Blurred boundaries are not the same as cross boundaries

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In providing health services, the main goal of the Malaysia Ministry of Health is to improve and achieve optimal health status for individuals, families and communities through programs of promotion, preventive, curative and palliative interventions to enable the public to enjoy a better quality of life, social interactions and better economic conditions. Assistant Medical Officers (AMOs) is among the backbone and front-line health delivery system in Malaysia, consistent working with doctors, nurses and other medical professionals with the same objective to provide services to patients. Even so, they are subjected to the act, regulations and code of ethics set by the board and government; boundaries define and separate professional roles from other roles. To summarize, the law has set boundaries and the limits of each profession. Peterson (1992) explained that professional boundary is the limits or borders between professionals and patients, which allow a secure connection based on the patient's needs. Professional boundaries also established the limit to allow health professionals to interact in a professional environment, ensure a secure and therapeutic environment with mutual respect between professionals and patients.

Blurred boundaries are not same with cross boundaries, blurred boundaries are uncertain or something that is not clear who should be doing and cross boundaries are something that crosses boundaries that did not exist. In daily works at the Orthopaedic Department, sometimes the boundaries were crossed with permission and sometime it crossed without permission or violated. When sharing boundaries are ignored, nothing is clear, collaborators will lose their certainty and ability to prepare realistic in collaboration. Working under blurred boundaries and no control will look like the invasion. Therefore, blurred boundaries seem like abdication and one of the parties seems do all the work. According to Rushmer et al (2002), inter-professional trust and confidence will be destroyed because blurred boundaries will not generate the synergies and it will cause anxieties, stress, low performance, and feelings of revenge.

According to (2010), "health professionals" are individuals who are accredited by professional body upon having successfully completed a program of study, and usually licensed by a government agency to practice a health related profession. While, "boundaries" defined as something that indicates bounds or limits to create a line restriction or bounding line. The professional health boundaries are very important in health services to determine the limits and responsibilities of health professionals who work and interact with each other in the workplace. As an AMO in the Orthopaedic Department, my duties are related to orthopaedic such as plaster applications and assist the orthopaedic doctors and surgeons in Emergency Department, orthopaedic operation theatre, orthopaedic wards and clinic. However, all AMO are bound by a strict code of ethics and must comply with those rules and regulations at all times.

Professional boundaries are established by legislation, determined by the governing body of licensing and certification, facility set policies and individual. When boundaries are functioning well they tend to go unnoticed, boundary violation may begin as an innocent situation and appear harmless, that is not felt to be a violation or not recognised. Peterson (1992) also explains that the boundaries violation occurs when a professionals places their own needs above the needs of the client. Awareness and understanding of the boundaries is important to avoid the boundary violation in professional practice. Therefore, this paper will discuss about professional health boundaries in our practice among patient, other health professionals and doctors, including health practices that cross boundaries in professional practise at Orthopaedic Department. To facilitate this discussion, this paper will discuss the professional boundaries in procedure of Closed Manipulation Reduction (CMR).

Every registered AMO in Malaysia must comply with the act and code of ethics that has been provided by government and Medical Assistant Board. It was given as a guide after graduating with an annual practicing license. With 10 years experience working in Orthopaedic and have advanced course of Orthopaedic Post-basic , my duties as an AMO remains subjected to the 3 matters below about the scope and professional boundaries that must be followed:

Act 180, Medical Assistants (Registration) Act 1977

Medical Assistant (Registration) Regulations 1979

Code of Ethics for Medical Assistants (1997)

I am among of AMO in the orthopaedic department which trained and experienced in matters relating to orthopaedics, including advanced skills course; Post Basic of Orthopaedic. Therefore, the professional boundary between the AMOs and doctors in the procedure of CMR has become blurred. CMR is a procedure of reduction and manipulation a fractured bone without incision into the skin, and performed under local anaesthesia or general anaesthesia, then immobilised with Plaster of Paris (POP). Usually 4 staffs involved, a junior or senior doctor, an AMO, a nurse and an attendant. They have their own tasks and contributions to this procedure. AMO's task is to help doctors to apply the POP and, assists manipulation and reduction. The doctor will give anaesthesia, cannulation, manipulate and reduction with AMO assisted, and consent from patient. Nurse is assisting in nursing care and attendant contributes as an assistant and send patient to X-ray after the procedure. Allen (1997) explains that an experienced and trained professional more easily blur the boundaries compared with junior professional. What was happened, due to trust and respect the skills of an experienced AMOs, AMO often has crossed the boundaries and has taken the doctor duty. AMO will take the doctor's job to make reduction and manipulation, will give local anaesthesia and cannulation, otherwise the doctor will become an assistant to AMO, especially when it involves a junior doctor.

All professionals in Orthopaedic Department shares a common goal of health services and delivered by professionals working collaboratively. Inter-professional working relationship is very important. Therefore, Ross et al (2005) clear that United Kingdom Department of Health to increase the emphasis on collaborative care, inter-professional working relationship, and partnerships. CMR procedure requires good cooperation between the staff involved, although the duties of doctors should make the reduction and manipulation was undertaken by the AMO. To ensure inter-professional working in CMR procedure is successful, it is very important they have a mutual respect for all teams and evaluate all the contributions at the same value. Inter-professional conflict is normal that there may be destructive or productive, depending on how they managed. Raven dan Kruglanski (1970) consider that inter-professional conflict as tensions between two or more individuals or groups that arise from differences of opinion. I believe that the process of conflict resolution is important because conflict can damage the quality of inter-professional relationships. Therefore, leadership and power is very important as a way of conflict resolutions. Leadership and power are closely linked, French & Raven (1959) shows how "French and Raven's Bases of Power" affects a person's leadership and is widely used in communications and organisations. If professionals understand French and Raven's Bases of Power (Appendix 1), so they can understand why they were influenced by a person, know their own power source and build leadership skills. Power is a measure of professionals' ability to control their environment, including the behaviour of professionals.

No doubt those doctors are better trained and educated in medical practice. In fact, doctors are also higher hierarchical position than AMOs and nurses, are allowing doctors to have more power and legitimated by law. Abbot (1997) explained that traditionally, doctors viewed as a medical team leader, while AMOs and nurses are a subordinate group of health care professionals. Therefore, frequent boundaries crossed either the doctor tried to take advantage of their power and hierarchy or maybe their respect the skills of AMO in CMR procedure, especially manipulation and reduction. I believe it can give a bad impression on the doctors' development of skills and experiences. As described in above paragraph, understanding of 'French and Raven's Bases of Power' is very helpful to know the source of power and how to handle it. According to Blair & Buesseler (1998), hierarchy and imbalance of power exists not only in the relationships among health professionals, but Hardy & Leiba-O'Sullivan (1998) states that it's also exists between health professionals and patients. In providing health services, physician perceptions may varies with the AMOs or nurses, Katzman (1989) also explained that doctors and health professional generally do not share perceptions of their own and the others' roles in providing health care.

AMO is a position that serves as a medical officer's assistant, has similarities but they have limited power or authority. However, AMO has mutual and overlapping concerns and responsibilities for patients. They cooperate with other health professionals including nurses and doctors to meet their responsibilities to patients. Especially during the CMR procedure, the goal remains same; providing the best service to patients. Smoyak (1997) explains that health professional including AMO and doctor works best as colleague with mutual agreement to achieve goal, does not distinguish status and personal interactions, share knowledge, skills and expertises, and the efficiency of mutual trust and respect each other's. During the procedure of CMR, doctor will be happy if their task, cannulation, manipulation and reduction were undertaken by the AMO, because it would be reduce their workload and work pressure. Additionally, doctors often felt themselves lacked of experience and skills compared to AMO. Workman (2000) explained that junior doctors are still in the learning process and lack of experience and skills. However, this situation is also very good for the advancement of knowledge and skills of AMO and junior doctor, what's important is the benefits to patients.

During CMR procedures, reduction and manipulation requires energy and is more directly toward to male. At my workplace, all AMOs are male and gender dominance will happen when working with female doctors during the CMR procedure. Therefore, this reduction and manipulation is usually performed by AMO. Generally in Malaysia, all AMO are men and nurses are women, but the situation has changed gradually with the existence of female AMO and male nurses. Issues of gender dominance also explained by Bernard (1981), which states that men classified as having the characteristics such as strength, high spirit, courage male / strength, confidence and capable of dealing with unexpected situation, regarded as a "heavy" worker. Generally and historically, only a few women choose careers as Orthopaedic Surgeon. My Orthopaedic Department has dominated by men, all 6 AMO are men who served as plaster technicians. Moreover, my Orthopaedic Department has only 4 female surgeons from the overall total of 25 orthopaedic surgeons. According to Orthopaedic Today (2007), statistics in last 30 years only showed increasing number of women orthopaedic surgeon from 3% to 11%.

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