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BOUNDARIES WITH OTHER HEALTHCARE PRACTITIONERS

Other than the patient-doctor boundary, there are other professional boundaries that doctors need to navigate. Intraprofessional boundaries exist within one profession e.g. the relationship between ‘junior’ trainees and consultants. The intraprofessional boundary also separates different specialties within one profession; an example of this is the relationship between general practitioners and hospital consultants; interprofessional boundaries delineate different professions.

 

Interprofessional boundaries

Interprofessional describes the boundary between different professions, e.g. the interface between midwives and obstetricians, effective multi-professional collaboration is vital for high quality patient care and without it, patients can suffer. For an example of the importance of good multi-professional collaboration read the report of the Morecambe Bay Inquiry (2015) which identified that  poor working relationships between obstetricians, paediatricians and midwives led to avoidable harm to mothers and babies, including tragic and unnecessary deaths.

Teamwork is one of the four domains of Good Medical Practice, you must work collaboratively with colleagues, respecting their skills and contributions (GMC 2013). So, how can you establish effective professional boundaries with colleagues from other disciplines? In order that you can play your part in the team, it is essential that you know who everyone is, their roles and how to contact them. This means introducing yourself to new colleagues early; asking questions about their roles in the team demonstrates a respectful understanding of and commitment to team-working.

 

Thinking point:

What is your experience of working with different professions?  Have you been part of effective interprofessional teams? Can you identify what factors made the teams work well? How can you personally contribute to healthy interprofessional cultures?

 

Each team member has specific expertise and experience which is likely to be different from yours and new roles and role boundaries evolve on a regular basis, so it is not to make assumptions, especially when working in a variety of trusts.  This is key when you are working with new professional roles or ones that you that you are unfamiliar with e.g. physicians’ assistants, nursing associates and clinical pharmacists are all new NHS roles. Having established how important such relationships are, what are the first steps in establishing respectful relationships with new colleagues, establishing a healthy professional boundary? Imagine you are new to a trust and starting a night shift, you are introduced to the senior site nurse practitioner - how could you find out what this colleague does? How your roles can complement each other? When will you refer to each other?

The team structure works best when all members seek advice from each other appropriately and promptly, making sure that referral documentation is clear and correctly filed in the patient's notes. You may have gained experience from previous jobs e.g. wound dressing or catheterisation - but it is essential that patient care is co-ordinated and documented carefully by the person with responsibility for each task.

At times, however, your commitment to close working relationships with colleagues may be in conflict with your responsibility to take action if patients are not receiving the care they require.

 

Interactive exercise: Dr.Sharma

In this interactive exercise, the GMC presents a dilemma for a new consultant who witnesses a number of incidences on the Unit where patients are not receiving basic care – and she has to decide what actions she has to take.

https://www.gmc-uk.org/gmpinaction/case-studies/dr-sharma/scenario-01/

Undertake the interactive exercise and think about the way you would raise this concern, how would you plan the required conversations? How would you start to talk with the senior nurse?

In this scenario, Dr.Sharma knows the Unit and the staff well as she worked there as a Specialist Registrar. When she became aware of the shortcomings in patient care, Dr.Sharma knew that the Good Medical Practice (GMC 2013) indicated that her responsibility was to immediately tell someone who was in a position to take immediate corrective action; in this case it meant talking with the nursing staff in a way that respects the professional boundary between the professions.  She was able to put this situation into context because she knew there were staff shortages and a reliance on agency staff. This knowledge will have helped Dr.Sharma to discuss her concerns openly and sensitively with the senior nurse in charge and suggest a constructive way forward. The guidance is clear that a doctor’s duty is to the patient rather than colleagues; having respectful conversations with colleagues from a different profession requires sensitivity and assertiveness. The GMC offers detailed advice on raising and acting on concerns (GMC 2012).

 

Intraprofessional boundaries

Intraprofessional boundaries exist between individual healthcare practitioners and their colleagues. Intra-professional boundaries relevant to medicine include the boundaries between different medical specialties and sub-specialties, between specialist and generalist practitioners, between day and night staff, and between staff at different levels of seniority. Intra-professional boundaries and their associated hierarchies facilitate independent working but can also lead to practitioners competing for resources and influence (Currie et al 2009). Earlier, we highlighted that in the Morecambe Bay investigation revealed that there were problems in which obstetricians and paediatricians.

There is persistent evidence that NHS staff experience bullying, undermining and harassment. West (2020) observes that in the 2019 NHS Staff Survey the percentages of staff experiencing bullying and harassment from managers (13.5 per cent in 2015, 12.3 per cent in 2019) and colleagues (18.1 per cent in 2015 and 19.0 per cent in 2019) have shown little or no decrease. Over half report strained relationships at work boundaries. Specifically in medicine, Crowe et al (2017) found that post-registration education was characterised by a respect for hierarchy, anger and fear, intimidation, and disillusion were key themes in participants' narratives of relationships with senior staff who oversaw their postgraduate training. Given this backdrop, there is a possibility that you or one of your colleagues might at some point have one of your professional boundaries breached by being undermined, micro-managed, harassed or bullied.  The BMA has very clear advice for doctors in such situations, discuss your experience with a trusted friend, family member, colleague or your educational supervisor or clinical supervisor for advice and support (BMA 2018). Become familiar with your Trust policy on dignity at work and some Trusts have Anti-Bullying Ambassadors who may be helpful to meet with and all Trusts have a Freedom to Speak Up Guardian to offer advice (https://www.gmc-uk.org/ethical-guidance/ethical-hub/speaking-up/speaking-up-a-freedom-to-speak-up-guardians-experience).

 

In addition, you might want to visit the following websites:

Civility Saves Lives

The Anti-Bullying Alliance

GMC Building a supportive environment

GMC supports Anti-Bullying Guide

 

Thinking point:

Have you seen evidence of professional boundary crossing in your medical career?

How did you know a boundary had been crossed?

What did you do? Or wish you had done?

 

The GMC (2019) is committed to addressing bullying and undermining in medicine and has piloted a training programme ‘Professional behaviours and patient safety programme’ which has been designed to help improve doctors’ skills and confidence to address unprofessional behaviours. The BMA (2018) too, offers very clear guidance on how to address bullying at work (https://www.bma.org.uk/advice/work-life-support/your-wellbeing/bullying-and-harassment).

Racism is a specific form of bullying that can impact on the professional boundaries of doctors and other healthcare professionals. If racism has challenged your professional boundaries, these two resources may be helpful: