Territorial wars, imaginary boundaries and the patient journey

This blog is personal and some will have a problem with me writing about it, truth is I will probably end up in some trouble for posting this.

For most of my career I have had a foot in two worlds.  One world is inside of a hospital as a highly specialised nurse with the other world being out of hospital as an ambulance practitioner.  These worlds are governed by separate bodies with different regulations and scopes of practise.  The sad part is that these governing bodies do not recognise the other’s training, skills or competencies.

For example as undergraduate nurse I had to demonstrate competency in intubation and I had to demonstrate it again as critical care nurse student.  As critical care nurse and educator I have been involved in training paramedics, medical students and nurses to perform this and other skills.  In one of my previous jobs I was required to demonstrate proof of intubation competency on a yearly basis.  However as ambulance practitioner I am not allowed to intubate a patient as the governing body and ambulance act do not recognise my nursing competency or scope of practice.

Recently…in my private vehicle, dressed for a business meeting I came across a patient.  There was an airway problem and there was equipment on scene to intubate and resolve the airway problem.  No one else on scene was skilled to intubate. Just to reiterate…intubation is a skill that I’m deemed competent to perform, it falls within my scope of nursing practice, I have experience executing the skill and I’ve taught paramedics and medical students to perform it.  The problem was that I was in the wrong territory where none of the before mentioned are recognised… yet I treated the patient based on my nursing scope, competencies and also my conscience.

That I resolved the airway issue and that we could now ventilate the patient, appears to be a non-factor…. a formal complaint was laid against me for treating the patient according to my nursing scope in paramedic territory.  I see the enquiry as a suggestion from my paramedic colleagues that the acceptable patient management would’ve been to continue non-ventilating the patient and as such withhold that fighting chance for survival.  Why?  Because of territory…

The irony is…if I did that, if I managed the patient according to my out of hospital (ambulance practitioner) scope, if I did not intubate, if I disregarded my nursing scope, training and experience, the nursing board would’ve (rightfully) take action against me for negligence.

This territorial fight is not ok; it is not ok to say that a patient should rather die than recognise our colleague’s competencies in our territory.

Healthcare is defined as a series of interconnected processes and the end product which is the healthy patient. Are we nurses and paramedics not bound in this definition of healthcare and in the patient journey? If the reason for the existence of the healthcare system is a healthy patient would it not be in the patient’s best interest that practitioners capable of executing a skill being allowed to execute it based on patient requirement regardless of territory?

There seems to be an absolute conviction that healthcare is territorial and divided.  I believe that healthcare is one.  No function in healthcare can stand alone, and neither should they.  When we fight about territories we create barriers between functions that are dependent on each other. The compelling context that glues us together should be the patient and a shared interest in the patient journey.

In healthcare our governing bodies create the boundaries, these are typically functional boundaries.  In other words the boundaries groups specialised functions together to better manage them.   So the boundary of where we practice is actually arbitrary.  And yet, time and again we find ourselves trapped and our patient care crippled by these boundaries and even worse we allow the boundaries to create territories, that is fiercely protected.  It is so fiercely protected that we start believing that it is fair to withhold life saving measures from patients due to functional territory.

Regardless of speciality, field of practice or board that we belong to, we should never settle for less than the best possible patient outcome within our scope and competency regardless of where we are. Because if we don’t, we fail to understand our interdependency.   How can we not share the one goal of health care which is a healthy patient as outcome?

How can any practitioner be conditioned to think that it’s in the patient’s best interest to let them die rather than allow a competent colleague to practise within their territory? Sounds like sick system….


Pre-empting comments on scope:  My scope as per the South African Nursing Council. (http://www.sanc.org.za)   



Critical Care Nursing is care of patients with life-threatening illnesses and injuries and it occurs within a continuum from the scene of initial incident or onset of critical illness such as home through stabilisation, transfer/transportation, emergency and intensive care up to and including transfer to care in lower acuity levels/ step down units.

Specific competencies

2.4.3 Executes airway management in accordance with the patients’ needs or state of respiratory failure, e.g. position, anatomical alignment……….. including intubation (oropharyngeal, nasopharyngeal, endotracheal)

2.4.7 Initiates/performs advanced resuscitative procedures informed by the patient’s cardiopulmonary status and technological parameters, using advanced airway management techniques, cardioversion, defibrillation, external cardiac pacing and emergency drugs, among others, as spelt out in the care management tools such as protocols or Advanced Cardiac Life Support (ACLS) algorithm

9 thoughts on “Territorial wars, imaginary boundaries and the patient journey

  1. The paramedic who layed a charge against you should be sat down, and given the reasonable man test!. As a paramedic of 25 years experience I stand by what you did, the patient came first!!! did the insecure paramedic who is offended that you crossed over into his territory not get the just of emergency medicine, the patient comes first. There is no need for this kind of petty behaviour by paramedics towards nursing sisters, we all benefit mutually by sharing our knowledge A recent case in Johannesburg, where a Btech refused to hand over a patient to a CCA was over ruled by the HPCSA. The after math of this case has done nothing to strengthen the ties between the various fragmented paramedical professional but rather inflamed the situation even more. There is no space for so called medical professionals to incite this kind of behaviour. He clearly also forgot the first law of medicine, First do no harm!!! what harm were you doing by maintaining his airway !! He needs to address his insecurity issues, there are trained medical professionals for just that


  2. I doubt the HPCSA PBECP will even entertain his charge once they evaluate the complaint against your response. If they are foolish to proceed, they stand zero chance of success. The HPCSA Act makes provision for emergency situations to perform procedures out of scope of protocol.


  3. Thank you for the replies. A key aspect for me is that it goes both ways. Paramedics are at times treated poorly by nurses in hospital and questioned on treatment etc. It should be about the patient as opposed to ego’s and territories. This paramedic is acting on a preconditioned (and prevalent) belief as does nurses (and doctors) about ambulance drivers. We should break these territories down by focusing on the patient. I must also thank all the paramedics that has retweeted this post. The support from paramedics has been amazing.


  4. This territorial war is so true, and I have experienced it in many ways across my travels in Africa. It bothered me so much, that I actually did my dissertation on something similar. How do we fix this?


    • We need to keep pushing against the system and speak up. Some Universities has started interdisciplinary courses that allows the different disciplines to work and learn together prior to entering the workplace. It might break down some boundaries, but it will take years before we see that in the workplace. I also think that we need to teach people to value their own contributions and flatten hierarchies in healthcare.


  5. Thank you for having the courage of your convictions to place patient care first, it is a rare trait in today’s world. Yes the system is broken at so many levels and I see no way how it will be fixed in the immediate future, until that happens it will take brave and courageous practitioners to place patient care at the forefront of the fight, and rudely push politics, ego’s and non-aligned protocols/councils and scope of practise aside. Sadly the EMS profession is in a very turbulent place and until real leaders stand up we will continue to have battles waged about issues other than putting the patient first. Thanks for a thought provoking article.


    • Hi

      Thank you, I sometimes wonder about that thin line between courage and being silly! I do however feel that one has to raise these issues so that we can talk about it and improve things!

      Tell me more about the editorial?

      I must be honest, working both pre-hospital and in-hospital, that EMS is still much ‘easier’ from a bureaucracy and administrative point of view. Bu definitely heading in the same direction

      Have an awesome day in the Congo!


      Charmaine Cunningham ccharmaine@live.co.za 082 450 6689 @cunningham_char Blog: chacunningham.wordpress.com


      Liked by 1 person

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