Nurse is a profession that serves the need of society in the area of health. The roles of nurses have expanded because they carry out multiple roles in healthcare. In this paper I will discuss on Professional boundaries in my workplace context. As describe by Hawkin et al (1991), professional is define as someone who highly skilled, whereas boundaries is a line or border that marks a limit and context is the circumstances in which an event occurs.
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If we look around us, we will see that every living being has its own limit and bound by its own territory in which it dwell and defend against any sort of invasion. Boundaries have it own fundamental place in life. It fundamental that even criminals who thrive on violating the integrity of others have their own boundaries. Unlike the law, which is absolute, rules allow things to function smoothly because everyone within a particular context agrees upon it. Rules can refer to a game or office procedures. Our moral values provide our own internal guidance about what is wrong or what is not in sense of good value, stated; Raymond Lloyd (2009).
I’m a qualified registered nurse, working in Emergency and Trauma Department (ED), ED provides 24 hours emergency care. Operating twenty-four hours, my ED provides the different level of care and patient needs and it also provides a comprehensive service which includes pre-hospital resuscitation, stabilization and definitive care. Service also includes Disaster Management, Domestic Violence, and Emergency Medicine. The purpose of this paper is to access the professional boundaries of roles and practice between nurses and doctors at Emergency and Trauma Department.
In this paper, I will highlight and analyzed the concept of boundaries and contextualize the theory in the political context of professions, the nature of the professional relationship, provides information to help members recognize potential crisis situations, debate issues of boundaries evidence within my practice and suggests some strategies in managing professional boundaries on defibrillator.
Occasionally, most of the nurses in my ED today are still nurses seemed uncertain about the limitation or boundary of their own work. But, sometimes boundaries are often consider not clear-cut issue of right or wrong. It’s dependent upon numerous factors and required careful thinking through of all the issue, always keeps in mind that all action must be in the best interest of patient care. All the staffs in ED are required to take Basic Life Support (BLS), and Advance Cardiac Life Support (ACLS) and Paediatric Advanced Life Support (PALS). Why we need this training? Because it’s involves advanced medical skills, certification and training. Is purposely offered for medical professionals such as doctor, assistant medical officer (AMO) and nurses, since lay public do not have the necessary knowledge and skills except for BLS where lay public can go for training but in different syllabus compared to health care provider.
Although, ED staff especially nurses and AMO underwent the training and qualified, pass the courses in theory and practically. It still not a ticket for them to ride in fast lane because, they must be well trained, recertification and monitored by experienced support staff such as nurses or AMO, senior doctor or specialist. Why we still have to be monitored? Because, from my experience although the doctor pertain his MBBS (in Latin Medicinae Baccalaureus, Baccalaureus Chirurgiae or Bachelor of Medicine, Bachelor of surgery) from Wikipedia, the free encyclopedia, (2010) but he or she still new in service, some are still not competent to use the defibrillator machine.
Sometimes doctors also required to attend this short-course of BLS, ACLS or PALS because anyone who’s works in ED must to be well trained with these courses. Example like in resuscitation, the goal of ACLS is to begin and identify what is wrong with the patient and when it is the best time can perform defibrillators to patient and also a long term treatment plan can be created. These short-courses guidelines are constantly changing, due to new information in the medical field, and frequent (every 5 year for ACLS, PALS and 3 years for BLS) as these standard guidelines provided by Ministry of Health (MOH) Malaysia, recertification is required for each personal after they are certified. Recertification also ensures that the material is always fresh, so that a healthcare provider or ED staff can confidently make the right decision in a critical moment.
As a trained nurse at ED, providing encompasses and comprehensive treatment plan is essential step whereby sometimes I have to perform defibrillation when a patient having ventricular tachycardia (VT) with hemodynamical instability in order for proper treatment plans. My workplace environment is dedicated and confined to the critically ill patients with unstable hemodynamic and in need of urgent emergency life saving treatment which stipulates that all trauma patients requiring prompt and urgent treatment within a prescribed and stipulated time is observed strictly.
My ED, nurses do defibrillation because of the recertification and trust gain from senior doctors and specialist or consultant. According to General Medical Council (2001), doctor can delegate medical care to nurses, or AMO if they had the trust and believe it is the best for the patients but in count that the nurses must experienced and competent person. Unfortunately, some doctors always take an advantage of this procedure because of some nurses are seemed uncertain about their own limitation or boundaries of working practice. Usually this procedure should be performed by them instead of nurses. Perform defibrillation to patient has been commonly practiced by most of the senior nurses and this knowledge have been past down to new intern; I meant the newly in service staff nurse. It seems likely this positive act becoming norm, among the nurses and other paramedic especially in ED. As describe by Burkhdart & Nathaniel (2008), different culture have it own different approach by interacting individual, consisting of learned pattern of values, belief, behaviour and custom shared by the group.
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My ED is interdisciplinary department multidiscipline’s. These approaches change the professional boundaries. As define by Avis, Drysdale, Gregg, Neufeldt & Scargill (1983), professional boundaries is a behaviours where by boundaries are crossed. Boundary includes the concept of limits, lines or borders. Boundary can be crossed, can be violated, or misconduct can come to mind. Crossing of a boundary involves a brief act or behaviour outside of the helpful zone. See appendix. Apparently, it divided into two substitution which is vertical substitution and horizontal substitution. The vertical of my workplace is by hierarchy starting from top to bottom. Examples as specialist is the highest of the hierarchy give order to hierarchy below them like medical officer and the order move on till the lowest hierarchy. See appendix.
While the horizontal substitution is the interaction between workers in same phase or level. Examples like para-professional (Nurses, AMO, Cardiovascular Technician), where both are in same a group who had a similar roles and same hierarchy grade. Therefore in emergency situation, performing defibrillation the act just don’t bound on doctor shoulder only. It can be either nurses or AMO, using their expertise and clinical judgments in diagnosed and to save patient life. As these working boundaries happen in my ED, realized it or not these act has an impact towards the patient. ED is a unique place for clinical experience where most of the cases are sudden or unexpected incident that requires immediate attention and need the staff on high alert in providing fast and effective care as well as treated according to their severity. Unfortunately, it hard for new doctor to conduct the situation without any experience. In addition, the aim of my workplace is to become an excellent working environment and culture through suitable working conditions, teaching and humanistic approach for all new staff in every categories will failed if the competency, skill and knowledge of new staff is doubted in performing the procedure.
The reason to have a standard guideline in ED is to provide professional guidance in making decisions with specific practice, according to their severity. While allowing flexibility in professional judgment and meets Nursing and Midwifery Board Malaysia criteria for guideline development for a safe standard of practice and facilitate the nursing profession to demonstrate responsibility and accountability in practice. To uphold a high standard of safe nursing care by competent and caring nurses through the implementation of regulatory processes and code of conduct established in Nursing Act 1950. The disadvantage in my unit is the shortage of doctor in recovery area, where their present is do come helpful if the patient place at recovery develop complication such as VT. As experienced nurse, providing an excellent work and comprehensive service with the knowledge and skill can make me become autonomous. The patient who are acutely ill were not being assessed and treated quickly enough, it will deteriorate their condition, Norris & Melby (2005).
Since the workload in ED increases prior to the amount of a patient had burden the existing nurse’s role in ED. Sometimes situation at ED a bit chaos with multiple task had to be done at the same time such as; had to be chaperon, send blood specimen to Lab, send patient for X-Ray and as well as documented patient data since ED operates, based on the Total Hospital Information System (T.H.I.S.). ENB/DoH (2001) explained, in accessing the effectiveness management of information and associated technology which is now part of patient and client care management. Meanwhile, the doctor are facing the same issue as their also had a shortage issue of working personnel. This impact the excellent service provided in patient care due to load of workload. According to Halcomb et al (2002), in term of cost to the health system, workforce implication and value to consumer, alternate cause to the nurse and paramedic should be explored. Therefore the nurse’s manager in my unit should encourage each staff to attend courses to increase each knowledge’s especially in cardiac care management.
In any professional relationship there is an inherent power imbalance. Nurses have a responsibility to ensure that relationship based on plans and goals in objective and the outcome of interaction between professional with para-professional. It means it is the responsibility of the nurse to maintain their professional and personal boundaries, in the best interest of patient. When a nurse crosses that boundary, they are generally behaving in unprofessional manner and misusing the power in the relationship recognized by Masterson (2002). It seem, some of the nurses missing the chance to build up its own core principles by taking more expanded roles said Radcliffe, 2000. Most of professional practitioner like doctor is delighted to see nurses take over his job like perform defibrillation. This regarded as basic activities and bored for them. But there is some dispute, were some nurses uncertain and disagreed about the changing work boundaries and expended rule would make it harder for nurses to undertake nursing task. Most of the nurses insist that their main concern was nursing care. The scope of professional practice; UKCC, 1992 support role expansion providing it does not result in unnecessary fragmentation of patient care or lead to inappropriate delegation of work.
In concluding this issue I have analyzed the concept of boundaries in context of nursing care. My advice can be categories into three; engagement for future collaboration involving in clinical management, moving away from the traditional relationship, with differences in power and influence, nurses and doctors are now becoming equal partners in the clinical field with professional respect, diplomacy and sensitivity in helping and supportive. Although it is important to understand each profession’s roles and responsibilities, as well as areas of conflict and disagreement, it is the mutual understanding of nurses and doctors will lead, the way to true clinical collaborative in ED. The nature of emergency practice makes it even more vital towards communicate and clarify the ways in which, relationship can be affected by vibrant relations in provide fast and effective patient friendly services for our patients, their family and the community within excellent working culture and humanistic approach.
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