy’s continual emphasis on science, research, and expertise aligned it with academia and elevated the profession. The profession also set minimum require- ments to be a member to help differentiate dietitians’ med- ical and scientific expertise. As of June 2017, there were over 100,000 registered dietetic practitioners, globally.1 Approximately 74% of RDs are members of the Academy,6 a notably high percent for professional associations. Academy members work in a variety of occupational settings and fields, including hospitals, nonprofit organizations, and the food industry, and as such make significant contributions to patient health and public health outcomes.1 While the profession remains quite diverse, its practi- tioners are unified through their RD credential and, for many, their Academy of Nutrition and Dietetics member- ship. To become registered, dietitians must complete a bachelor’s degree from a certified program, finish a six to twelve month internship, and pass a national certification exam. Once registered, dietitians are required to pay an annual registration maintenance fee, to complete 75 con- tinuing education credits every five years, and to submit a professional development portfolio to remain certified.1,3 In addition, many states require dietitians to obtain a state- issued license – with its own structure and rules – in order to practice in that location. The national and statewide cer- tification processes are important legitimacy symbols that set dietitians apart from other food and nutrition profes- sionals. Recently, the Academy made several title changes to address a professional tension within nutritional profes- sions. First, the association changed its name, and second, it now offers two credential designation options: RD or RDN. The Academy explained that the inclusion of the word nutritionist in the [RDN] credential communicates a broader concept of wellness (including prevention of health conditions beyond medical nutrition therapy) as well as treatment of conditions1 designed to increase the general public’s and non-experts’ awareness of the field of dietetics. Incorporating the word nutrition into the as- sociation’s legal name increased its online media impres- sions from 20 billion prior to the name change to 30 billion.1 The Academy argued the name change helped to optimize its presence among the public and non-experts who were searching for nutrition information. While incorporating the term nutrition(ist) was de- signed to increase the scope of work and awareness of the dietetics profession by drawing on the term’s familiarity, the new labels also served to help distinguish the knowl- edge and services of dietitians from those provided by nu- tritionists. The label nutritionist is used to identify someone who provides nutritional advice; however, for- mal requirements governing the provision of nutritional advice vary from state to state, with a wide range of rules, educational requirements, and certification types.1 Fur- thermore, there are also special requirements for those performing nutritional work related to specific agencies, such as health care providers and government reimburse- ment programs. In the United States, a nutritionist may be someone who obtained a certification or degree in nutri- tion and works in research, health, or educational con- texts. However, in some states, it is also legal for a person who provides nutritional advice with little to no formal education in nutrition, such as a health food or supplement salesperson, to use the nutritionist label. RDs are nutritionists because they are nutritional ex- perts; however, not all nutritionist can claim the RD title. To claim the RD title in the United States, one must meet the specific academic and professional requirements of the Academy’s credential process (the data collected for this manuscript was collected after the Academy changed its name but before it changed the credential options – RD or RDN – for individual members. As such, we decided to refer to individual registered dietitians as RDs – the only label option Academy members had at the time of data collection. We use the label RDN in the manuscript to highlight current and future symbolic conditions). The new label helps to address overlapping scopes of practice to enable efficient and effective client-centered services. The recent name and credential changes demonstrate a new chapter in RDs’ ongoing struggle with profession- alization. A study of Canadian dietitians found that many RDs reported being felt disappointed that they never ob- tained the level of professionalism promised to them dur- ing their educational training.7 The Academy has [page 122] [Qualitative Research in Medicine & Healthcare 2018; 2:7376] Article No n- co mm er cia l u se on ly acknowledged similar struggles. In the organization’s 70th anniversary book published in 1990, the editor noted that another long-standing problem was the profession’s seem- ing lack of self-confidence.4 The current study seeks to ex- amine contemporary attempts by RDs and their professional organization to strategically frame their iden- tities as professionals as well as distinguish their profes- sion’s scope of practice from other related occupations. Communicating professionalization Professions claim expertise in specialized areas of knowledge and skills. In return, the public and other non- expert professionals frequently look to them for expert ad- vice or services. Attaining professional legitimacy is important because it allows the profession to develop, maintain, and affect organizational and work life, as well as the development and diffusion of expert knowledge. While professions are important, professional legiti- macy of any job is not given or pre-determined. An occu- pation does not have a predefined set of properties or features needed to obtain recognition as a profession.2 Rather, professional status reflects a precarious set of on- going, co-constructed definitions and public performances of competence, scope of work, and occupational identity. Professionalization discourses are fundamentally rhetorical process[es].2 Professionalization discourses represent workers’ attempts to make sense of who they are and what they do in relation to their jobs.8 Workers, as individuals and collectives, have active roles in staking a claim to their sphere of competence, defining their scope of work, and setting expectations regarding intra- and inter-professional interactions.2 However, the agency of a given profession to set its boundaries is bound by the larger social structures in which it exists. Professionaliza- tion discourses are dynamic social negotiations that shape and are shaped by culture, norms, politics, institutions, and history within and outside of a given profession. Pro- fessionals, as individuals and collectives, are simultane- ously a product of and contributor to their historical moment. This approach helps contextualize professions as existing in a larger complex social system of intercon- nected occupations that strategically exclude and include groups of workers. Professionalization boundaries and strategies Torstendahl shifted scholarly theorizing about profes- sionalization discourses by adopting a strategic approach.9 This approach accounts for the dynamic nature of profes- sions and situates workers, as individuals and collectives, as having active roles and purposeful goals in profession- alization. Adopting a strategic approach, Esser and Ten- scher described professionalization discourses as an on-going strategic attempts to present an occupation as the only competent and responsible group to tackle a spe- cific problem.10 Professionalization discourses can be understood as a set of strategic boundary setting practices.11,12 Professional associations and individual workers distinguish their ex- pertise, skills, and services from those of other occupa- tions. By doing so, professionalization establishes arbitrary professional boundaries that include certain in- dividuals and exclude others. While professions may be able to reach mutually agreed upon boundaries, boundary setting has also been described using combative terms. Professional boundary work has been described using a battlefield metaphor,11 wherein different kinds of experts and even non-experts fight for the right to determine who has professional le- gitimacy and, therefore, occupational jurisdiction or turf. Discursive battles for turf and professional legitimacy de- termine which occupation’s advice and services are ac- cepted as permissible, autonomous, or valuable to social policy, organizational practices, and members of the gen- eral public.13 By gaining monopoly over a certain area of expertise, occupations achieve market control, re- spectability and social status in the community.14 Nanacarrow and Borthwick argued that the dynamic role of boundaries have the potential to challenge the mo- nopoly of all the healthcare professions.15 Indeed, profes- sional boundary setting discourses have been identified as occurring in many healthcare contexts, including but not limited to disputes between traditional, complemen- tary, and alternative medicine16 and nursing and mid- wifery.17 In addition to inter-professional boundaries, professionalization discourses can also establish intra-pro- fessional boundaries.15 By creating co-cultures, specified scopes of practice, and new formal associations, profes- sions can strategically segment parts of a profession from the whole. In addition to differentiating scope of practice, intra-professional boundary setting often establish hierar- chy among segments. Professionalization within the healthcare context in- cludes a variety of discursive and institutionalized prac- tices. First, specialized expertise, often scientific in nature, is often cited as differentiating between in-group and out- group healthcare providers.17 Second, occupations tend to emphasize holism and patient centeredness to establish that they are able to treat the whole patient within very specific circumstances.18 Third, occupations stress their ability to simultaneously provide emotional reassurance to patients and medical care.18 Fourth, occupations pro- mote their ability to prevent problems, while others treat the symptoms. Fifth, occupations commonly adopt pro- fessional licensure and credential programs to set firm boundaries regarding their professional turf and assert their professional accountability.2,18 Professional outcomes of boundary setting Establishing and maintaining a discursive turf war over professional boundaries has important implications for those included, those excluded, and patients. First, [Qualitative Research in Medicine & Healthcare 2018; 2:7376] [page 123] Article No n- co mm er cia l u se on ly healthcare systems around the world are adopting inter- professional collaborative care models.19 Continually evolving external and internal professional boundaries supports a clearer division of labor and reduces the po- tential for conflict when workspaces of different occupa- tional groups overlap.10 Second, professional boundaries maintained with regulations, licenses, or certificates pro- vide a level of professional accountability.18 By expecting certain levels of professional competency, these practices protect the public from incompetent practitioners.20 Pro- fessional endorsements also help healthcare consumers and potential employers easily identify credible profes- sionals. In addition to helping providers and consumers find qualified advice and services, professional bound- aries serve to protect healthcare providers from litigation. For example, regulations, licenses, and certificates in the field of nursing standardized nursing care, protecting the general public by reducing medical mistakes and protect- ing nurses from litigation due to medical mistakes. On the other hand, the National Center for Complementary and Integrative Health argued, regulations, licenses, or cer- tificates do not guarantee safe, effective treatment from any provider – conventional or complementary.21 Third, by establishing clear professional boundaries occupations are able to self-regulate work.12 At the macro- organizational level, self-regulation represents the auton- omy of an occupation to dictate guidelines for training, development, and practice. Autonomy is also represented in micro-organizational practices, where many profession- als now work on inter-professional allied health teams. Professionalization claims jurisdiction over specialty services and provides autonomy from other medical pro- fessionals, which increases the likelihood of being able to bill for care.13 Sela-Sheffy and Shlesinger argued that examining professional boundary work is particularly useful for studying a range of different processes in the construction of professions.14 While boundary work has been identified in some research as a key outcome of professionalization processes, researchers have yet to talk to actual workers about their motivations and strategies related to profes- sionalization and boundary management. In this study, we understand RDs as a professional social group, united by the Academy, which has and continues to engage in pro- fessionalization processes to attain and maintain their pro- fessional legitimacy as the nutritional care providers among food and nutritional experts, as well as health care professionals within a larger healthcare contexts. The cur- rent project adopts a communicative-based approach to understanding how workers’ in the field of dietetics un- derstand and strategically frame their individuals and col- lective identities as professionals to achieve professionalization. We also discuss the possible implica- tions of these professionalization discourses on their oc- cupation and related-occupations. Specially, we ask, RQ1: How do RDs discursively frame and organize their identities to establish their profession legitimacy? RQ2: How do RDs’ discursive choices serve to affect their profession and related-occupations while also seek- ing the right to provide nutritional care? Materials and Methods This study was supported with funds from a competi- tive Agricultural Experimentation Station Hatch grant. The grant funded project originally focused on partner- ships between the Academy and the food industry. Data collection began after the researchers received university Institutional Review Board approval. Participants and data collection Seventeen participants were recruited through an ini- tial group of key Academy member informants and snow- balling techniques. To participate, interviewees had to be RDs or RDNs who were past and/or current members of the Academy. The first and second authors recruited par- ticipants through email from three stratified sample pop- ulations: authors of recently published articles in nutrition and food science journals, authors of popular nutrition blogs, and faculty from university nutrition and dietetic programs. To increase the diversity of our sample, we used snowball sampling, in which interviewees recom- mend other potential interviewees. Interviewees represented a diverse subset of Academy members. The age of interviewees ranged from 20 years old to 66 years old (M=39). The number of years spent as an Academy member varied from less than one year to over 38 years (M=13). Fourteen of the interviewees iden- tified as female (82.3%) and three interviewees identified as male (17.6%). Approximately 88% of interviewees identified as Caucasian (n=15), with one interviewee identifying as Hispanic and one interviewee identifying as Asian. Professionally, the interviewees ranged from having less than one year of experience to more than 30 years as a RD. Interviewees worked in a variety of set- tings, including hospitals, universities, public health set- tings, and the corporate food industry. Three interviewees identified as current students, and one interviewee identi- fied as a doctoral student. The participants hailed from 13 states and the District of Columbia. Interviews The first and second authors conducted face-to-face, semi-structured interviews during the 2012 Food and Nu- trition Conference and Expo (FNCE). Interviews took place in quiet, private locations near the FNCE venue. In- terviews took place over four days. The first and second authors completed follow-up phone interviews after the event with RDs who could not attend an interview during FNCE or to obtain follow-up information. Interviews lasted approximately 45-60 minutes. [page 124] [Qualitative Research in Medicine & Healthcare 2018; 2:7376] Article No n- co mm er cia l u se on ly The first and second authors developed an interview protocol and research plan prior to attending FNCE. Based on the nature of the grant, questions focused on RD’s experiences and attitudes related to organizational partnerships between the Academy and the food industry. Questions included broad questions related to the RD oc- cupation and the Academy, including the average RD workday, the perceived importance of the Academy to RDs, and Academy-industry partnerships and their im- pacts on public perceptions of RDs. Semi-structured interviews follow a preconceived in- terview script, but also give the interviewer freedom to di- gress to explore emergent themes.22 At the end of each interview and the end of each day, the first and second au- thors reflected together on the content of the interviews. The original interview protocol focused on RD’s percep- tions of Academy partnerships with industry. After several interviews, we noticed a reoccurring defensiveness from participants. Interviewees constantly redirected the dis- cussions by highlighting their individual and collective expertise and by telling stories that emphasized their in- dividual and group professionalism and the differences between dietitians and nutritionists. After identifying these patterns within the first five interviews, we added questions about professions and professionalization to the original interview protocol. The new questions included, what does it mean to be a professional in the field of nu- trition and dietetics? What is a dietitian? What is a nutri- tionist? How does the Academy help you attain or maintain professional status? Data analysis We used constant comparative methods to inductively identify themes in the data. Constant comparative analysis is a cyclical and continuous method of processing, reduc- ing, and explaining.22 Researchers continually identify codes and themes within and across interviews as well as in comparison to the extant literature. Analysis starts dur- ing the data collection process and calls for the continual refinement of themes as data is collected and then for- mally analyzed, through constant comparisons and recod- ing of the data set.23-25 During data collection, issues related to profession were consistently mentioned across all interviews. As themes emerged during data collection, the first and second author compared themes with other interview cases and previous research to understand how they confirmed, expanded and/or diverged from previous scholarship. The themes were so forceful and reoccurring, that we stopped inter- viewing when we reached saturation on this theme of pro- fessions, rather than the original aims of the project. Interviews were transcribed verbatim, resulting in 292 single-spaced pages. In our initial analysis, the first and second authors read and coded the transcripts multiple times independently until forceful and recurring themes began to emerge from the data. The first and second au- thors discussed their codes and collapsed related codes into each other while dividing other codes to offer more detail as patterns began to emerge. The authors then re- read and re-coded the data independently before meeting to discuss the data again. This iterative process continued until no new codes or themes emerged. We used forceful and representative quotes from the interviewes to repre- sent the interviews’ unique voices and to support our claims as researchers. The third author joined the project after the analysis process was complete to help with writ- ing and revising the written manuscript for publication. Results Based on our analysis of the interview transcripts, RDs – as individuals and a collective united by the Acad- emy – are actively engaged in on-going professionaliza- tion struggles. Specifically, RDs are employing a discursive turf war as a professionalization tactic to claim jurisdiction over the provision of nutritional counseling and care. This turf war establishes boundaries of expertise between dieticians and nutritionists to establish legitimacy within an already tenuous healthcare landscape for nutri- tional experts. We argue that this turf war is fueled by unmet professional expectations. After establishing the discursive exigency for a turf war, we highlight the dis- cursive practices that comprise this professional turf war. We discuss the possible implications of these profession- alization processes on dietetics and related-occupations. Setting the grounds for a turf war During discussions of the Academy, RDs continually justified their profession and their training. They empha- sized how hard they worked, how long they spent in school, and how they were diligently trained in objective, scientific research methods. Despite having bachelor’s de- grees or more advanced professional degrees, members often voiced complaints of being underpaid. One RD ar- gued, There should be more recognition in terms of pay and things like that for people who have spent some time…and effort into becoming an expert that they might not be recognized for right now in terms of pay or posi- tion. Their comments underscored frustrations with the misunderstandings related to how people view their field. Moreover, the dietitians used these arguments as ways to prove their value – and their status as professionals. One member described the process of becoming an RD as re- ally difficult. Much more difficult than people realize. Salary is associated with legitimacy and status, and the lack of it was a catalyst for RDs’ frustrations. One RD explained, dietitians are not super well paid, especially for half our workforce having a master’s degree or higher education level. She went on to compare dietetics to other health professionals to emphasize this inequity. I think that we make less than half of what the pharmacists at our [Qualitative Research in Medicine & Healthcare 2018; 2:7376] [page 125] Article No n- co mm er cia l u se on ly hospital make, and other – and like the P.T.’s and things like that – and the O.T.’s... And I have a master’s degree and I make less than half of them. In order to counter their perceived unequitable salaries, members reported having multiple jobs. One RD explained that she strings things together by working a clinical job at a long-term care nursing facility, an advising job at a college campus, and a nutritional messaging job with a food service company. The participants who identified money as a reason for frustrations also talked about a perceived wage ceiling within the occupation and greater professional inequalities within the health field. Many members of the Academy felt that they were paid less than other health profession- als, though they had similar or higher levels of educational training and/or experience. Members frequently voiced frustration that other healthcare providers and the general public did not under- stand the dietetics occupation or differentiate it from other nutritional professions. Many doubted that the Academy was known outside of specific public health circles and wondered if the public understood the occupation’s value. Members repeatedly told stories about how RDs were often confused with nutritionists, which they perceived as negative. Academy members lamented this confusion, suggesting that it dismissed RDs’ specialized training, skill set, and expertise. One dietitian began her interview by assuming that this was a common theme in other in- terviews: And I’m sure you’ve probably heard that before where people – you talk to people, you want to be a dieti- tian, and they’re like, what is that. So we’re really trying to get that information out there. Another member com- mented that, when he gave public lectures, the audiences rarely understood the difference between nutritionists and dietitians: They all have that kind of confusion. So it’s nothing new…But at least luckily I have the opportunity to tell some people. As RDs made sense of who they were in relation to their jobs, they struggled with the perception that their profession lacked status and public recognition. Further, they continuously voiced frustration about the confusion between dietitians and nutritionists, emphasiz- ing the need to frame the RD profession as distinct from and more legitimate than other nutrition professions. Academy members’ stories and frustrations suggest that their expectations for professionalization are not being met. Interviewees reported specifically not feeling respected as professionals by the public and by other healthcare professionals. They also were concerned that they were being underpaid for their professional-level services. To legitimize and elevate their profession, mem- bers strategically created a discursive turf war to set pro- fessional boundaries between nutritionists and dietitians. Constructing a turf war Members’ stories about unequal pay and public con- fusion about their occupation suggest that, despite being members of a regulated profession, RDs are still working to achieve professionalization. Their comments reflected continuity with earlier identity work that suggested, dieti- tians have a melancholia... associated with lack of recog- nition, loss arising from unfulfilled promises of professionalism and spiritual injury.7 Their unmet profes- sional expectations included disappointment that they were not seen as having nutritional expertise that is dif- ferent from nutritionists. All of these frustrations created a space for a professional turf war between dietitians and nutritionists. Academy members create a discursive turf war by i) (re)claiming nutritional expertise and ii) crafting monetary legitimacy. (Re)claiming expertise Academy members feel professionally marginalized. Weick et al. argued that individuals use organizational sensemaking to organize unmet expectations.26 Sensemak- ing is a communication process that seeks to answer what’s going on here and what do I do next.26 When faced with perceived marginalization, members of the Academy used organizational sensemaking to claim control over formal nutritional knowledge and (re)define themselves as professionals. This process involves categorizing, la- beling, and creating hierarchies to bring order to their oc- cupational identity.26 To legitimize and elevate their profession, members used turf war rhetoric to create a hi- erarchy of nutritional professionals. As one member put it, Really there are turf wars happening in the states on who gets to practice as a Dietitian or practice the practice of nutrition. And Dietitians fight long and hard to have the control of the nutrition field. Drawing on this RD’s comment, we describe the material, discursive, and orga- nizational practices that Academy members used to bound their profession through a rhetorical turf war. Academy members symbolized and communicated their expertise by discussing their education and RD certi- fication to differentiate their profession. One member com- pared his education to basically [getting] a pre-med degree, while another emphasized that over 50% of dietitians who are practicing and [are Academy] members also have a master’s degree, so that’s at least five to six years of edu- cation on top of their internship. Members described their RD certification as culminating proof of their extensive training and as validation of their expertise. As described by one member, it is a credential that means that you have a certain set of skills that you have…mastered and demon- strated your mastery of. Another member used her certifi- cation to illustrate her journey to becoming a professional. She emphasized the specific course load of work that you have to do, undergraduate, bachelor’s degree work in sci- ences –in nutritional sciences and food safety. She then noted the exam that RDs must pass to become registered and discussed her profession as a certified practice. This member went into great detail about how she became a pro- fessional, noting the specific, bureaucratic symbols and milestones along the way, such as her course load and the [page 126] [Qualitative Research in Medicine & Healthcare 2018; 2:7376] Article No n- co mm er cia l u se on ly exam. Other Academy members also made claims to pro- fessionalism by discussing the milestones – like their edu- cation and certification – that best communicated their journey to becoming professional. In this view, the profes- sion is framed as an achievement to be gained after long years of hard work. Members’ descriptions of their profession as an achievement starkly contrasted with how members de- scribed and defined a nutritionist. While RDs self-defined themselves as specialized, scientifically trained profes- sionals, nutritionists were continually described as having an unknown level of expertise and status. One member described a nutritionist as anyone that self-proclaims as an expert – and they don’t even have to say expert, but just someone who gives nutritional advice. Another mem- ber further explained, the term nutritionist is not defined. It’s undefined. So you could read a book about diets or a book about nutritional science and call yourself a nutri- tionist. Anyone can call themselves a nutritionist because it’s not overseen by an entity. Others went even further and described nutritionists as lacking any practical expe- rience in public health and nutrition. While the RD process is highly structured, bureaucratic, and framed as legitimate, members described nutritionists as having varying – often-unknown – degrees of expertise. By contrasting nutritionists’ occupational ambiguity with the highly specific regulations of RDs, Academy members created a nutritional Other. Members drew on the nutritional Other to communicate what it is that they are not: nutritionists are undefined; RDs are certified; nu- tritionists are amateurs or have ambiguous educational backgrounds; RD are carefully regulated and therefore le- gitimate. Members used nutritionists – as the Other – to elevate their own profession. One member noted, As far as job descriptions go…RD is kind of a distinction and level of education whereas…anyone that wants to call themselves a nutritionist, they don’t really have to have anything to verify that. This strategy fits into Ashcraft, Muhr, Rennstam, and Sullivan’s review of the literature on how professions are crafted.27 They argued that the construction of professions entails not only aligning oc- cupations with particular people, but also contrasting them with lowly Others.27 Those that are excluded from the profession are therefore a necessary part of occupa- tional identity. The implication is that, while members often complained about nutritionists, they are actually an important component of how members made sense of their occupational identity and claimed expertise. To make sense of their unmet occupational expecta- tions, members framed themselves as more educated, trained, and/or legitimate than nutritionists, drawing a hi- erarchy of expertise within the nutritional field to strate- gically create professionalization. As one member succinctly explained, A dietitian is a higher level than a nutritionist. Some members added to the hierarchy by comparing RDs’ work to health professions that are al- ready seen as legitimate, such as doctors or physicians: So, what I’d like to see is in the future the dietitian is rec- ognized as important as the doctor. When we talk about nutrition as a preventive medicine, it’s important. The hi- erarchy creates an us (RDs) and a them (nutritionists) di- chotomy that RDs use to claim expertise for their profession. This hierarchy is thus one way that members labeled, categorized, and ordered their work to make sense of their occupational identity. Despite this con- structed hierarchy, members often noted that while this hierarchy might be true in their opinion, the public still did not understand this difference. Crafting monetary legitimacy Given RDs’ unmet professional expectations, partic- ularly around salaries and perceptions of legitimacy, members looked to the Academy to increase economic benefits for their profession. Members discussed the Academy as an important resource for helping to differ- entiate between nutritionists and RDs and to elevate the profession of dietetics. For example, one member noted how the Academy defined the dietetic profession by de- scribing a page on the Academy’s website: There’s actually a link that simply breaks down the dif- ference between a Dietitian and a nutritionist…the Academy plays a great role in that – in really trying to educate the public about the difference in the qualifications and how to safely choose a practitioner for their nutrition health care. For these RDs, the Academy plays an active role in creating economic benefits for dietitians by promoting the turf war rhetoric to limit nutritionists’ influence and scope of work. Academy members discussed their desire to claim nu- tritional expertise for themselves so that their services – and only RD services – would be reimbursable by insur- ance agencies. Many members advocated for state licen- sures that would differentiate the profession and, hopefully, allow exclusive insurance reimbursement op- portunities. One member explained, Every state has an opportunity to have licensed Dietitians, just like every state license. She went on to describe the concept of state licensure and insurance reimbursements, especially given new healthcare laws, by comparing RDs to other medical professionals: If you’re a doctor, for example, or a physical therapist, you have a state exam and a state licensure which allows you to bill and collect payments. And in the state of Wash- ington, we are not licensed Dietitians and the regulations are written for licensed health care professionals which could, depending on which way the political winds blow – could mean that Dietitians who are not licensed cannot be reimbursed. Similarly, another member explained her participation in an advocacy group by saying that she wanted her pro- fession to be at the front in terms of knowledge of food and nutrition to make sure that we’re getting reimbursed [Qualitative Research in Medicine & Healthcare 2018; 2:7376] [page 127] Article No n- co mm er cia l u se on ly for those services; where they already are being reim- bursed for and then where we would like to see them be reimbursed for. RDs were very aware that their dismissal of nutritionists had economic implications. These members’ interest in insurance reimbursements highlights how the turf war rhetoric was being used as a professionalization strategy. As members differentiated themselves from other nutritionists, they sought to create greater exclusivity in their field. This reinforces Freid- son’s view that credentialing was designed to build an oc- cupational cartel that has the exclusive right to offer specific services, a right sustained by the state.13 The question over which nutritional professions are licensed and reimbursable – nutritionists, RDs, or both – is con- tested. By using the turf war to claim RDs as the nutri- tional experts, members hoped to become the only reimbursable nutritional experts. RDs also viewed the Academy’s professionalization strategies as extending beyond individual monetary ben- efits and having broader impacts for public health. When discussing the Academy’s mission, one member noted, It is about positioning members as nutrition experts and it is about the health of the consuming public. While this member sees the value in establishing RDs as the nutri- tional expert, they also situate the changes as having the potential to positively influence public health outcomes. Other members mirrored their concern for public health, but were concerned about their ability to affect positive changes because they did not feel the public fully under- stood their claims to expertise. Commenting on why the Academy changed its name, one member said, if you say dietetics, people don’t know what you’re talking about. So, if you put that word “nutrition” in there, it helps them understand better. This member perceived lack of public support as the impetus for the name change and hoped that by changing the name the Academy would garner public support for the profession and subsequently im- proved health outcomes. Discussion RDs and their professional association, the Academy, are actively engaged in strategic communication to attain and maintain professional status. RDs have long had to establish and defend their professional legitimacy within the broader healthcare context. However, their contempo- rary struggle is marked by efforts to distinguish them- selves as the nutritional experts while simultaneously excluding other occupations that provide nutritional ad- vice and services, specifically nutritionists. Indeed, ques- tions surrounding the differences between nutritionists and dietitians are pervasive and hinder professionaliza- tion. As Freidson argued, it is hard to justify a certification when another profession can seemingly do the same job using a different occupational title.13 The Academy has a page on its website that specifi- cally addresses the reasons behind its name change, noting that the new name better communicates who we are and what we do. We are the nutrition experts.23 The success of the name change, according to the Academy, also pro- vided the catalyst to offer the new title, Registered Dieti- tian Nutritionist. The name was approved by elected members of the Academy’s House of Delegates, as well as the organizational units that manage the RD creden- tial.24 Thus, the changes to incorporate the word nutrition(ist) into the Academy and the RDN title suggest an institutional acknowledgement of the struggle between RDs and nutritionists as well as the Academy’s response – to delineate professional identities by claiming nutri- tional expertise as its own. We argue the individual RDs/RDNs as well as the Academy itself stand to gain from the incorporation of the word nutrition(ist), though this gain comes at the expense of other nutrition professionals. The title change serves to benefit individual professionals because it distinguishes between RDs/RDNs and nutritionists. Differentiating RD/RDN knowledge and services will help members of the public identify qualified nutritional experts. This boundary setting activity also serves to establish/ maintain the legitimacy of the RD/RDN profession in the grander context of health care, by ensuring training and scientific grounding of RDs/RDN. In addition to the organizational discursive practices, we found that individual RDs/RDNs were interested in and actively engaged professional boundaries setting and spanning. Interviewees simultane- ously claimed nutritional expertise as their territory and sought to differentiate and defend their profession from nutritionists. In addition to supporting the professional legitimacy of RD/RDNs, these discursive choices also establish/re- inforce the legitimacy of the professional organization it- self. Organizational legitimacy enhances organization survival. By securing the recognition of the public and other relevant organizations, the Academy stands to in- crease competitiveness for resources (such as grants, sponsorships, and member dues). Additionally, organiza- tional legitimacy makes the Academy a necessary and de- sirable social organization for those wanting to practice dietetics. The Academy is able to leverage their legitimacy to recruiting new RD/RDN members. Its structured certi- fication and continuing education process also ensures that RD/RDNs continue to pay for their membership, con- ferences, conference materials, and educational credits. Theoretical implications Our findings contribute to and complicate past schol- arship on professionalization. We found that a profes- sional turf war discourse reflected a set of purposeful communication activities aimed at claiming RDs right to be the nutritional experts. Their turf war discourse strate- gically excluded the advice and services provided by nu- tritionists, framing RDs as the only competent and [page 128] [Qualitative Research in Medicine & Healthcare 2018; 2:7376] Article No n- co mm er cia l u se on ly responsible group to address nutritional issues, according to Academy members. These findings align with theoriz- ing of professionalization as a strategic process,9,10 and support a strategic communication-based approach to studying professionalization. The use of purposeful turf war discourse as a rhetori- cal strategy is a novel contribution to theorizing profes- sionalization. In addition to claiming jurisdiction over rights to membership and scope of practice, professional discourses of inclusion and exclusion can be used to cre- ate and foster conflict among experts as a way of legit- imizing one group over the other. The potential ramifications of professional turf war discourses aimed at creating conflict and discord to establish legitimacy are concerning. Healthcare systems around the world are adopting inter-professional collaborative care models to better address complex health and wellness issues with the goal of improving patient and community outcomes.19 Professional territorialism on collaborative teams are a difficult barrier to effective collaboration and healthcare provision. To effectively engage in inter-professional col- laborative care, team members will have to continually co-construct, maintain, and sometimes defend their pro- fessional legitimacy with all of these group members, clients, and communities. Dieticians and nutritionists have struggled to be seen as legitimate members of healthcare teams.6,28 By using conflict to achieve professionalization, professions exclude and diminish the legitimacy of a po- tentially close ally they have in their larger fight for legit- imacy on collaborative health teams. In addition to contributing to understandings of how a turf war can be used to professionalize, our findings also contribute to strategic communication-based understand- ings of professionalization by describing the attempted ef- fects of the turf war discourse on professional boundaries. Past research has described professionalization as a set of discursive boundary setting practices most often between distinct fields, such as medical doctors and alternative health providers.16 Our findings highlight tensions present in the everyday use of a professional identity when it per- forms as a distinct identity from those of people who also offer similar occupational services, in this case the provi- sion on nutritional care. Counter to previous claims that professional identity is fluid, 2 the rhetorical turf war here shows how this fluidity is problematic when trying to stake a professional claim. Instead, the rhetorical turf war is about solidifying professional identity. Weick and col- leagues argued that organizational sensemaking con- tributes to identity negotiations by using language, talk, and communication to organize chaos.26 By labeling nu- tritionists as undefined or amateurs, they use nutritionists as foils as a way to reinforce their occupational identities. Additionally, members used bureaucratic, objective sym- bols – such as their education and certification – to create a hierarchy in which RDs were shown to be more than nu- tritionists. By establishing the hierarchy, the turf war’s message is clear: RDs are more qualified, more trained, more professional. Within the Academy, members partic- ipate in organizational sensemaking and identity negotia- tions by labeling, categorizing, and dismissing what they are not – nutritionists. In addition to setting boundaries to distinguish their expertise, skills, and services from other related occupa- tions (nutritionists), we found that RDs use a turf war dis- course to also take away another occupation that has a scope of expertise and practice. This is a meaningful con- tribution to theorizing professionalization discourses. Turf war discourses can be both defensive and offensive. Pro- fessions can use the turf war discourse to maintain current boundaries and/or advance a profession’s boundaries, at the exclusion of other occupations. Future research should compare and contrast boundary setting and spanning prac- tices between fields that offer similar services as well as distinct services. Practical implications Our findings have practical implications for RDs and nutritionists alike. The turf war discourse currently being waged by dietitians and the Academy simultaneously highlights and diminishes RDs’ identities as nutritionists. We argue that the fluidity of professional identities has benefits and drawbacks. At the organizational level, the profession attempts to gain control over nutritional knowledge and services by in- corporating the term nutrition(ist) into its formal titles. The Academy argued that these changes increased public awareness of the field and drove the general public and non-experts to the profession’s formal knowledge.1 Indeed, a key to professionalization is that the public and non-ex- perts are aware of the field and its advice or services. How- ever, we found that the interviewees seemed bothered by the potential blurring of RD and nutritionist identities. When asked about the distinctions between RDs and nutri- tionists, interviewees recognized similarities and were able to clearly articulate differences. We also found that the in- terviewees tended to overcompensate with information that would bolster their performance of professional legitimacy. Specifically, interviewees emphasized the rigor of the ac- creditation process and their reliance on the scientific method. Interviewees reported using similar techniques to boost their performance of a competent professional when participating with inter-professional teams comprised of non-experts, such as other health care providers, directors of public health, or policy makers. Our findings also highlight the interplay of material and social realities of professionalization. RDs were mo- tivated to engage in turf war discourses as a way to estab- lish professional legitimacy and exclusivity. Ultimately, their turf war stemmed from unmet professional expecta- tions related to respect and compensation. A turf war dis- course was thought to increase their monetary standing as a health profession. By limiting nutritionists’ ability to [Qualitative Research in Medicine & Healthcare 2018; 2:7376] [page 129] Article No n- co mm er cia l u se on ly provide nutritional services and advice, RDs hoped to be- come the only reimbursable nutritional experts, which, in turn, frames them as the only legitimate nutritional ex- perts. Theoretically, this furthers Meisenbach’s conceptu- alization of occupational identity.8 As Norander, Mazer, and Bates explained, The material realities of becoming a [professional] shape the ways in which [professionals] discursively construct the potentials and limits of their professions.29 By using credentials and reimbursements to craft their professional identity, RDs rhetorically create the structures of their profession. Although this helps to create the clear boundaries of the profession, it also con- strains future opportunities and growth. What is most interesting about the potential gains and losses of the turf war discourse is that many RD intervie- wees voiced a long-history of unmet professional expec- tations, suggesting that, to date, professionalization strategies have not worked. The turf war discourses were reported to be motivated by unmet professionalization, which was ascribed in large part to the lack of clarity be- tween the boundaries that separate nutritionist and RDs. However, it is very important for both RDs and nutrition- ists to consider if the lack of professional boundary clarity is the real issue. Professional identity is deeply rooted in conflicted, shifting, historical, cultural, gendered dis- courses.27 Past research has situated dietetics and nutri- tionists as gendered occupations that face a host of cultural challenges.3,28 Through this lens, waging an intra- professional turf war with nutritionist is perhaps an inef- fective professionalization strategy. We ask, are Academy members working to solve the right problem? By using the turf war discourses, RDs may be further marginalizing their profession and another already-marginalized occu- pation—the nutritionist. Perhaps, RDs and nutritionists should join efforts to address the larger cultural and his- torical constraints that bind both groups. Conclusions There are several limitations and opportunities for fu- ture research. First, our findings only reflect one voice in the turf war: the RD. Our focus on RDs reflects an in- depth examination of one profession’s purposeful at- tempts to claim and defend a professional turf. While an in-depth analysis is valuable, our findings are limited be- cause they do not take into account the lived experiences or implications of the turf war discourse for other fields. Specifically, this analysis does not include the nutrition- ist’s voice and experiences. However, more generally it also does not take into account how the turf war dis- courses are actually recognized or experienced by other providers in the health industry. Future research should investigate how turf war discourses are experienced by other healthcare professionals, including but not limited to, nutritionists. It would be interesting to examine what, if any, role these workers have in co-creating the turf war and potential impacts engaging or ignoring the turf war has on their work life. In addition to examining the dynamic co-construction of the turf war, research should examine the broader cul- tural and historical discourses surrounding the profession- alization of dietetics. We did not directly analyze historical and/or cultural discourses within and beyond the Academy’s borders. Additional research is needed to understand how cultural and historic discourses are en- abling and constraining the Academy of Nutrition and Di- etetics and the occupation of dietetics. For example, research could examine discourses that support or chal- lenge the hierarchical nature of medicine and health oc- cupations in relation to one another. The social construction of power and authority of physicians within allied health care would be interesting to compare to that of dieticians. It would also be valuable to examine how cultural and historical discourses outside the health care arena shape the professionalization of medicine and health occupations. In the context of RDs, it would be interesting for future research to examine how media representations of food politics and public understandings of and trust in nutritional advice reflect, respond to, or shape profession- alization strategies and outcomes. References 1. Academy of Nutrition and Dietetics. Eat Right. 2018. Avail- able from: http://www.eatright.org Accessed: 19 February 2018. 2. Cheney G, Ashcraft KL. 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