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Introduction
Nurses represent the biggest health care sector in Malaysia. They are the main givers of care, especially in remote rural areas. There are approximately 60,000 nurses in the country, increasing the nurse-to-population ratio to 2.25:1000. To date, acquiring licenses to practice nursing is easier with 6 universities, 18 colleges controlled by the Malaysian Ministry of Health, and 32 private sectors offering university nursing degrees and diploma programs (Lundy & Janes 2009).
Nurses serve as the comforting interface between clients and hospitals, and between communities and the country’s health care system. Health care provision in Malaysia requires nurses to play extended roles to complement the services that are rendered by other members of the health care team. Performing these extended roles make Malaysian nurses more involved in practices that may have legal consequences. In order to promote competence and confidence in their decision making, these nurses must understand the importance of professional boundaries and recognize ethical and legal issues that may have impacts on their practices.
Malaysian nurses hail from diverse backgrounds that lead to their uncertainty of the concept of nursing. A report done by the Ministry of Health in Malaysia showed that complaints from patients rose from nurses overlapping their role boundaries, their difficulty in imposing legally right choices but ethically wrong ones into their decision making, and the challenges of setting aside their political and organizational inclinations when giving nursing care (Chee & Barraclough 2009).
The ever evolving ethical and legal standards in the global setting prompted this exploration of the professional nursing boundaries in Malaysia. Recent updates in the provision of health care services made nursing laws and ethics more relevant in the country. Malaysian nurses are regularly affected by litigation concerning issues such as negligence, malpractice, failure to properly document nursing care, administration of wrong medications, failure to honor confidentiality agreements, and more. Technological advances also added to the challenges of the nursing profession. Raising the awareness of nurse practitioners on professional boundaries will help them provide better client care, develop deeper sense of accountability, and promote personal commitment to their profession.
How it is supposed to be
Although not exactly held in great esteem, nurses are generally respected by the society. RNs work with a variety of clients and specialize in various special areas to help with the suffering from physical, spiritual, emotional or psychological disorders (Koerner & Karpiuk 1994). They perform their roles in a manner that is consistent with the norms established by the culture of the society they live in. They possess competence to master their tasks and practice ethical and legal behaviors to police their ranks. They are accountable to the public, and as such must fulfill their advocacy for public health to safeguard the public trust that they enjoy.
With so many degrees of interaction, social relationships may be context but nursing laws exist to maintain the boundary that should exist between and nurses and their patients, and nurses and the other members of the health care team. This professional boundary will allow for rightful power differential, encourage patients to feel safe with the nurses they work with, and preserve the integrity of the nursing profession to strengthen the trust of the public in it. RNs have ethical, moral, and legal obligations to care for their clients with confidentiality, nonmaleficence, and beneficence. Their behaviors and actions must be initiated with the best interest of their patients in mind.
It is the job of Malaysian nurses to establish trust, build rapport, and educate their patients and their significant others about their conditions. They are also expected to work with physicians and other health care professionals to establish patient treatment plans, treat medical emergencies, and implement appropriate interventions.
The necessity of professional boundaries in good nursing care
Nursing is a profession dedicated to helping clients meet their health care needs. It establishes standards of practice, conduct and training to protect its practictioners and the people who are dependent on it. Professionalism in nursing means practicing with commitment, compassion, and competence. A professional nurse must adhere to moral, legal, and ethical standards using the right skills, knowledge and attitude to meet the rigorous demands of hospitals, nursing homes, health centers, and other health care environments.
The nursing profession must be regulated for provision of competent, legal, safe, moral, and ethical nursing care. Guidelines and boundaries for registered Malaysian nurses and other professionals help implement appropriate nursing practice. It is crucial to differentiate therapeutic relationships between nurses and patients from other types of relationships. Violating boundaries can harm not only the patient but also the professional and possibly others related to them. While incidence rate of boundary violations in Malaysia is low, some cases go unreported when they should have never occurred in the first place. Harmful incidents of boundary violations are lessened when nurses have a good understanding of what is expected of them.
Nurse-patient and nurse-doctor relationships are based on trust. Thus, a Malaysian nurse must observe proper decorum not only in hospital settings but at all times. When he does something to violate this trust, he may be convicted criminally which may lead to disciplinary events even when his offences are not connected to his professional practice.
Boundaries help establish evident roles for nurses to define their therapeutic territory. They create safety, security, and emotional stability for patients, their nurses, and the society. These boundaries are being clearly ignored when nurses act in their interests instead of their patients’.
Boundary issues
Any disruption of the accepted and expected physical, emotional, spiritual and psychological boundaries separating nurses from patients is considered a boundary issue. A therapeutic nurse-patient relationship is established for the purpose of treatment and therapy. Whenever the relationship deviates from this purpose, it becomes non-therapeutic and thus becomes a boundary violation. There are two major issues of boundary cited by Gutheil and Gabhard: boundary violations and boundary crossings. A boundary violation is a deviation from therapeutic activities that is potentially harmful to patients and to therapies. It may constitute an exploitation of the client. On the other hand, a boundary crossing is non-exploitative. Similarly, both types may arise either from the client or from the nurse.
In trying to fulfill their responsibilities, many nurses often face clinical situations that result to ethical, legal, and moral conflicts. These conflicts may lead to job dissatisfaction, arguments with other health care professional, and feelings of powerlessness and frustration that can compromise patient care.
Cognate Theory
The Cognitive theory asserts that violating professional boundaries is explainable through understanding the thought processes of the nurse(s) involved. The assumption is that the nurse makes choices that make sense to them (Clak & Beck 1999). While some boundary violations stem from anger and insecurity issues, or from substance abuse, not all of them are abusive and signs of disrespect to individuals and the profession. The following are some of the possible reasons for these violations:
- Moral distress – This occurs when a nurse knows what is supposed to be done yet is restricted by institutional constraints that make it impossible for him to pursue the right course of action.
- External constraint – This stems from issues that arise not from the nurses but from people or things surrounding them. Nurses do not occupy the highest rank in the power structure hierarchy, so their decisions are sometimes affected by what the administration, the physicians, and the institutional policies have to say.
- Powerlessness – It is difficult to be in a hopeless situation and know that means are available to save or prolong a client’s life (money, medical equipment, medications, availability of surgeons) yet there is nothing that can be done to do so.
- Internal constraints – These result from a nurse’s perception of his value and his lack of confidence on himself. His actions may be limited by the futility of the nursing interventions he carried out in the past, his fear of getting fired, personal issues that he has with those who give orders, or his lack of assertiveness.
- Personal issues – An employee who is anxious, depressed, sick, or has personal problems may not be able to focus on his work and thus unintentionally violate professional boundaries.
- Withdrawal/Avoidance - Some nurses want nothing to do with dying patients. They can’t bear witnessing their last moments, feeling like any intervention at that point is just additional torture.
Conclusion
This study explored boundaries in the Malaysian nursing profession to understand the internal and external factors that influence nursing practice in general. Sense of power, political context, and personal doubts were cited as some of the causes of boundary violations. This clearly shows the need for a redefinition of the nursing profession, putting emphasis on what nurses should and should not do. While nurses have been crossing boundaries for years by carrying out orders that are meant for physicians, dieticians, physical therapists and other members of the health care team, the increasing number of litigation concerning legal, moral and ethical violations call for the development of a strong role definition. Key changes in the job description of Malaysian nurses will give them needed “professional space” so they can adhere to organizational rules and influence patient care decisions.
In fast-paced settings where a few seconds could make lasting and irreversible impacts on a patient’s life, it is necessary for nurses to know how to act and what to do. Crossing the line that separates nurses from physicians may save patients’ lives in some cases, but making the wrong decisions especially those that should not have been theirs to make could result to death. Shifting from an emphasis of preventing death to prolonging life will introduce a doable and easy-to-implement dimension into the roles of a nurse. Originally, nurses are placed at the center of holistic care, giving them the power to significantly contribute to a patient’s case management. Updates in task allocation, should there be any, will fundamentally alter the nurse-doctor relationship. As more responsibilities are given to nurses, they needed to be assigned to fewer patients. Moreover, doctor’s instructions can be directly given to the assigned nurse, saving the health care team valuable time. As a result, nurses will be able to converse with the respective physicians more freely.
On the other hand, the impetus for nursing roles will create tension between doctors and nurses and rekindle issues of qualification. Some physicians consider nurses to be unqualified for hands-on care and think that nurses take on loads of work and responsibility that may possible exceed their authority and expertise.
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