Professional Boundaries Research Articles

From Detached Concern to Love: Reconsidering Physician-Patient Boundaries

Abstract Developing appropriate professional boundaries is part of becoming a mature clinician. Boundaries help physicians fulfill their duties in relationally complex and emotionally fraught situations. The concept of “detached concern” has been used to characterize physician-patient relationships in which physicians show empathy and concern while maintaining due emotional distance. However, if the default tendency of trainees and clinicians is toward detachment, then emphasis on professional boundaries may do less to promote proper detachment than to diminish human connections with patients, thereby leading to clinician disenchantment and patient dissatisfaction. The authors propose that the physician-patient relationship is better characterized by love—specifically the kind of ordered love described by the fourth- and fifth-century bishop and philosopher Augustine of Hippo. Augustine’s vision of love has influenced many social reformers through the centuries, including, notably, Martin Luther King Jr. Importantly, such love is consistent with safeguards for which professional boundaries in the clinical context are corollaries, including guarding against forms of compassion that interfere with reasonable judgment, acknowledging humans' finite capacity to love, and recognizing potential harms of disordered love. Against a horizon of love, however, such boundaries are transformed from walls that prevent human connection and concern to walls that create spaces for and encourage any human connection that does not hinder healing and the patient’s good. By shifting their emphasis from detached concern to love, medical educators can re-enchant medicine for trainees by encouraging the human connections that make the practice of medicine its own reward.

Exploring facilitators and barriers to scope of practice expansion with Pharmacist independent prescribers in North Wales: a qualitative study

Abstract Introduction Independent non-medical prescribing allows qualified nurses, pharmacists and other healthcare professionals to prescribe within their competence, which is initially narrow in scope. Previous research identified that this competence requirement has potential to limit pharmacist independent prescribers’ (PIPs) ability to expand their prescribing scope1. The Royal Pharmaceutical Society has published guidance for PIPs on expanding scope of practice after qualification2. Research asking how, why and what factors affect the process of scope expansion is lacking. Aim To explore the reasons why PIPs may or may not expand their prescribing scope of practice after qualification and what factors may prevent or enable this. Methods A qualitative semi-structured interview study was utilised. Participants were PIPs working within North Wales who self-reported at least 2 years’ experience as a prescriber, prescribing at least monthly and had expanded their scope of practice since qualification. Recruitment was via gatekeepers. The study obtained ethical approval from Cardiff University School of Pharmacy Research Ethics Committee (Reference 2324-03) and was registered with Betsi Cadwaladr University Health Board. Purposive sampling ensured inclusion of pharmacists from multiple pharmacy sectors. Interviews were face-to-face or online and recorded on MSTeams®. Deidentified verbatim transcripts were analysed via inductive thematic analysis. Results Ten participants were interviewed, from a mixture of hospital, primary care, out of hours and community pharmacy sectors. Themes identified included intrinsic factors (experience and attitude) and extrinsic factors (support, service factors, governance and workplace social context). Experience sub-themes included confidence, a holistic approach and awareness of professional boundaries as facilitators for scope expansion. Attitude included being motivated and fulfilment in the role. Support was a key factor including time, funding, mentorship, peer and managerial support – all identified as facilitators and lack of each as a barrier. Other support sub-themes included structured training programmes, such as the All Wales 111 competency framework, easy access to experienced colleagues for advice on cases and space for reflective thinking, either as a team or with a mentor. Governance was identified as both a barrier and facilitator, with some appreciating the structure of local prescribing policies whilst others found it restrictive. Service factors included new roles, an expectation of the role to prescribe for multiple conditions, such as in 111 or the community pharmacy independent prescribing service, changes in team skill mix, service review and patient requests. Workplace social context that facilitated scope expansion included independent prescriber role models, nurturing teams and working within a multidisciplinary team. A lack of multidisciplinary working, such as lone working in community pharmacy, was seen as a barrier. Discussion / Conclusion Themes identified align with previously published literature and models on expertise development in independent prescribing(4), suggesting that expanding scope of prescribing aligns with expert practice development needs. This exploratory study highlights factors that PIPs found both helpful and a hindrance for expanding their prescribing scope of practice, although limited by the small sample size. Further research is needed to corroborate these findings with other professions and in other parts of the UK before incorporating into future guidance.

Addressing psychological barriers to student learning: our role as learning developers

Since the launch of ALDinHE’s Health Community of Practice (CoP) in 2021, members have been sharing practice ideas and resources via monthly activities. One activity that stimulated particular interest related to the topic of psychological barriers to student learning (i.e. low confidence, anxiety, perfectionism and imposter syndrome) and how, as learning developers, we might address these. Although healthcare students may be particularly vulnerable to these kinds of issues (Bogardus et al., 2022), they are on the rise among all students (Curran and Hill, 2019). Therefore, it is pertinent to consider how they infiltrate learning development practice and how they can best be supported. The purpose of this workshop was firstly, to explore the professional boundary issues that this may raise, and secondly, to share and explore practice possibilities. This involved showcasing ideas from the aforementioned Health CoP activity and drawing on relevant research. In doing so, we aimed to open up a wider discussion about how learning development spaces can foster emotional growth and provide takeaways that participants can apply to their own practice.

A discourse analysis of professor-student conversation: a corpus-based study

This study is a corpus based discourse analysis of professor-student conversations in order to identify the linguistic features, power dynamics, politeness strategies, and identity constructions in academic discourse. This research employs a mixed methods approach combining quantitative corpus linguistic tools with qualitative discourse analysis, to study how language reproduces or shapes the hierarchical and mutually working professor-student relationships. The findings show that professors tend to employ complex language, academic terminology and more authoritative speech patterns, as they establish themselves as knowledgeable and guide the conversation, and that the students generally speak more simple language and deploy more deferential politeness strategies as learners. Students, however, varied in their agency, especially when graduate students showed more independence by asking the challenging questions and negotiating power dynamics. To create a collaborative learning environment, professors also hedged their authority with hedging questions and open ended questions. The study’s findings seek to further understanding of how language is used to build academic identities and retain professional boundaries in educational contexts. Finally, recommendations for how to be more inclusive and effective in communication through pedagogical strategies are made, as well as suggestions for future research involving comparative studies among other contexts and multimodal discourse analysis in order to better understand the academic interactions.

Teaching Belonging in Nursing Using Narrative Pedagogy.

As Abraham Maslow asserts, belonging is essential to achieving self-esteem and self-actualization. With increasing numbers of novice nurse burnout and a perceived education-practice gap, promoting a sense of belonging is important to nurses' growth and psychological well-being and should start in nursing school. An elective course, Belonging in Nursing, was developed to assist undergraduate nursing students in understanding the importance of belonging through narrative pedagogy. Course topics include the concept of belonging, managing moral distress, professional identity and boundaries, and readiness for practice. Student feedback was positive, including the promotion of belonging in the class through hearing others express their fears and doubts and an increased awareness of moral distress and professional boundaries. Teaching Belonging in Nursing through narrative pedagogy aids in integrating this vital concept into the undergraduate nursing curriculum. Promoting belonging should start in nursing school and continue into novice nurse practice. [J Nurs Educ. 2024;63(X):XXX-XXX.].

Mental health matters: Evaluating the preparedness of sport psychologists to incorporate within their role.

Mental health has become increasingly important for the applied sport psychologist, a factor which may include screening, promoting literacy, individual support, and educational programs. However, despite of this importance, few checks have been made on the perceived preparedness of sport psychologists to undertake this work and whether differences may exist between those recently qualified compared to experienced practitioners. Underpinned by the theoretical domains framework, 62 Health and Care Professions Council registered practitioner sport and exercise psychologists (30 females: age: M=46.13years and SD=10.44years and 32 males: age: M=43.25years and SD=10.47years) completed an online survey to assess whether they felt equipped to address the mental health dimension of their work. The survey comprised three sections: Demographic and background information, a series of statements (n=31) adapted from the determinants of implementation behavior questionnaire, and three questions with space for free text comments, inviting participants to explain their level of preparedness to incorporate and deliver mental health interventions. A 6×12 analyses of variance yielded significant differences between domain ratings but not across levels of experience or interactions. Data from free text comments were analyzed thematically and categorized into the following three themes: (a) complementing the performance role, (b) awareness of professional boundaries, and (c) importance of further continued professional development. Combined, although practitioners emphasized importance, preparedness ratings ranged from neutral to somewhat agree, calling for further specific sport psychology-based mental health training.

Public Youth Services Librarians’ Perceptions Towards and Experiences in Promoting Teens’ Positive Mental Health: A Mixed Methods Study

Over the last decade, teen mental health has declined rapidly. In Florida, high rates of youth mental health concerns and lowered access to care led to its ranking as the 19th worst in the nation. To help address these issues, a “whole community” approach to mental health promotion has been advocated, with public libraries identified as potential partners. But research exploring public youth librarians’ perceptions and experiences related to this agenda is lacking. Informed by Seligman’s well-being theory, this study addresses that gap by exploring public youth librarians’ perceptions towards and experiences in promoting teens’ positive mental health through an explanatory sequential mixed-methods design consisting of surveys of and interviews with Florida public librarians responsible for teen services. Survey results (n=183) showed that most librarians viewed promoting teens’ positive mental health as an important part of their role and engaged in a variety of related activities. But challenges in carrying out these activities were identified as well as concerns related to professional boundaries and training. Interviews (n=30) further explored how librarians define the scope of their role and their experiences, including any training and support received and challenges related to promoting teens’ positive mental health. Findings provide greater understanding of what members of the profession are doing and what they perceive as their role in response to declining teen mental health, thus improving service provision by informing future education and training efforts and the development of new models for how to best promote teens’ mental health through a holistic lens.

WhatsApp: A Blessing or Bane for Communication between Emergency Physicians and Vascular Surgeons?

Abstract The integration of WhatsApp (WhatsApp Inc., Mountain View, CA, USA) into the health-care sector is transforming the dynamics of medical communication. Launched in 2009 and incorporated into the Facebook suite of companies in 2014, WhatsApp has become a pivotal platform for health-care professionals. It allows for quick, personal, and group messaging, which is increasingly used to exchange patient information, discuss cases, and make timely decisions. The app’s end-to-end encryption is critical for maintaining patient confidentiality, ensuring that sensitive data are only accessible to the intended recipients. This security feature and the group sharing format enable health-care teams to communicate confidentially and efficiently, bolstering the oversight capabilities of attending senior consultants or physicians over their junior peers. The real-time exchange of information is crucial in providing continuous supervision and facilitating immediate feedback, which is indispensable in clinical training and patient care. However, the widespread adoption of WhatsApp also comes with challenges and potential drawbacks, which have been the focus of past research. These studies assessed the impact of WhatsApp on health-care delivery, considering both the enhancement of communication it offers and the issues it may present, such as data security beyond encryption and the blurring of professional and personal boundaries. In this “medical opinion” from an academic tertiary care center in Muscat, we explored how emergency medicine physicians can effectively use WhatsApp to expedite or bypass referral processes for emergency cases, particularly those involving vascular and other surgical emergencies.

Exploring a role for community pharmacists in the identification of alcohol-related liver disease: a qualitative interview study with professionals, patients, and the public.

To explore the views and attitudes of professionals, patients and the public to a role for community pharmacists in the identification of alcohol-related liver disease (ArLD). Semi-structured interviews were conducted with a purposive sample of patients with ArLD, members of the public, pharmacy staff, and clinicians managing patients with ArLD across the Wessex region of south England. The interviews explored experiences of alcohol, ArLD and health advice in pharmacies and elicited views of what a pharmacist role in identifying ArLD could entail and factors influencing this. Transcripts were analysed using reflexive thematic analysis. Twenty-six participants were interviewed and three themes were generated: (i) acknowledging, seeking help and engaging with a hidden problem; (ii) professional roles, boundaries and attributes; (iii) communication, relationships, collaboration and support. Participants reported key challenges to identifying people at-risk of ArLD. Offering testing for ArLD was perceived to motivate engagement but there were concerns about pharmacists performing this. A role was mostly seen to be finding people at-risk and engaging them with further care such as referral to liver services. This was perceived to require developing interprofessional collaborations, remuneration and training for pharmacy staff, and community-based liver testing. Professionals, patient and public participants recognized a role for pharmacists in the identification of ArLD. This was envisaged to incorporate educating pharmacy users about ArLD risk, and identifying and directly engaging those at-risk with liver and support services through development of interprofessional collaborations. The findings of this study support and can inform future work to develop this role.

“They’re Doing Their Own Kind of Nursing”: Challenging the Gender Bias

ABSTRACT Despite Iceland's reputation as a gender equal country, men make up about 4% of nurses which is low in comparison with similar countries. To shed light on what determines the choice of nursing and on cooperation at work, interviews with ten female and seven male nurses were analysed with reflexive thematic analysis. Drawing on poststructuralist and feminist theories, focusing on power relations and gender in the workplace, the analysis revealed stereotypical gender differences. Choosing nursing was for the female nurses a “natural” channel for their talents, the males were conscious of crossing a line and prepared for stereotyping obstacles. A powerful hierarchy characterized daily work, female nurses described suppressing working situations and lack of support, males ranked themselves higher in respect and opportunities, prioritized their professional boundaries, self-care, and nursing competence, free of gender labels. This difference is an important and self-sustaining part of nurses’ image as powerless, deters young people from nursing education and leads to distance between genders in the workplace. The findings highlight the need to recognize and tackle stereotyping, which maintains inequality, prioritizing diversity instead is a task for educational and health systems, and the debate on gender equality in Iceland.

How High-Performing Personal Support Workers Set and Maintain Boundaries When Providing Care: A Case Study in Ontario, Canada

Personal support workers (PSWs) provide a large proportion of in-home care services for Canadians. PSWs must negotiate with clients and their family on how prescribed care is delivered. How PSWs set and maintain professional and personal boundaries during care is poorly understood, and failure to manage boundaries can expose both PSWs and clients to risk. High-performing PSWs ( n = 9) and supervisors ( n = 4) within an Ontario, Canada, home care agency were engaged in workshops ( n = 3) to identify field-tested strategies and tactics for identifying, managing, and supporting PSW boundaries. A boundary-management framework was generated, including types of boundary challenges; decision-making principles (e.g., consider the purpose of home care); response strategies (e.g., work with the client on an alternative solution); and tactics for action (e.g., use proactive reminders). Supervisory and organizational supports (e.g., enabling “shop-talk”) were identified. The framework can inform teaching and practice materials for PSWs in Canada and other countries.

Needs Assessment for a Leadership Course in Saudi Medical Schools: The Student Perspective.

Leaders in healthcare no longer need to hold formal management positions; instead, leadership is perceived to be the responsibility of all healthcare professionals. Despite changes in curricula and teaching design, however, this review of the content taught in medical colleges in Saudi Arabia reveals a lack of leadership and a failure to equip young graduates to compete on the global stage. Medical students need leadership skills for patient care, cooperation, and navigating the complex healthcare system. Clinical management skills in hospitals require these talents also. The complexity of healthcare and the impact healthcare executives have on people's lives highlight the importance of these skills. Thus, healthcare practitioners must develop non-technical skills like proactivity, motivation, and change management to lead across professional boundaries and negotiate the increasingly complex healthcare landscape. This cross-sectional study combines a quantitative approach with a self-administered questionnaire-based survey. The sampling procedure is a non-probability convenience technique, adapted for 700 male and female undergraduate medical students from four medical colleges. Of the students, 75.46% had minimal leadership experience and 22.69% had some leadership experience; 3.02% of 464 students considered themselves highly experienced in leadership. As the needs assessment and other relevant factors show, leadership should be introduced as a skilled subject. There will always be a growing demand for competent medical graduates, who are capable of becoming future leaders. Although elementary leadership concepts remain fundamentally the same, curricular development must focus on the needs of society and stakeholders.

A Collaborative Approach to Understanding the Intersections of Practice and Policy for Peers in the Alcohol and Other Drugs Sector.

Peers in the alcohol and other drug sectors possess lived-living experience (LLE) crucial for shaping community care. However, genuine consumer collaboration is often confounded by stigma. This study examined peers' perceptions, exploring their experiences regarding workforce dynamics, policy implications, and impacts on health equity. In presenting the research, we sought to synthesise the research methods and illustrate the methodological innovation and knowledge production in substance use research through authentic collaboration. We purposively sampled peer networks and community organisations, involving peer-researchers in planning, design, and analysis. We conducted semi-structured digital interviews with 18 peers and applied iterative coding to analyse the data. This collaborative process provided nuanced insights into sectoral challenges. Peers expressed emotional strain revisiting personal substance use experiences, blurring personal and professional boundaries. Tokenistic peer involvement critiques underscored the need for genuine leadership and organisational support. We advocate for a shift towards equitable and inclusive policy development through both organisational and systemic restructuring. However, these changes are hamstrung by broader policy frameworks, which require a shift to peer-led principles, ensuring the expertise of peers is genuinely valued. Policymakers should invest in expanding peer frameworks, acknowledging the diversity within communities of people who use drugs to improve health equity and public health outcomes. This innovative approach to substance use research emphasises the transformative impact of integrating LLE into research.

Money talks: Analysing the PGA Tour-LIV Golf jurisdictional contest via Western media narratives

This paper analyses Western media narratives of the jurisdictional contest between LIV Golf, a novel upstart professional golf tour, and the long-established PGA Tour, generally understood to be the pinnacle of men's professional golf. In doing so, the paper seeks to answer two research questions: How do dominant incumbent sporting professions utilise the court of public opinion to defend their territory from encroachment by new rivals? What are the potential implications of such professions’ failure to successfully do so? Viewed through the lens of Abbott’s concept of ‘bump-chains’, this paper shines critical light on how the long-established and dominant PGA Tour and its partisan (but not full contingent of) members initially sought to defend their territory against encroachment by a new entrant to the profession of competitive golf, before capitulating and proposing a ‘merger’ with LIV Golf in June 2023, which as of July 2024, has still not materialised, nor the finer details even made public. Utilising a critical qualitative analysis of popular Western-centric news media sources, the paper argues that the PGA Tour adopted a three-fold set of defensive rhetorical manoeuvres to seek to de-professionalise LIV Golf and discredit it in the court of public opinion as a convincing rival to the incumbent profession. It concludes that the PGA Tour's rhetorical defence attempts and thus its position as a dominant superordinate were untenable in the face of the new entrant's reach and power. In doing so, the paper adds theoretical depth to our understanding of bump-chain attacks within the sporting arena, and also acts to highlight sporting jurisdictions’ vulnerabilities to encroachment by previously unconsidered entities. These findings bring implications for governing bodies and institutions in the sporting arena concerning the strength of their jurisdictional positions, extending beyond professional boundaries.

From Photography to Radiology: How Physicians Leveraged Early Hospital X-ray Machines to Supplant Photographers.

At the end of the nineteenth century, the advent of x-ray machines fueled American medicine's reliance on technology, transforming hospitals and the medical profession. X-ray manufacturers pursued the nascent hospital market as competition and patent feuds accelerated x-ray machine modifications. Hospitals incorporated clunky new machines and employed x-ray photographers, but as the unruly apparatus stabilized, physicians joining the new specialty of radiology discounted the toils of machine troubleshooting and promoted their medically qualified x-ray interpretations. This article frames early medical radiography in terms of boundary work, highlighting how discourse among physicians, x-ray photographers, and hospital administrators vied to establish a privileged demarcation between radiological science and photographic craft. Ultimately, radiologists supplanted x-ray photographers by leveraging the automation of x-ray machines and capitalizing on the epistemic shift from photographic objectivity to qualified interpretations. By focusing on this overlooked aspect of x-ray incorporation into hospitals, this work provides a unique perspective on how harnessing mechanization and authoritative medical interpretations can shift professional boundaries.

Rethinking professional boundaries: the climate crisis and brain health.

Since climate change affects psychiatric, neurological and neuropsychological disorders, as well as brain development, the Irish Doctors for the Environment working group on mental health has changed its title and remit to brain health. Mental health professionals need to respond coherently and effectively to the climate crisis. This need challenges traditional professional, disciplinary and academic boundaries and demands a holistic, person-centred approach. We propose that meeting this challenge is vital if the public, policy-makers and legislators are to grasp the full extent of the significance of climate's impact on brain health.

Podiatric surgery: a canary in the coalmine for professional monopolies.

What is known about the topic? The health workforce and health tasks are highly contested and largely controlled by regulation. Since the introduction of medical regulation in the mid-19th century, the practice of surgery has been largely dominated by medically trained surgeons. A small group of Australian podiatrists have defied these historic boundaries by creating their own colleges of training and convincing government and regulators of their safety and efficacy in surgical practice. The Podiatry Board of Australia commissioned an independent review of the regulation and regulatory practices of podiatric surgeons in Australia. What does this paper add? This paper discusses the implications of a regulatory review of the role of podiatric surgeons for professional role boundaries. What are the implications for practitioners? Despite historic role boundaries and definitions, with appropriate training, regulation, and financing, the health workforce can be mobilised in different ways to meet population needs, overcoming a professional monopoly over roles.

Why sedative hypnotics often fail in development.

Drug development to support anaesthesia and sedation has been slow with few candidates emerging from preclinical discovery and limited innovation beyond attempted reformulation of existing compounds. The market is well supported by low-cost generic products and development compounds have not been shown to improve patient outcomes or possess other distinctive characteristics to justify the cost of development. To make progress in a large-volume, low margin and highly competitive environment requires meaningful advances in relevant basic science. Opportunities exist, but probably require bolder initiatives than further attempts at reformulation or fiddling with the structure of propofol. Extending development ambitions to include nonanaesthesiologist providers challenges professional boundaries but may facilitate cost-effective changes in patterns of care.

Obstetrics during the French Revolution: political and medical controversies around the new obstetrical surgery

ABSTRACT During the French Revolution, obstetrics underwent substantial transformations in practice, teaching, and the physical spaces where it was conducted. The revolutionary authorities implemented reforms in French medical institutions that promoted an instrument-centred style and the dissemination of novel surgical techniques in obstetrics. The selection of professors for the obstetrics chair at the newly established École de santé and the appointment of chiefs for the new maternity ward in Paris favoured proponents of a mechanistic approach to labour assistance. This essay explores the theoretical principles and societal pressures that guided these transformative reforms and the remarkable changes they introduced in healthcare and in the practise of medicine and surgery. Furthermore, it examines the consolidation of new epistemological, ethical, and professional boundaries within the context of late eighteenth-century French obstetrics. A critical section of this study focuses on the debate ignited by the contemporaries who voiced concerns that the rise of surgical interventions on pregnant women's bodies might result in unwarranted violence, in a diminishing of midwives’ roles, and in a departure from the tradition of natural childbirth. These controversies among obstetricians highlight significant contradictions within the Revolutionary medical reforms.

A cog in a wheel? Journalism under pressure during coups d’état in Burkina Faso

This article explores how the (attempted) coups and popular uprising that occurred in Burkina Faso between October 2014 and January 2022 have impacted the professional boundaries of journalism. These events are considered crucial in understanding the complex and ongoing interactions between political actors and the media, and contribute to a better understanding of the broader reality of journalism’s boundary-making process across Africa. Drawing on semi-structured interviews conducted with journalists, editors and journalism teachers in Ouagadougou in 2022, this article investigates the roles that private and public media journalists aimed to play in these extreme conditions and how their reactions reflect the constantly evolving nature of the journalistic profession.