Boundaries and Professional Wellbeing

How Does a PA Craft Healthy Boundaries?

By Jennifer Hohman

It might be said that all healthy relationships involve strong boundaries. Boundaries allow one to say “no” when something is not right, personally or professionally, (and therefore imbues “yes” with depth, conviction, and enthusiasm). In professional practice, how does a PA craft healthy boundaries, even as the PA role is so involved with being a team player and being adaptable in response to the needs/demands/expectations of employers?

In this article, I’d like to discuss some of the interpersonal and professional dynamics observed when helping clients to navigate challenging team practice situations, and argue in favor of the importance of boundaries as part of a healthy PA career with some suggestions for establishing and maintaining them.

Contracts: Frameworks for Professional Protection

Essential professional boundaries are defined (or left undefined) during contract negotiation. A contract creates a legal framework for your employment relationship, and that framework has much to do with boundaries: what you agree is acceptable, and, by implication, what is not. This includes the specifics of your compensation and benefits, your scheduled availability and guaranteed time off, any stipulations about where you can work after you leave the job, and more. The contract negotiation process also helps establish the employer’s understanding that you intend to be an active agent of your professional wellbeing.

The negotiation process is an important one for asserting your vision of a fair and sustainable offer. Knowing your walk-away points during the negotiation process is a crucial means of asserting boundaries: the ability to say “no” to an offer that does not reflect your value or support work/life balance. I especially recommend that new graduates evaluate their first contracts with a constructively critical eye: I’ve spoken to many new graduates over the years who regretted signing contracts that did not protect their interests and were searching for a new position as a result. In the understandable eagerness to land a first job, take care not to accept one whose terms are not sustainable.

Professional and Ethical Boundaries

Studies have found that one of the key rewards of PA practice (reflected in high rates of professional satisfaction overall) is providing personalized, empowering care to patients. The unfortunate reality is that some employers do not share this philosophy of medicine and press PA employees to prioritize efficiency over individualized care. It will be up to each PA in this situation to gauge whether they can provide treatment up to their personal standards or if those standards are impossibly compromised by the employer’s bottom-line oriented expectations.

In yet more problematic situations, some employers demand that PA employees prescribe or otherwise practice in a manner that keeps the business busy and lucrative but is clearly not in the interests of the patients. Keeping careful documentation is key in these situations. AAPA’s Guidelines for Ethical Conduct of the PA Profession is an excellent professional resource for guidance and support should you find yourself in an ethically questionable workplace. There comes a point where the conflict in values and ethics requires leaving the job. It’s best to create an exit plan in these situations as they do not improve over time.

Work and Well Being

I frequently speak with PAs who have unsustainable schedules, prompting their interest in help with a job search that would yield a better quality of life. Negotiating a contract that stipulates a fair and manageable schedule, ideally including a maximum number of hours per week along with paid vacation and sick leave in line with AAPA’s Salary Report fringe benefits data is one way of preventing overwork and burnout.

Negotiating your availability and having that agreement in writing offers legal protection and peace of mind—don’t be afraid to speak up and reference your agreement if an employer “forgets” or otherwise tries to override the contract. Contracts are two-way agreements with obligations on both sides. An employer who ignores their agreements or otherwise violates professional boundaries and respect undermines the trust and reciprocity that make the PA practice model work. In short, they may be creating a toxic practice environment.

Over the years I’ve spoken with many PAs who were trying their best to make a dysfunctional team practice relationship work. In many of these situations, their personal boundaries were violated through abusive behavior–angry, insulting, and belittling–directed at them from supervising physicians (and sometimes in concert with practice managers or other staff). PAs tend to be amazingly resourceful, intent on making the best of even very challenging situations.

That said, I’ve really never seen an instance where a toxic workplace relationship dynamic was salvageable, despite the efforts of a PA to make things “work.” The axiom that PA’s quality of professional life is closely linked to the quality of their professional relationships is proven in these situations, and it really helps to talk about what you are experiencing with trusted friends and peers should you find yourself in an abusive workplace. Overcoming the feelings of isolation felt in a toxic work setting by reaching out for support is an essential first step. In doing so, it becomes easier to identify the problem and move towards a healthier work situation.

Symptoms of an Abusive Workplace:

Do you feel like your contributions, efforts, and concerns are ignored?

Are you subject to verbal abuse? Threats or coercion of any kind?

Do you feel burned out? Are you questioning your choice of profession?

Are you expected to put profits above patients? To engage in unethical conduct or ignore it?

Is your collaborating physician unable or unwilling to carry out their responsibilities as part of the clinical team? Do they criticize you for consulting with them when you feel it is in the best interest of patients to do so? Conversely, do they micromanage your work and doubt your abilities? Do you feel scapegoated or caught between opposing factions in your practice or institution?

Are agreements made to you being broken—whether as elements of your employment contract, a promise to review and update your compensation?

Do you have trouble sleeping and dread the upcoming work week?

In conclusion, all PAs deserve a workplace where they are respected, feel safe, and where they can practice patient-centered medicine. Standing up for your professional wellbeing will have a positive ripple effect on PA peers—and fighting for sustainable employment also benefits patients.

Jennifer Anne Hohman is founder of PA Career Coach, a service dedicated to helping PAs create healthy and sustainable careers. Contact her at [email protected].

Thank you for your interest!

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