Professional Boundaries in Interprofessional Care

Professional Boundaries in Interprofessional Care

By Bachchu Kailash Kaini

It is an accepted fact that effective collaboration and teamwork in health care are required to achieve the desired outcome in health and social care. Odegard (2005) highlighted that interprofessional collaboration is affected by factors at the individual as well as the group and organisational levels (Odegard, 2005). Pete et al (2010) suggest that partnerships are complex arrangements that present several challenges to the professionals and managers seeking to coordinate and deliver health and social care across traditional professional and organisational boundaries (Pate et al, 2010).

Teamwork requires all individuals to embrace the concept of interdependence (Scarnati, 2001). Professional boundaries can be marked within the concept of interdependence so that all health care professional can practice their professions for the best interest of service users. An effective interprofessional care team does not weaken the power, responsibility or the status of the team leader. In fact, the sharing of responsibilities among health care professionals is a key element of the team leader. The professional boundaries between health care professionals are often defined by the roles these professionals play. All professionals have their own unique images that are considered as a basic requirement to separate themselves from the rest of the other professionals (Pellatt, 2007, pp.166).

Two studies by Hughes (1998) and Allen (1997) suggest that the communication and interaction between health care professionals like doctors and nursing staff are changing and the conventional and professional boundaries between health care professionals are breaking down.

Crozier (2003) claims that medical students are differently taught  to the nursing and midwifery students in universities as medical students are more focused on cure whereas nurses and midwifes are more inclined to see the patient as a whole person with a life outside the hospital ward and, in consequence, regard their skills as caring rather than curing. Henderson (2004) agues that the professional boundaries between health care professionals who are in any kind of working relations with each other are often defined by the roles they play.  

There are mainly two opposite views of professional boundaries. In one way, there are no clear boundaries between health care professionals as many grey and overlapping areas make their boundaries unclear. Just opposite to that, professional boundary is a clear demarcation line which is like a concrete wall between two or more professions in terms of their expertise, knowledge, skills, roles and responsibilities. In some aspects of interprofessional care, there are grey areas between two professions’, but in other aspects there are clear professional roles and responsibilities defined by theories, standards, guidance, protocols and practices. Therefore, both concepts should be equally valued and are practiced in the NHS  hospitals in the UK.

Sebas (1994) argues that collaborative care practices occur between different health care professionals such as doctors, nurses and allied health care professionals but in a way defined by their respective areas of expertise and practice.

Section 2.3 of the NMC code of professional conduct: standards for conduct, performance and ethics in the UK says that nurses must maintain appropriate professional boundaries in the relationships they have with patients and clients (Nursing and Midwifery Council, 2004). HPC (2008) suggests that all registered health care professionals should only practice in the areas in which they have appropriate education, training and experience. It also recognises that the scope of practice of health care professionals may change over time (section 6, HPC Standards of Conduct, Performance and Ethics)

Hornby and Atkins (2000) assert that professional differences lie in their functions, methods, skills and responsibilities; but there are large overlap areas of shared professional territory. A shadow area of professional boundaries may bring threat to professional identity. Some functions carried out by health care professional are common and shared by many different groups. Traditional boundaries between health care professionals and their territory are also shifting in many cases (Reel and Hutchings, 2007).

Miller et al (2001) state that the ability to learn about each other’s work helps to boost flexibility at professional role boundaries and support to create a pool of team knowledge and skills. A careful examination and assessment of professional roles and role boundaries in different professional groups and settings may enable health care professionals to recognise the periphery of professional groups.

Health care professionals are bound to follow their code of conduct, professional norms and ethics which set boundaries of standards of conduct for health care professionals. They should communicate those norms and codes to service users so that everyone understands what to expect. The government has attempted through The NHS  Constitution for England (DoH, 2012) to set rights and responsibilities of patients, the public and the NHS  Staff.  According to Wall (2003), health care professionals need to define their professionalism; and service users need to know what codes and definitions are meant to them to protect health care professionals and service users.

Professional boundaries are not solid form of concrete walls. They are set by professionals themselves and professional bodies for some reasons in different forms such as legislations, code of conduct, guidance and standards of practice. Professional boundaries are changed, amended and modified time to time to reflect change in practices, service users’ voice and to improve the standards of practice. Wall (2003) states that health care professionals have three reasons for altering the professional boundaries of their practice – firstly for the more fluent care of patients, secondly due to the consequential need to redefine boundaries of professional practice and last is that exerted by citizens and their mouthpiece, the media. Professional ethics are formulated to set professional boundaries and to reduce differences between people such as clinicians to patients, clinician to clinician, clinician to profession, clinician to manager and clinician to public (Wall, 2003, pp. 71).

Different individuals may have different levels of skills and capabilities within the same professional group and it creates inner boundaries within the same professional group. Wall (2003) asserts that a junior doctor in training cannot be expected to carry out the same level of responsibility as a senior consultant even though both are in the same profession. Therefore, collaborative practice and team working help to sort out these issues of separate skills and capability at different levels. Roles and responsibilities of each member of the interprofessional care team have to be carefully assessed and allocated to balance the interdependence between different sub-groups of professionals within the same profession as teamwork does not bring benefits automatically to the professionals and service users automatically.

D’Amour and Oandasan (2005) assert that structures such as those found in health care set up and professional systems have a great impact on the development and regulation of professional boundaries. The professional boundaries can be among the main obstacles to teamwork, interprofessional care and collaboration in the health delivery system. However, social values and pressures can drive innovative ways of working and can compel health care professionals to be more open to new orientations and new approaches to clinical practice (D’Amour and Oandasan, 2005, pp.17).

Health care professional are resistant to their professional boundaries, values, cultures and beliefs. Therefore, health care professionals have to reach an agreement over work sharing, involvement and desired optimal outcomes that are mutually beneficial and acceptable or agree to differ (Leathard, 2003, pp.98). To keep the professional boundaries intact, which are encroached by other competitors at different times, health care professionals have to be competent and have to make their professional concerns functionally dissimilar.

Evers et al (1994) argue that ongoing maintenance of professional boundaries limits the potential of health care professionals to gain a working knowledge of each other’s roles, responsibilities and functions. Therefore, there is always a chance of interprofessional and intra-team mis-communication, confusions and misunderstandings due to the professional boundaries.