An exploration of setting healthy personal boundaries as a veterinary professional. Part 2: how to set and maintain personal boundaries

Personal boundaries are the metaphorical behavioural and emotional walls we erect to help us maintain healthy relationships with our clients, colleagues, places of employment, friends and family. We need to draw boundaries when we judge our physical or psychological safety to be at risk. Where we construct our boundaries is unique to us based on own personality, ethics, values, priorities, life experiences, feelings and needs. Despite them being fundamentally important for our safety, many of us struggle with setting boundaries that would hugely benefit our wellbeing. This is the second in a two-part series that explores setting and maintaining healthy boundaries as a veterinary professional at work and beyond.

The approaches detailed in these articles draws from evidence-based practice in the disciplines of psychology (Maslow, 1943; Rosenberg, 2015), psychotherapy (Cloud and Townsend, 1992; Lerner, 2009), cognitive behavioural therapy (Tawab, 2021), life coaching (Levin, 2020; Wise, 2020), social work (Brown, 2015; 2018a) and human healthcare (Chen et al, 2018; Puder, 2018).

Some academic points are illustrated using examples from my personal experience. While this approach has helped me over the last 2 years as I learn to set and maintain healthy boundaries as a veterinary professional, I am conscious that the presentation of this information varies significantly across different authors, depending on what their priorities are. This subject is hugely important to our wellbeing and if the approach in this article does not speak to you, I would urge you to engage with the material through a different source.

The first article in this series outlined what a personal boundary is, why they are important, and discussed why veterinary professionals may find instigating them a challenge. This may be a result of veterinary professionals having compassion-driven personalities, or struggling with perfectionism or people pleasing. This second article will discuss how to instigate and maintain healthy personal boundaries and how these benefit us in veterinary practice.

How do you know when you need to set a boundary?

Figure 1 shows a comparison between Maslow's hierarchy of needs (Maslow, 1943) and Levin's boundary pyramid (Levin, 2020). Our survival may depend on our ‘bottom line’ boundaries being met. As our increasingly complex needs are met, we thrive and reach our full potential. Drawing boundaries allows us to meet our needs.

While it may be obvious that meeting our physiological and physical safety needs is a ‘bottom line boundary’, many of us in the veterinary profession have worked through sleep deprivation, often making us dangerously exhausted, and told ourselves that it made us tougher, or more conscientious, resilient or dedicated. Many of us have worked in situations where we did not feel safe, because we thought it was our job to do so. In addition to being dangerous, working without taking adequate rest leads to burnout: a state of emotional, physical, and mental exhaustion characterised by apathy and depression (Nagoski and Nagoski, 2020). It is important to be aware of the shadow beliefs we hold that result in our compliance and prevent us from taking action to look after ourselves. Our boundaries reflect our needs and as our more complex needs are met, we stop living in a state of survival and begin to thrive.

When in situations where we could benefit from setting a boundary, some people may become aware of particular physical sensations in their bodies (Tawab, 2021), such as:

• Tension in the shoulders
• Tightness in the chest or elevations in heart rate
• Physical manifestations of anxiety
• Physical manifestations of fear
• Sweaty or numb hands.

Many people have become disconnected from the feelings in their bodies and practicing mindfulness can be a useful tool in helping people to reconnect with themselves (NHS, 2018). Understanding and recognising the physical sensations that present themselves when we need to set a boundary is a useful first step (Tawab, 2021). However, some people find it easier to intellectualise the issue. Some questions that might be useful to ask yourself are:

• Am I physically and psychologically safe? Are my physiological needs being met?
• Do I like the person I am in this situation? Does this align with who I want to be and what I want to achieve in my life?
• If someone I loved was in this situation, what would I advise them to do?
• If this situation continues for a day/month/year/decade, what does it now look like, how do I feel, and will that meet my needs?
• If I use my energy in this way, what opportunity am I missing by not spending it another way; what is the opportunity cost?
• How do I feel and what do I need? What emotion/need is driving my behaviour?

Being aware of our feelings and needs can give us useful information about when we need to set a boundary. Being able to name our feelings and needs can help us to be more aware of them. Humans experience universal feelings and needs (Figures 2 and 3). Outwardly expressing our boundaries in terms of feelings and needs is not essential, and some people may perceive this as a demonstration of vulnerability with which they are not comfortable. However, it may be beneficial because while someone may not understand our situation, they may better understand what is it like to experience a particular feeling or need (Rosenberg, 2015); understanding fosters empathy and connection which increases the likelihood of our boundaries being respected.

Figure 2 shows the wheel of universal human needs (Stein, 2011a). The wheel is based on a non-violent communication model of universal human needs, which are the same for all humans (Rosenberg, 2015). By recognising that all human behaviour is driven by the same needs, it allows us to have a better understanding of ourselves and other people. This will aid us in expressing our boundaries.

Figure 3 shows the wheel of universal human feelings (Stein, 2011b). The wheel is based on a non-violent communication model of feelings that are felt by all humans as a result of universal human needs (Rosenberg, 2015). All human behaviour is driven by our feelings and needs. Understanding and processing our feelings gives us useful information about where we should draw our boundaries.

How do we set up healthy boundaries?

When we start setting boundaries, we may meet resistance from individuals or organisations who benefit from maintaining the status quo (Cloud and Townsend, 1992). If the status quo is unsustainable for us, we need to instigate a self-protective boundary, whatever their thoughts or feelings. Relationships may consequently change (or end), but by setting personal boundaries we will set higher standards for how we want to be treated moving forward.

When we start to assert our boundaries, people may be confused and feel vulnerable following the change and what they perceive as inconsistency in our behaviour. They may then ‘act out’ these emotions to try to maintain the status quo, and it can be hard to maintain our position in the face of this potential unpleasantness (Lerner, 2009). Their behaviour is a reflection of their needs which are not within our boundary. If a relationship cannot continue to function once we have instigated boundaries to protect ourselves physically and psychologically, then this relationship will inevitably have to end.

Some individuals may benefit from therapy to establish why they find setting boundaries challenging. Life coaching can also help us to define our core values and implement boundaries going forward (Levin, 2020). We may even want to recruit someone we trust to be an accountability partner. Accountability involves feedback that is constructive and focuses on problem solving and self-improvement, rather than attributing blame and subsequent shame. We could also consider a clinical supervision model similar to that used in psychotherapy, which allows caregivers to process their emotions, needs and behaviours around their work (Snowdon et al, 2017). If the thought of instigating boundaries produces extreme anxiety or physiological symptoms, we may want to discuss this with a trained medical professional.

Identify the situation or person that we need to set a boundary with

Initially we need to ask who or what we struggle to say ‘no’ to? Ask when do we say ‘yes’ when we want to say ‘no’? We may come to this information mindfully through being aware of our body, or cognitively come to the conclusion.

Pause and think

It can be useful to stop to consider why we are struggling to draw a boundary and to consider what consequences we are afraid of. It is useful to have a pre-programmed response such as ‘I will get back to you later’ to enable you to consider what kind of response would help you meet your goals in this situation. What is the opportunity cost of using your resources in this way? You may benefit from discussing it with a safe person or accountability partner.

Identify the ‘reality versus expectation gap’?

Sometimes a boundary violation is actually an opportunity to have a conversation and clarify everyone's expectations. We may feel frustrated because our expectations appear different to the reality of the situation, but once we have asked for clarity it may transpire that this is not the case. What is the ‘reality versus expectation gap’? Our choices should be based on information and not assumptions. After a discussion, the issue may be resolved without requiring us to enforce any boundaries.

A four step boundary template: it starts with ‘me’

Setting a boundary involves a calmly considered request for change to ensure our wellbeing and an assertion of what we will do if this is not met (Table 1). We may set boundaries in the moment, in advance or on returning to the conversation after a period of reflection. Table 1 shows a worked example comparing different ways of communicating a boundary. These examples may be more verbose and formulaic than required to illustrate the process of breaking down boundary setting.

The example shows that punishment is something you do to someone else to force them to comply, as opposed to protective action which is something you do to protect yourself. There may be situations where you judge demands and punishment to be a more appropriate response than boundary setting, and that decision is within your boundary.

If the receiver believes they will be blamed or punished if they do not comply with our request, then it will be perceived as a demand, giving them the choice of either submission or rebellion (Rosenberg, 2015). Consequently, demands have the capacity to escalate a situation or build resentment in the receiver, neither of which is conducive to maintaining a long-term healthy relationship, and the receiver is less likely to meet the request.

Step 1: it's about me statement

To introduce a boundary, we start with an ‘it's about me statement’: talk about specifics as precisely as possible – avoid the temptation to generalise. Our boundary is about what we feel and need in each situation and could be introduced by: ‘When I observe … I feel… because I need…’.

Step 2. A request for a change in behaviour

Second, we request the specific behaviour change we would like and state how it will benefit us if this boundary is upheld. This may be expressed as: ‘Would you be willing to (request behaviour change)… because … I feel… and I need…’.

If the receiver believes they will be blamed or punished if they do not comply with our request, then it will be perceived as a demand, giving them the choice of either submission or rebellion (Rosenberg, 2015). Consequently, demands have the capacity to escalate a situation or build resentment in the receiver, neither of which is conducive to maintaining a long-term healthy relationship, and the receiver is less likely to meet the request.

Step 3: state your protective action

Third, we need to articulate what we are going to do to ensure our wellbeing if our request is not met. Our protective action is about our safety and is not to punish or coerce another person to change their behaviour. This could be expressed as: ‘If you do not (requested behaviour change) … I will do (actions to ensure my wellbeing) because …. I feel… and I need…’.

Following step 3, we may feel internal pressure to fall back to previous behavioural habits and to further explain or justify our position. However, there is nothing further we need to say: how the receiver thinks, feels and responds is about them and their needs, and this is not within our control nor is it our responsibility to manage.

Do not state a protective action that you do not want to follow through on or that does not address your feelings and needs. For example, someone may ask for flea treatment out of hours and you agree but only if they pay the out of hours call out fee, but if you do not want to go into work because what you really need is rest rather than financial gain, then you will still feel resentment and have not created an effective boundary.

If we are unable to identify a protective action, it may be that this situation does not really impact our psychological or physical safety. Ask whether this is really an opportunity to have a conversation to clarify everyone's expectations? Alternatively, we may need to spend some time reflecting on what we feel and need in the situation, in order to ensure that we can identify a protective action going forward.

Step 4: following through on our protective action and boundary violations

Boundary setting is not about manipulating or punishing the behaviour of others, and we have no control over whether someone will change their behaviour as we have requested. We do have control over what we then do to ensure our wellbeing, and it is important to follow through on our protective action. When we do not follow through, we violate our own boundary which can lead to feelings of helplessness and reduce self-confidence and self-esteem (Wise, 2020).

‘Holding the line’ requires practice and repetition. When we have not followed through on our boundaries, it is important to notice this non-judgmentally and then try again (C. Knottenbelt, personal communication, 2021). When we judge ourselves negatively for ‘failing’ to follow through on our boundary, we blame and shame ourselves and when we are in this mental state, our chances of future success are diminished.

In human medicine, the failure of clinicians to hold to their boundaries can result in emotional distress (Chen et al, 2018). This may be acute, resulting in anxiety and feelings of being overwhelmed or overstimulated or it may be chronic, leading to compassion fatigue, burnout, numbness, depersonalisation, substance misuse and suicidal ideations or actions.

For patients, boundary violations can result in them having unrealistic expectations of clinical availability or the role of medical providers and may also lead to patients having an unhealthy dependency on the clinician resulting in learned helplessness, anxiety, depression and reduced self-esteem and self-confidence (Chen et al, 2018). While this does not directly apply to our veterinary patients, it applies to our clients and shows that ‘holding the line’ in the veterinary professionalclient relationship helps to make clear expectations that benefit all stakeholders.

Drawing compassionate boundaries

‘No’ is a complete sentence. You owe no one an explanation for your boundaries. If your immediate mental or physical safety is in jeopardy, then there is no need to enter a conversation. However, if you have the capacity, you may choose to engage further. For compassion-driven people, learning to draw compassionate boundaries may help them instigate boundaries where they have previously been unable to. In the words of compassion and shame researcher Brene Brown, “When we combine the courage to make clear what works for us and what doesn't with the compassion to assume people are doing their best, our lives change. Yes, there will be people who violate our boundaries, and yes this will require that we continue to hold those people accountable. But when we're living in our integrity, we're strengthened by the self-respect that comes from the honouring of our boundaries, rather than being flattened by disappointment and resentment” (Brown, 2015).

Compassion is not a ‘zero sum game’ (Haga, 2020); when you have compassion for yourself and your boundaries, this does not mean you cannot have compassion for the person impinging on them.

Compassionately expressing our boundaries can further strengthen relationships through creating sustainable empathetic human connections. One framework we can use to compassionately express boundaries is nonviolent communication; an empathy-based form of communication based on the teachings of Dr Martin Luther King (Ludford, 2021). Understanding that humans have universal feelings and needs (Figures 2 and 3) forms the foundation of non-violent communication. Before expressing our boundaries, it may help to acknowledge the other person's position: their behaviour, which is infringing upon our boundaries, is a result of them addressing their own feelings and needs. The practice of verbally reflecting the observations, feelings, needs and requests of another is referred to as ‘receiving empathetically’ (Rosenberg, 2015). Having had their position understood, people may be more open to respecting our boundary requests and meeting their needs in another way. Setting boundaries helps us maintain heathy relationships and doing this compassionately may help to further strengthen these connections.

Undermining behaviour and bullying

We are not obliged to respect other people's boundaries. However, taking advantage of people who are struggling to maintain boundaries in order to coerce them to change their behaviour is bullying. Attempting to prevent someone from honouring their boundaries is trying to manipulate them into a position in which they are not safe. Assuming it is solely the victim's responsibility for their uncomfortable situation is victim blaming and prevents the perpetrator taking responsibility for their behaviour, or considering how they are being perceived. The Royal College of Surgeons of Edinburgh's (2020) anti-bullying and undermining campaign states that bullying has a negative impact on individuals, teams and patient safety in human healthcare and they encourage people to self-reflect on how their behaviour might impact others. One example among veterinary professionals is the pervasive belief that ‘I had it tough, so you should too’. If at any point in your career you were in a situation where you were not physically or psychologically safe, this was a violation of your boundaries. Propagating this narrative will not help you heal from this trauma and will only serve to repeat the cycle in the next generation of veterinary professionals.

Drawing personal boundaries and patient outcomes

There have been many studies in human healthcare demonstrating that empathy and compassion have a positive impact on patient outcomes through better treatment compliance, a reduction in complaints, fewer mistakes and increased patient satisfaction (Del Canale et al, 2012; Flickinger et al, 2016; Howick et al, 2018). However, without the ability to draw personal boundaries, compassion and empathy are unsustainable and result in stress, burnout and poor mental health (Puder, 2018).

Boundaries are a fundamental aspect of trust in relationships. Using grounded theory qualitative analysis, Brene Brown established seven components of trust, which can be presented as the acronym ‘BRAVING’ (Table 2). For trust in a relationship, we need to make our own boundaries clear and respect the boundaries of another. If we are unsure of where these boundaries lie, we can ask for clarification. In human healthcare, trust between team members has been demonstrated to positively affect team performance, improve case outcomes and patient safety, and reduce procedural complications and mortality rates (Sifaki-Pistolla et al, 2020).

Teaching personal boundaries to the next generation of veterinary professionals

Chen et al (2018) argue that clinical and personal boundaries are closely related and that developing healthy personal, as well as clinical boundaries is integral to mature professional practice in human healthcare. However, this is an area lacking in both the human and veterinary medicine curriculum. Chen et al (2018) reflected that resistance to teaching students personal boundaries may stem from the concern that encouraging them to prioritise self-care will ‘coddle’ students and that it does not fit with the idealised model of the ‘country physician, which demands that the physician is constantly available. Poor work-life boundaries have been linked to burnout, substance abuse and suicide in doctors (Shanafelt et al, 2017), as well as martyrdom or even masochism (Weissman, 2011).

Culturally, the belief that students, interns and residents will be present at all hours if they are committed to their education is still pervasive, as is the belief that veterinary professionals should not draw boundaries to protect their personal (non-work) time (Holowaychuk, 2018). Rest is a physiological need and play is essential for our mental health; foregoing these for more work time can result in chronic stress, which may affect both physical and mental health (Maté, 2019).

Nagoski and Nagoski (2020) suggest that 42% of our time should be spent attending to our physiological needs, such as sleep, rest, exercise, food and human connection. Continual failure to meet these needs is unsustainable and leads to burnout. It may be that, on a particular occasion, sacrificing this time for a learning experience does serve us, but this should be a conscious choice by someone who is in touch with what they feel and need in that moment, not an institutional expectation. For example, if an organisation's staff rota is set up so that it cannot fully function without veterinary nursing students working into their free time, this creates an institutional expectation that students should not draw protective boundaries around their personal time. Consequently, if the students refuse to work overtime, then they may be perceived negatively because the system results in the needs of the rest of the team being unmet.

Penalising someone for drawing a boundary because their need for rest is greater in that moment then their need for active learning is not respecting their boundaries. As veterinary professionals, we need to learn to identify and accept our individual limits and clearly express when we need to draw a boundary to ensure we get what we need and live sustainably (Holowaychuk, 2018). Following through on our boundaries to ensure a healthy work–life balance will enhance our lives both professionally and personally and help to ensure a sustainable living and learning trajectory.

I propose that one thing that might help us to retain the next generation of veterinary professionals is to teach them that's it's okay to say ‘no.’ Boundaries are a fundamental aspect of trust in our relationships with our colleagues, clients, family and friends.

Conclusions

A personal boundary is a metaphorical, behavioural or emotional wall we erect to ensure that our needs for physical and psychological safety are met. Where we erect these boundaries is specific to us based on our ethics, values, priorities, experiences, feelings and needs. Being able to clearly express our boundaries helps us to maintain healthy relationships, which improves our mental health and protects our physical safety. Boundaries allow us to sustainably behave compassionately and build trust in our veterinary teams. Both trust and compassion have positive effects on patient outcomes in human healthcare. One way to express our boundaries is through a 4-part boundary template:

• ‘It's about me’ statement
• Request for a change in behaviour
• State our protective action
• Following through.

We may choose to instigate our boundaries compassionately. We should consider teaching healthy personal boundary setting to the next generation of veterinary professionals because it has benefits for physical and mental health, and may help with staff retention.

KEY POINTS

• Healthy personal boundaries help us to maintain healthy relationships. We create boundaries to protect ourselves from physical and psychological harm. Where our boundaries are erected is unique to us based on our own personality, ethics, values, priorities, life experiences, feelings and needs.
• To understand when we should draw a boundary, we may benefit from therapy to help us understand why we find boundary setting challenging, or life coaching to help us implement our boundaries going forward.
• We are responsible for our own behaviour. When we choose not to respect the boundaries of another person this will result in them being physically or psychologically unsafe. This is bullying.
• Healthy personal boundaries will allow us to practice compassion sustainably in our relationships and creates trust in veterinary teams. Trust and compassion have positive effects on patient outcomes in healthcare.
• Teaching healthy personal boundary setting to the next generation of veterinary professionals may help with professional retention.