Nurses known as a caregiver and provide close relationship not only between patient and the hospital but also for other healthcare profession such as doctors and assistant medical officer and also between communities. Their services are very important and therefore they performing “heart” in the medical and healthcare service provision in Malaysia.
Due to the rapidly changing in Malaysia healthcare environment, the nurses are required to provide care through their extended roles and provide services rendered by other healthcare professional in order to complement the health service to the population. Therefore, Malaysian nurses have become aware for legal and ethical issues that have impacted on their practise and recognised the importance of practice that have legal and ethical principle thus promoting competency and decision making.
In Malaysia itself, most of the major population still choose to get treatment from government. It is because government hospital provides good quality service in healthcare, provide an advances technologies, provide skilled staff, sophisticated equipment beside the cheapest service that they get. In the healthcare service nowadays, professional boundaries are important issues and have been a quite popular topic. Basically, if we search an internet pertaining to professional boundaries we always often get the result are mainly about interactions between nurses and patient or client. According to College of Registered Nurse of British Columbia (no date), urged that within the nurse and client relationship, the client relationship are often vulnerable because the nurse has influenced, access to information, and specialized knowledge and skill. If the nurse does not use her judgement carefully they tend to misused their power.
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Like other health care service, nurses can cause harm to patient if they do not full fill their needs. To provide a safest care to patient, nurses must know the concepts of professional boundaries. This boundary also defined as a professional relationship are sharing or gave other profession or nurse their work based on cooperation and team work among them. ‘Professional boundaries in nursing are defined as limits which protect the space between the professional’s power and the client’s vulnerability’ stated by (Nursing & Midwifery Board of Australia, 2010 p1). However, also quoted by Nursing and Midwifery Council (no date, p1) ‘that boundaries in nursing also define as the limits of behaviour which allow a nurse or midwife to have a professional relationship with a person in their care’. Within this assignment I intend to explore the problem encountered in both relationship and professional boundaries between the perioperative nurse and the general anaesthesia nurse (GA nurse).
This assignments objective are also to gain knowledge and experience between the Ga nurse and perioperative nurse. I am a trained staff nurse currently work as a general anaesthetic nurse for almost 10 years in the tertiary hospital situated in Kota Kinabalu. I have my post basic in advance diploma of anaesthesia after I finish my 1 year course in anaesthesia field. I noticed that there is a boundary in my workplace between the perioperative nurse and the general anaesthesia nurses, the boundaries are mainly traditional boundaries. But even though the work task is different but the main purpose is for patient safety and quality of work.
Basically perioperative nurse are working in the operating theatre.Their roles are to assist surgeon in various surgical procedure, and also helping patient comfortable before surgery. Scope of perioperative work also widening by helping patient after and post operatively. This nurse helps the smoothness of the surgical procedure. A scrub nurse and circulating nurse is specially trained nurse who work with surgeon in the operating room. Most of our scrub nurse and circulating nurse are very experienced, skilful nurses and most of them already had their advance diploma in perioperative nursing. In my workplace I identified a traditional blurred boundaries pertaining to my practice area. The blurred boundaries are identified in some operating room setting between the circulating nurse and general anaesthesia nurse. In my workplace the general anaesthesia nurse will be allocate in each of operating room setting.
The general anaesthesia nurse will assists the anaesthesia doctor during the induction of anaesthesia, giving medication, setting intravenous line, anchoring endotracheal tube also to keep patient calm and safe before the induction of anaesthesia. Normally, the GA nurse tends to have an advance training in anaesthesia such as certificate in anaesthesia where we will get after 1 year attend post basic in anaesthesia. In Malaysia, we had to have the certificate before we can work in the operating theatre as a GA nurse. As quoted by Lukosius et al (2004, p523), ‘to be a good nurse in practice, the organization must have legislation and protected titles for clinical nurse specialist, nurse midwives, and nurse anaesthetist, so they can work according to their standard practice’.
Working in the operating room is about team work among the various types of healthcare such as nurses, assistant medical officer, surgeon, anaesthetic doctor and also hospital attendance. Each of them plays their roles in the operating theatre by providing service direct and indirectly. This team work among the health care services are the strength of all organizations but the boundaries within this working area a still been taking care and are respected. Blurred boundaries that I identified happen in my workplace are due to some problem such as shortage of staff and because of an ineffective inter-professional working. The Ga nurse and the perioperative nurse have tried to worked together and share task based on common practice or skill, but the job description are still remain unclear. Both of them are still not understands about their placing parameters.
Because of the unclear job description and not understanding the role ambiguity is created and misunderstanding can arise. As quoted by Rushmer et al (2005,p.80) said, ‘when the limits (boundaries) of sharing are ignored, nothing is clear and certainty is lost, the ability of collaboration to prepare realistically for their work together is gone where one of the parties ends up doing all the work, or all the unpleasant parts of the work’. Miers et al (2009) revealed, that the nurses are key to the success of inter-professional team. The effective of inter-professional also mentioned in the NMC code of conduct (2008), where the competencies that set by a mentor able to maintained professional boundaries and coordinate learning in an working environment and in an inter-professional working.
Because shortage of staff especially nurses, some of the general anaesthesia nurse are need to cover more than one operating room at the same time. When GA nurse are needed in the other operating room, the circulating nurse who worked in that particular operating room will had to act as a GA nurse. At the other hand GA nurse also can act as a circulating nurse when the job is compromised. As stated in NMC code of conduct (no date), ‘a nurse had to have advance skilled as well as increased knowledge’. Even though the circulating nurse does not have experience and skill as a GA nurse, it is they responsibilities to learn and gain knowledge and skill as a GA nurse. In Malaysia Nursing code of conduct (1998.p2), quoted ‘that nurses are responsibilities and accountability for her owns nursing judgement and action.
When delegating work, the nurse remain accountable for the work done and appropriate supervision and support and guidance to be given to her’. The circulating nurse needs to be supervised and teach by the senior nurse who had the experienced or qualified as a GA nurse before she act and helped as a GA nurse. Also quotes by Nursing and Midwifery council (no date), ‘nurses must always be aware of their limits and ability and role boundaries, acknowledge their professional limitation and make accountable for their decision making and ability to work in a safe and effective manner’. This is reflected in the following paragraph of the Code of Conduct (2008), which states that ‘the nurse must have the knowledge and skill for safe and effective practice when working without direct supervision, recognise and work within limit, keep knowledge up to date and take part in learning and practice that maintain and develop your performance and competencies’.
Although the nurses considering working in the position not related to their job, they have to fulfilled their task even though their do not have required registerable in that possess. For example although a registered nurse may work in operating theatre as a GA nurse or circulating nurse, they must not necessary to have a post basic course and qualified anaesthesia course. The environment also influenced the role of professional boundaries in my workplace. The nurses who work in operating theatre are abiding by nursing policies and regulations. In the operating theatre we also have our standard of practice called standard operating procedure where all the nurses will follow the standard of practice procedure while performing their job.
According to Brown (1998), Read (1999), Hamric (2000), Styles & Lewis (2000) cited in Lukosius et al (2004, p522), quotes’ that environment influence the development boundary in nursing roles, including work environment, policies and procedure, scope of practice, work schedule and work practice can influence the new roles in nursing practice’. Creating boundaries is a good way to keep professional relationship among the GA nurse and the perioperative nurse. The professional relationships are based on trust, respect, meeting the need of client and the appropriate use of power. According to National Council of State Boards of Nursing (no date) quotes, ‘that the power of a nurses comes from his/her professional position’. According to Retzklf (2012), when nurses show respect to each other, professional task, patient safety and nurse feeling of being part of the team are improved. However study has done by Lowe et al (2013), he suggest that once other staff familiar with the task given and their role, they are more comfortable working with other colleagues.
Convesly, when nurse do not acknowledge of each other, competence or disregard their suggestion , unhealthy competitive attitudes can develop, colleagues can began to mistrust each other and the nurses can lose their interest in the nursing profession. Most nurses are aware of of blurring boundaries in professional practice but they still need to touch other professional discipline with permission and with clear instruction due to the role uncertainty and role ambiguity. As quotes by Alberta Association of registered nurse (2005, p.3),‘that a registered nurse in any role can ensure that professional boundaries are respected by applying the following guideline to their nursing practice as appropriate for their role’. This happen in my workplace where the perioperative nurse and the Ga nurse will work according to our nursing practice standards.
Health providers can choose to change or develop new disciplinary boundaries after identified new areas of work according to their interest of work such as an advance practitioners nurse in anaesthesia or as a clinical nurse to gain more knowledge and skill in their own field. According to Chang et al (2011,p3), that the advance practice nurse position is a result of changing healthcare needs and positive effects from this new roles have been widely document, improve patient out came and increased patient satisfaction. But in Malaysia there are still challenges in developing and implementing of advance practice nurse role. I hope there will be implement in the future. However, according to Witz (1992) cited in Nancarrow et al (2005) revealed his theory working in workforce in four direction; diversification, specialization, horizontal substitution and vertical substitution allow any healthcare provider to change their disciplinary boundaries and identified a new areas of work.
Boundaries are important in successful professional project. It is good to have boundaries among health care workers but it is has to be in the positive way and within limits. Boundaries are also important for staff well-being , staff can develop wider expertise, gain knowledge of the new role and skills, contribute actively to new development, provide cross over and for effective client service.
Courtney from Study Moose
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