Dr Gerard Panting discusses the six domains within professionalism, and emphasises the importance of setting and maintaining boundaries with patients


Professionalism is one of those words that crops up everywhere: everyone knows what it means although finding a consensus on a definition is elusive. Definitions aside, it is about adherence to an agreed and communicated set of standards, covering everything from dress code to compliance with clinical guidelines or even variation from them. Deviation from these standards can lead to allegations of unprofessional behaviour.

These issues were the focus of the National Clinical Assessment Service conference, Professionalism: dilemmas and lapses, held in March 2009.1 A guide drawing on the presentations and workshops at the conference—to be published in July 2009—will encapsulate the points that emerged on the day. It does not offer answers to every question, but identifies principles to guide individual professionals and those responsible for managing professionalism in practice.

Dr Deborah Bowman has developed a model of professionalism based on six domains (listed below), which together with leadership and probity comprise the core aspects of professionalism that doctors, their patients, and society as a whole expect their healthcare professionals to adhere to.1

Competence—this encompasses knowledge, skills, ethics, and their appropriate application in practice, which means that each GP’s competence has to be assessed against his or her own practice.

Interpersonal relationships and emotional function—the ability to communicate properly and work effectively in teams are self evidently crucial to good patient care.

Maintaining professional boundaries
Out of the six domains, this is the one that professionals seem to find most difficult in practice, especially when living and working in the same community. This domain is discussed in further detail below.

Consistency and reliability—infallibility is unattainable, but good practice requires an appropriate degree of care to be taken to prevent foreseeable and significant harm.

Reflection and learning—this entails keeping up to date and ensuring that all members within the team have the requisite skills to deliver high standards of care.

Commitment to service—this, in some respects, extends to an individual’s private behaviour; for example, contributing negative comments to social networking sites or belonging to organisations that colour the GP’s approach to patient care is not appropriate.

Professional boundaries

Not all transgressions of professional boundaries are deliberate, harmful, avoidable, or even inappropriate. Moreover, they may not always be the fault of the practitioner; some are instigated by managers and patients. In some instances, normal boundaries prevent provision of care and need to be crossed to achieve specific goals (e.g. home visits without a chaperone); these should be identified, so that appropriate safeguards can be put in place. These precautions might include prior agreement from relevant colleagues and supervisors or the maintenance of clear communication and a formal approach with patients. It is the deliberate or inadvertent crossing of boundaries through poor awareness, ulterior motives, or conflicting roles (e.g. managerial and social, or friend and patient) that can cause problems.

Boundary crossings can be instigated by the patient, either inadvertently or deliberately, or develop from unforeseen situations. Examples include meeting a patient unexpectedly at a social event or having to see a patient at home perhaps with the genuine need for an intimate examination or discussion.

Regardless of the circumstances and who is responsible for crossing the boundary, it is up to the healthcare professional to reset it. Failure to do so can damage the relationship with the patient, and worse still, hiding or ignoring it can lead to boundary violation.

The Clear Boundaries Project found that hazard areas for abuse included one-to-one encounters: intimate touch, confidential dialogue, and private settings.2 It was more likely for patients to be abused in obstetrics, gynaecology, general practice, psychiatry, psychology, and other talking therapies, and also in long-term care settings.2 However, the Project concluded that greater awareness of guidelines, sanctions, and targeted educational and training programmes all reduce prevalence rates.

A variety of warning signs may be noticed by colleagues—is the healthcare professional:

  • behaving differently towards this patient compared to others?
  • concerned about how the patient may be interpreting their actions?
  • acting based on patient needs?
  • reluctant to discuss some things about their work with a supervisor?
  • working beyond their competence?

Managing the risks associated with boundary crossings starts with awareness of the issue. An open environment allows situations with the potential for boundary crossings to be discussed, and measures taken to manage the perceived risk. In empathising with patients, it is easy to slip into making personal disclosures about similar situations encountered by the practitioner. This may seem innocent enough and may serve a purpose within the consultation and does not always leads to unexpected sequelae; however, in some cases it may be part of an inappropriate pattern of behaviour ultimately leading to patient harm. Practice policies on chaperoning, conducting physical examinations during home visits, and raising concerns where there are fears that professional boundaries are not being observed, all help to promote a safe environment for both patients and practitioners.2,3

Aside from the effect on the patient, abuse can have ramifications on the NHS organisations, including damage to the institution’s reputation, staff and relatives’ compensation claims, adverse effects of the associated publicity, and reduced trust amongst commissioners and other stakeholders.

Summary

Professionalism is at the heart of everything healthcare professionals do in their day-to-day practice. There have been many attempts to define it, none of which are perfect, but nevertheless disciplinary and legal procedures have been created around the perception of the expected norms of professional performance across all of the domains described previously. One of the greatest challenges is the maintenance of professional practice, including awareness of performance concerns in others. Identifying lapses earlier is important for everyone, as the sooner an issue is identified the earlier remedial steps can be taken, so improving the number of practitioners who can return to safe practice.

  1. NHS National Patient Safety Agency website. Conference reports (expected publication date July 2009) www.ncas.npsa.nhs.uk/trainingandevents/reports/
  2. Council for Healthcare Regulatory Excellence. Learning about sexual boundaries between healthcare professionals and patients: a report on education and training. London: CHRE, 2008. Available at: www.chre.org.uk/satellite/133/
  3. Council for Healthcare Regulatory Excellence. Clear sexual boundaries between healthcare professionals and patients: responsibilities of healthcare professionals. London: CHRE, 2008. Available at: www.chre.org.uk/satellite/133/G