Professional boundaries in
Karen Cox and Veronica James
A boundary is a demarcation of some kind. Specialist palliative care is a small but important area in the growing complexity of bounded, community and acute care provision. It is an area which, with the patient and family seen as a whole unit, prides itself on the delivery of care through multidisciplinary teamwork. Thus, from the beginning, a tension arises. Patients and families want us to see them as a whole, and work in collaboration with them to meet a range of changing physical, psychological and domestic needs. They also want us to work with each other, seamlessly across the boundaries of general services and specialisms, acute and community, professions and organizations, without bands of fragmented specialists marching up the path. There is a danger that, despite a notion of teamwork, organizational fragmentation overrides the core purposes of palliative care – the central work with patients, or users, and families. Obviously, there must be considerable numbers of people, often working part-time, involved in running any 24-hour service efficiently and effectively. Yet the greater the number and types of professions and occupations, the greater the demarcations – and the greater the need for a team approach. So how should lay and professional expertise, community and in-patient organizations, and curative and palliative care intersect to focus on the family as the unit of care?
In this chapter, we explore the concepts of boundaries, roles and teamworking within which palliative care is delivered. We first consider the definitions of team and teamwork. Both these terms conjure up images of positive working relationships and a shared common goal. However, teams are complex and the work of the team in palliative care needs to be centrally concerned with the patient (or user) and family as key team players, albeit with a variable interest in decision making. Other members of the team, affected by funding, political and organizational agendas, contribute within the context of committed professional and occupational teams, intra- and inter-team boundaries, and external influences. We