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A GREAT deal of resource is
invested in the area of
concordance and compliance
within human medical spheres, as
non-adherence to a doctor's
recommendations has a major
negative impact on individual and
public health.
However, it's rare that, within the
animal health profession, we focus on
these areas, the success of which
wholly depends upon our
communication skills. This article
argues for a
greater focus
and looks at
what needs to
be done to
begin closing
the
"compliancy
gap".

So what does "concordance and
compliance" actually mean?
Concordance is defined as an
agreement between a veterinary team
and their client in relation to
treatment. Essentially, it can be
summed up as shared decision
making.

The good news is that the practice
also benefits. Improved concordance
and compliance result in a greater
level of job satisfaction amongst staff,
which usually means happier,
motivated colleagues and a more
cohesive team. By virtue of the fact
that clients are happier too,
recommendations increase and the
practice can secure new clients whilst
reaping the financial rewards of
increased client visits and follow
through.

Total compliance can turn a good
practice into a very successful
business but in order to strive towards
this goal, practices need to go far
further than simply printing legible
prescription labels!

Practices need to ensure there is
effective and efficient communication
before, during and after treatment has
been agreed upon.
Measuring

In human medical fields, compliance
is frequently measured. On average,
compliance with human medicine is
between 15% and 50%. However,
adherence to recommendations in
lifestyle changes - such as dieting -
can be lower. It's fair to say that
compliance tends to be higher with
more severe conditions, and lower in
perceived less important situations.

Unfortunately, very few veterinary
practices measure concordance and
compliance and, if they do, it is only
with very few services and products.
But if we don't measure it, how can
we possibly manage it effectively?

Interestingly, where veterinary data
do exist, figures tend to mirror the
above at between 15% and 60%
which suggests there is a real
opportunity for practices to benefit
from a focus on compliance.

If, for example, a practice
turnover per vet was £240,000 (with
each vet having 1,436 active patients)
and if the average pet was (bear with
me!) a cross between a 30kg dog and
a 4kg cat, what would the turnover
per vet be if all patients were
vaccinated, received regular worm and
flea treatment and were fed on a
premium dry food purchased from
the practice?

If you have an 86% response to
vaccine reminder letters, your
compliance rate, more or less, is 86%.
Great! However, how would you
interpret data from your practice
management system reporting that in
the last 12 months 16% of canine
patients received dental treatment? Is
this a good result and/or a healthy
measure of
compliance?

In terms of
success, it could either
be an excellent result
if, for example, no dog
owners received any
recommendations to
have their pets' mouths
attended to; or it could
be a terrible result if
all dog owners who
came through the
consulting room door
received advice regarding the state of
their pet's mouth. In any case, it is not
a measure of compliance.

Could you be SMARTER in
managing and measuring your
dentals? For example, perhaps you
could agree categories of tooth and
gum disease and create codes for each
category. From this, you could then
agree a course of action for each
category and examine every patient's
mouth over a given period (such as
Pet Smile Month) and better manage
the results.
Closing the compliancy gap

So what are the main factors which
can help your practice to reduce its
compliancy gap? Firstly, strong
practice management. A practice
needs a business plan in place with
efficient processes to measure and
track compliance - ideally
benchmarking against previous years/quarters.

Processes also need to be rigorous - with clear standard operating
procedures that all team members buy
into. These processes will ensure
individuals are well versed in
encouraging repeat visits and
implementing efficient reminder
systems.

A vet's behaviour also impacts on
compliance. Careful consideration
needs to be given to the choices
presented to clients during a consult
and appropriate levels of information
should always be provided to ensure
understanding.

Summarising what is said during
the consultation can also be helpful in
boosting client understanding, whilst
providing clients with a "safety net"
will encourage all clients to repeat
visit, irrespective of their initial level
of co-operation.

Trust is everything. Clients need
to believe that your aim is to get their
pet as well as possible, as quickly as
possible, as easily as possible and as
cheaply as possible.

It is a common misconception
that financial concerns are the main factor for poor uptake
of veterinary services
and products.

Indeed, in a recent
study, only 7%
declined dental
treatment on cost
factors, only 4%
stopped diet treatment
due to cost and only
5% abandoned senior
pet screening due to
financial constraints.

Clients frequently
have a very strong pet
bond and owners essentially want the best possible care
for their animals but they need to be
involved in that initial decision
making process and communicated
with regularly to be sure of
compliance.

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A GREAT deal of resource is invested in the area of concordance and compliance within human medical spheres, as non-adherence to a doctor's recommendations has a major negative impact on individual and public health. However, it's rare that, within the animal health profession, we focus on these areas, the success of which wholly depends upon [...]

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The role of the veterinary nurse in homecare for the cardiac patient - The Veterinary Nurse

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Home care for patients with cardiac disease which is life-limiting is palliative by nature. Palliative care can be defined as relieving or soothing the symptoms of a disease or disorder at any stage of an illness (Shanan et al, 2020).

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How well do you know your patient? The need for nursing assessment Hilary Orpet - British Veterinary Nursing Association

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ABSTRACT: Nursing assessment is currently under-utilised in many veterinary practices. One of the primary roles of the veterinary nurse is […]

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Vet Nurse role in client compl/concordance

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Case study: a critical reflection of implementing a nursing care plan for two hospitalized patients - The Veterinary Nurse

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Fundamentally, a nursing model is ‘a collection of ideas, beliefs and values about the nature and purpose of nursing, which influence the way in which nurses work with their patients’ (Davis, 2007: 98). In selecting a model of nursing care, the author felt it was important that the ideas, beliefs and values of the model closely resembled her own view of veterinary nursing.

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Client compliance is often one of our greatest obstacles as veterinary professionals. A study released by the American Animal Hospital Association (AAHA) in 2003 revealed that client compliance is as low as 17% to 35% for important veterinary care such as senior screenings, therapeutic diets, dental care, and heartworm preventives. ¹ Client compliance also happens to be one of the most important factors for a patient's successful recovery following surgery.

Advanced procedures such as an orthopedic surgery or neurosurgery often require more extensive, long-term postoperative care for the owner to perform at home. Because of this, additional consideration must be taken to make sure the client is thoroughly educated on what home life may look like as their pet recovers from these procedures. As veterinary nurses, relaying and decoding much of this information such as restrictions, or bandage care, exercise rehabilitation exercises is often our responsibility. Understanding complex instruction for life at home in these situations can be challenging, not to mention intimidating, for the pet owner. Improving your clinic's ability to provide thoughtful, detailed postoperative instruction helps to ensure a more smooth recovery for the pet, the owner, and your clinic.

Effective Communication is Key

Since many postsurgical discharges require extensive information for the owner, it may seem best to keep things simple in order to avoid confusing the owner during an already overwhelming situation. However, it is important to remember that much of the information we are asking them to absorb is not so simple or straightforward to a layperson, and the ability for us to relay this information effectively can often mean the difference between surgical success and failure. For intensive surgeries such as a limb fracture repair or a decompressive spinal cord procedure, patient recommendations can easily seem demanding, confusing, and overwhelming to take home. Major changes to the lifestyle of both the owner and pet are at play during the recovery period, which often includes expecting the owner to perform extensive daily tasks such as frequent medication administration, rehabilitation exercises, recumbency care, and bladder expression. So while we should want to communicate with the client in concise terms, spending extra time and attention to add detail and explanation will help the client feel adequately informed and empowered to carry out the recommendations at home.

Communication is key in these situations, and becoming comfortable relaying instruction takes practice, knowledge, and understanding. Remember that the core rules of effective communication such as eye contact, slower speaking pace, and leaving space for the client to ask questions are critical to articulating information successfully. To take your communication skills a step further, consider these strategies when discussing postoperative concerns.

Provide Adequate Preparation. Every client should know the full scope of the surgical process prior to consenting to their pet's procedure. Providing a clear expectation of possible complications, restrictions, at-home changes, timelines, and prognosis at the outset helps the pet owner make well-informed decisions and become more prepared for the months to come.

Similarly, you should also advise the client to expect a longer visit when it comes time for the animal to be discharged to allow the time needed to discuss instructions for at-home care thoroughly. The more information you are providing ahead of time, the more prepared the client will be when it comes time for the animal to go home. Consider offering advice that would help make their transition easier from the moment they leave the hospital, such as suggesting they bring along a crate in the car for safer transport or an additional person for help.

Set Aside the Time. It is often easy for veterinary nurses to get overloaded with tasks; we can find ourselves rushing through a discharge because we simply do not have the time, leaving opportunity for important instructions or questions to be omitted or insufficiently discussed. This does not result in good medicine and is never in the best interest of the patient. If ensuring you have adequate time to spend with the client is a tall order to fulfill in your clinic, you might consider setting aside a regular appointment time slot for these discharges where no other visits are seen, allowing for sufficient available staff and time in the schedule. These discussions are often lengthy, especially when the owner has many questions, so in order to ensure that neither party feels rushed, the clinic must first make it a priority to fit it into the schedule appropriately.

Provide Visit Summary Paperwork. Providing postoperative instruction in writing should be a standard in any clinic, as the client will use it for reference once at home. It also serves as record that the provider has properly communicated all pertinent information with the owner. Documenting anything in written form can leave much room for error, so extra care should be taken to make sure these instructions are accurate and detailed with the necessary information to decrease the risk of miscommunication. This paperwork should outline everything communicated during the postoperative visit, including but not limited to:

Pre- and postsurgical physical examination findings

Medication information and dosage

Pertinent diagnostic results or surgical findings

Restrictions

Potential for complications

Rehabilitation instructions

Follow-up visit schedule

Contact information for who to reach with questions or concerns

It is also worth noting that the visit summary often serves as your communication to the referring veterinarian, if applicable, so being thorough and consistent with the execution of these records is important to the patient's overall care.

Refrain from Bringing the Pet Into the Room. A pet's surgery can be an emotional and overwhelming experience for a pet owner, and being reunited after an extended hospital stay is an exciting moment. Because it can be difficult for clients to focus with their newly reunited furry family member in the room, abstain from bringing the pet into the room until the conclusion of the discharge to limit any distraction that may occur during important conversation. Once all necessary postoperative information has been discussed, you may then bring the pet into the exam room to proceed with demonstration of at-home care if needed.

Help the Client Envision a Routine. As previously mentioned, many post-surgical patients are sent home with lots of layered instructions and recommendations. To simplify, provide the owner with an example routine for care that they can follow or help them develop one that fits with their capacity and schedule. Establishing a schedule for medication administration, rehabilitation exercises, and incision care can make the process less overwhelming and help them envision how to incorporate these changes into their daily lives at home.

Encourage Hands-On Learning. Keep in mind that many of the things we ask owners to perform at home, such as rehabilitation exercises or medication administration, require nursing skills. By trade, we perform these skills daily and it can be easy to forget how challenging and uncomfortable some of these tasks can be for those who are not well-practiced with them.

A 2010 human study found that effective postoperative education provided by nurses is directly correlated with positive patient outcomes. ² Demonstrating instructions for the client and asking them to perform them in front of you is a great way to help them carry out these instructions at home and may also help them spot possible complications, should they occur.

Be Detail-Oriented. You have probably handled enough client interactions at this point to be able to anticipate some of the questions or points that may need further elaboration. Keeping common concerns in mind during client communication and including them in your instruction can help minimize questions and confusion throughout the postoperative process. Clarifying terms that could have a broad range of interpretation during these conversations will greatly decrease the likelihood that important concepts are misconstrued. A term like "exercise restriction," for example, could mean the owner only needs to omit certain daily activities or it could mean they must completely confine the patient to a crate at all times. Lack of specification can easily lead to an unwanted outcome, so don't be afraid to provide clear expectations to make sure as little is left for misinterpretation as possible.

Provide Resources. Inaddition to the visit summary paperwork, providing the client with something comparable to an FAQ sheet can further improve the written communication process. Some examples for a postoperative FAQ sheet can include stating the length of time needed in an Elizabethan collar, describing normal stages of postoperative swelling, or listing potential side effects from prescribed or interactive medications. Additional external resources, such as videos for rehabilitation exercises, provide an immediate and helpful reference should questions arise at home. Beyond adding FAQs, videos, or other educational resources to your practice's website, lists some suggestions of different resources that can additionally be provided to the pet owner.

Follow-up. Implementing a call-back protocol is an excellent way to strengthen your clinic's communication with clients that have a pet recovering from surgery. Allow time in your schedule for routine, periodic calls to check in on clients in an established timeframe. Calling the owner within the first 24 hours and again around the 1-week postoperative period is a good industry standard and is often the most vulnerable time, as the owners and pets are working to adjust to their new routines at home, based on the results from the previously mentioned AAHA study. ¹ These calls not only improve your clinic's client service quality but also give providers an opportunity to evaluate patient progress while ensuring that the client is following recommendations.

Put Yourself in Their Shoes. Empathy is something we already practice to a fault as veterinary professionals, but we can also easily shut ourselves off from practicing patience and understanding due to the daily demands of the job. The postoperative transition for some of these more intensive procedures often means a significant change in lifestyle moving forward for some pets and owners, and we must be able to recognize and acknowledge the challenges involved in these changes in order to fully lend a helping hand. While we are animal advocates first, providing supportive and thoughtful communication to the pet owner is at the center of that intent and ensures that our patients receive the best care possible.

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Client compliance is often one of our greatest obstacles as veterinary professionals. A study released by the American Animal Hospital Association (AAHA) in 2003 revealed that client compliance is as low as 17% to 35% for important veterinary care such as senior screenings, therapeutic diets, dental care, and heartworm preventives.

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ABSTRACT: The issue of owner compliance - or lack thereof - is a wide-ranging problem through all genres of veterinary medicine and, indeed, medicine worldwide. This article provides a discussion of issues commonly presented in relation to client compliance in the UK, and compares and contrasts these problems with issues in human medicine and in veterinary medicine around the world. Protocols are then presented to improve compliance within veterinary medicine, through the use of a diverse range of communication channels and methods.

'Non-compliance' - the extent to which a course of recommended treatment is not carried out (termed 'non-adherence' where specific to medications) - is a well-documented subject in human medicine. Indeed, studies have been undertaken to compile the results of the many reports published.

One study indicates that the cost of non¬compliance in America is in excess of $100 billion per annum, derived from adverse outcomes such as hospitalisation, development of complications, disease progression or death.1 Approximately 125,000 people with treatable ailments die each year because they do not take their medication properly.1 In human medicine, multiple factors, such as denial of illness by patients and confusion or physical difficulties associated with taking medicines, are associated with poor compliance.1

It is reported that up to 80 per cent of UK patients may be non-compliant; with those prescribed preventive medications most likely to display non-compliance.2-3

This problem of non-compliance is transposed into veterinary practice worldwide. The American Animal Hospital Associations (AAHA) pioneering studies in 2003 and 2008 found many of the factors associated with non-compliance in humans applicable to veterinary medicine.

Owners reported 'significant gaps' between the communication they would find useful and those actually adopted by veterinary practices.4 Owners listed the six most important forms of communication, which were significantly lacking and which contributed to non¬compliance, as:

*demonstrations

*suitable length of appointment

*written information

*calls

*reminders for chronic medication

*continuity with the veterinary surgeon.

UK research suggested that only 37 per cent of clients are fully compliant with medications or follow-up practices recommended by their veterinary surgeon. Some 70 to 85 per cent of clients give, at best, only one third of the required doses on time.5

Owner compliance has been analysed in the context of various treatment regimens. The results of a 2010 equine wound management survey showed that owners often found difficulty in applying or maintaining dressings as requested in their animals' follow up treatment plan (Figure l).6 Many consequently left the area undressed for fear of applying a dressing incorrectly.

Figure 1: Owner non-compliance prevalence in equine wound care6

Incidentally, veterinary surgeons reported that they too found difficulty keeping dressings in place - around 20 per cent of the time - which may indicate that some are not confident giving owners sufficient direction with regard to bandaging techniques, thus exacerbating non¬compliance. This is certainly an area where improved communication can have a significant impact on patient outcomes.

Another compliance issue is the high frequency of premature dressing removal, which is likely to cause an increase in time to wound-healing, scarring prevalence and impact upon final healing outcome.6 This survey found that all veterinary surgeons experienced issues with owners removing dressings prematurely, with 60 per cent finding this to be a relatively frequent occurrence (Figure 2).

Figure 2: Frequency of premature dressing removal in practice 6

Veterinary surgeons often report compliance issues when advising owners to utilise moist wound healing (MWH) techniques, with 55 per cent reporting that owners are completely unaware of the concept (Figure 3). This suggests that increasing owners awareness of MWH through better education could aid compliance. Non-compliance is not restricted to owners of particular species. A recent canine case study, involving a four-year-old crossbred Collie, highlights another factor for consideration in understanding reasons for non-compliance (Case study 1).

Figure 3: Owner perception of moist wound healing concept. Loftus, 2011.7

Owner education and understanding of owners' personal circumstances are important factors in improving compliance. Case study 2 discusses how these are used to increase compliance in the developing world.

Reducing non-compliance

There are a number of simple but effective methods to reduce non compliance. Many of these centre on improved communication and improved client-clinician relationships.

In the consultation

* Consider whether the clients non¬verbal communication (body language, such as pos
ture and facial expressions) contradict what the client is saying.

* Encourage clients to talk by asking open-ended questions beginning with 'what' or 'how'. Avoid 'why' as this can seem accusatory. Sentences beginning with 'when', 'where', 'did', 'is' or 'who' often encourage monosyllabic responses.

* Show empathy - acknowledge the client's emotions either verbally or through non-verbal gestures.

* Listen, understand, respond - show that you are listening by responding verbally or via facial expressions/ posture changes.

* Practice active listening - repeat what the client has said back to them to check your - and their - understanding of the situation and encourage them to expand their explanation.9

* Accept, don't judge - this will increase the likelihood of honest communication between client and clinician, through issuing non-judgemental statements, personal experiences, and expressing normal expectations.

Other methods

* Improve client education and understanding - especially of conditions and procedures associated with their pet.

* Repeat - clients are unlikely to take in all of the information if delivered only once, especially in traumatic situations. Evidence has shown that the same information delivered by a series of people can increase its impact; for example veterinary nurse, veterinary surgeon, reception staff and finally reinforced with printed material.10

* Demonstrate - show the client how to administer the required treatment and encourage them to practise in your presence to increase their confidence.4 It is often beneficial to conduct the first dressing change or administer the first dose of medication in the presence of the owner to ensure that even those who deem themselves competent take time to watch the techniques required being put into practice.

* Give 'top tip' handouts to clients, explaining how to complete common tasks, such as tablet administration, wound flushing or applying ocular ointments.

* Organise client information evenings specific to different species or issues - this adds value to your service and builds a stronger client-practice bond. Ensure that the staff receive training and regular participation in CPD so that they can provide appropriate and valuable advice to clients.

* Use computer software that provides a client-reminders service (and will deactivate in the case of euthanased pets) and ensures that follow-up calls are made in a timely manner.10 Add value by making the practice accessible through various communication channels, including telephone, e-mail, post, text and social-networking media.

With some thought - and minimal procedural alterations - all clinicians and veterinary nurses can improve communication and education in practice. This will help to reduce the incidence of non-compliance, thereby improving patient outcomes and increasing the strength of the relationship with their clients.

Loni Loftus BSc(Hons)

After attending university to study Business Studies, Loni owned and ran a training, livery and competition yard for a number of years. She has recently completed a BSc in Equine Science with The Open College of Equine Studies (TOCES) and continues her affiliation by lecturing and marking, as well as managing the online assignment system.

Loni is a freelance trainer focussing on training young horses, in addition to rehabilitation of more experienced horses. As she completed her degree, she developed a particular interest in equine injury, disease, training and rehabilitation and has based much of her project work, including a dissertation, in this field.

To cite this article use either

DOI; 10.1111/j.2045-0648.2012.00201.x or Veterinary Nursing Journal Vol 27 pp 294-297

References

1.WERTHEIMER, A. I. and SANTELLA. T. M [2003] Medication Compliance Research: Still So Far to Go. Journal of Applied Research in Clinical and Experimental Therapeutics. ISummer 20031 313).

2.DUNBAR-JACOB. J. and SCHLENK. E. [2001] Patient adherence to treatment regimens In: Baum. A., Revenson, T. and Singer, J. (eds): Handbook of health psychology [pp 571-580]. Mahwah, NJ: Erlbaum

3.CARTER. S. and TAYLOR. D. [2005] A question of choice - compliance in medicine taking - a preliminary review. 3rd Ed. Keele University Medicines Partnership Programme.

4.AMERICAN ANIMAL HOSPITAL ASSOCIATION [AAHA] [2009] Compliance: Taking quality care to the next level. Executive summary (online), available from http://www.aahanet.org/Protected/ Compliance ExecutiveSummary0309.pdf. accessed January 2012.

5.MADDISON, J. E. [2011] Medication compliance in small animal practice. Veterinary Ireland Journal, 64 [1].

6.LOFTUS. L [2011] Review of current wound-care protocol and dressing choice in equine veterinary practice, VNJ (Sept 2011) 26: 309-313.

7.CALDER. C. and VETERINARY WOUND LIBRARY (2012) Case study - Non-compliance in a canine case. Personal communication AND www.vetwoundlibrary.co.uk

8.POLLOCK, P, [2012] Case study - Increasing compliance in the developing world. Personal communication. European and RCVS Recognised Specialist in Equine Surgery. School of Veterinary Medicine, University of Glasgow

9.GARRETT. L. [2011] Master this veterinary procedure in DVM360 at http://bit.ly/Hlyznf. accessed 25/03/2012.

10.THOMPSON, B [2011] How to maximise compliance in a weak economy at http://www.vetermarybusinessbriefing.com/public M93.cfm?sd=21 accessed 25/03/2012,

Veterinary Nursing Journal * VOL 27 * August 2012 *

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The non-compliant client by Loni Loftus - British Veterinary Nursing Association

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ABSTRACT: The issue of owner compliance - or lack thereof - is a wide-ranging problem through all genres of veterinary [...]

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The Veterinary Nurse - Experience of designing and implementing a care plan in the veterinary environment

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Experience of designing and implementing a care plan in the veterinary environment - The Veterinary Nurse

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As well as forming an evidence base of its own, the progression of the veterinary nursing profession has led to the modification of the way in which veterinary nursing is approached, hence the ‘nursing process’. This theory broadens the outlook of patient care and encourages VNs to consider all aspects of the patient’s wellbeing, rather than focusing solely on the disease or injury of the patient (Pullen, 2006;Chandler et al, 2007)…

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Instructing and preparing clients for home care is essential for patient healing and return to well-being. This includes verbal and written discharge instructions as well as hands-on demonstrations of wound care, medication, and rehabilitation. Patient care, however, does not end when the animal walks out of the door. Following-up with clients within a few days of discharge provides an opportunity to monitor the patient's condition, answer clients' questions, assure compliance, and allay concerns.

Clients must receive home care instruction to provide their pet with the optimal healing experience. Communication is essential to patient care. Verbal instructions are important, but as with preparing for surgery, visual aids are helpful along with written instructions. Engaged clients retain and understand more information. While clients are anxious to be reunited with their pet, talking to them without this distraction is beneficial. Bringing a client to a quiet area such as an exam room eliminates other distractions and provides a private setting for a conversation. While providing oral instructions, it is beneficial to emphasize important points in the written instructions. Using a highlighting marker to stress certain aspects of the discharge underscores their importance for the client. When providing instructions for medications, asking the client to repeat the dosing schedule assures their understanding. It is important to provide information on when the next dose of medication is due after the patient is discharged.

Many studies, in human medicine, compare the appropriate reading grade level for discharge instruction comprehension and the actual reading level created (Bukata 2012). Studies indicate that the appropriate level of instructions be at the level of sixth grade reading (Somes 2003). While using medical terms is common knowledge for veterinary professionals, the general public may not understand them. Defining terms provides client education and understanding. For example, using the term "medial patella luxation or MPL" in a sentence is clear to the veterinarian and technician; however, a client may not recognize these words. Explaining this in layperson terms states this condition to be "the kneecap dislocates or moves to the inside of the knee." Use of acronyms, "MPL" in the above example, is also confusing and in need of explanation. Discharge instructions must be clear, concise, and free of errors. Creating a defined format for all clinic personnel provides consistency. When using a template, assure all pertinent information is correct for the individual patient. Include the following information:

Patient and client names

Client contact information

Caregivers: veterinarian and technician

Clinic/hospital/emergency contact information

Diagnosis - medical and layperson terms

Procedure-medical and layperson terms

Medication(s)

name of drug (brand and generic)

dose (size in milligrams and quantity per dose)

route of administration (oral, transdermal, injection, topical, etc.)

frequency (how often to give)

number dispensed

special precautions (give with food; do not mix with other medications, etc.)

example: Rimadyl® (Carprofen) 25 mg, give one tablet by mouth - with food, twice daily

Duration of medications - as needed, use all medications, etc.

Feeding instructions - usual diet or special needs, when to start feeding

Exercise - normal or restricted

Tests and results - laboratory tests, imaging, etc

General instructions for wound care, bandages, rehabilitation, etc.

Follow-up - call, appointment, suture removal, bandage change, etc.

Using a larger font size (14 pt.) aids in readability. Break down the instructions into short paragraphs and bullet points for clarification. Providing extra space allows the client to make notes. Printing on a special color paper may help the client to find the discharge instructions when needed (Day 2012).

Not all clients are proficient in or knowledgeable about medicating their pet. Providing a demonstration is important for client compliance. Asking the clients to also perform the task helps them to perfect their technique. Empty gel caps for oral medication and saline-filled syringes are great teaching aids. When bandaging is required at home, it is imperative to explain all steps and materials to the client as well as have them practice. Figure 8.1 shows a patient requiring slight compression on a neck incision. Using stretch stockinette as a "hood and shirt" allows the client to replace the gauze covering the wound.

Figure 8.1 Patients may go home with a stockinette bandage, like this Yorkshire terrier following neck surgery. The bandage requires monitoring and changing by the client.

Providing photos or videos helps clients who are visual learners. Anatomical models, electronic images, and hard copy books are additional aids to enhance client learning and understanding. Offer clients images of scoping procedures and radiographs. Explaining the images to clients enhances their experience. Reviewing charges with the client gives them a perception of all aspects of the surgery and its related costs. Through all stages of the discharge process, encourage and provide the client an opportunity to ask questions.

Patients may require special diets following their procedure. Short- or long-term needs are explained to the client. This information includes details of how to handle situations immediately after going home when food may need to be restricted to avoid vomiting due to anesthesia or pain medication-induced nausea. Patients are returned to their normal diet as soon as possible to avoid gastrointestinal upset. Some animals benefit from moistening dry kibble to be more palatable. Crushing the kibble prior to soaking in water hastens its water uptake. Patients reluctant to eat need coaxing with special foods such as commercially available canned pet food, baby food, boiled hamburger or chicken, water based tuna, and so on but not a high fat content food.

Long-term needs may include diet changes to comply with a specific medical condition, for example liver and kidney disease, degenerative joint disease as well as obesity. Pet obesity is on the rise in the United States. Recent studies indicate veterinarians classify 53% of dogs and 55% of cats as overweight (Association for Pet Obesity Prevention 2012). This study also shows that most pet owners are unaware of their pet's obesity. Providing clients information on weight-related conditions is imperative. These include kidney disease, breathing difficulties, hypertension, osteoarthritis, and type 2 diabetes. Showing and providing a body condition score and chart gives clients a visual aid in determining their pet's current and optimal fitness ( Figures 8.2 and 8.3).

Figure 8.2 Canine body condition system scoring chart.

(Courtesy of Nestle-Purina Petcare Company.)

Figure 8.3 Feline body condition system scoring chart.

(Courtesy of Nestle-Purina Petcare Company.)

Clients need instruction on measuring food intake, determining calorie content, and finding healthy treat alternatives such as raw vegetables. Advice is given on adverse foods not to be given as treats including products containing the artificial sweetener Xylitol, grapes and raisins, chocolate, avocados, garlic, onions, and macadamia nuts (Vetlearn 2011).

The stress of hospitalization alone may cause gastrointestinal upset. Clients are warned to watch for vomiting, anorexia, constipation, and diarrhea and to contact the veterinarian or technician if these occur. This is especially true for patients prescribed narcotics and non-steroidal anti-inflammatory drugs (NSAIDs). Patients deprived from food in the perioperative period and receiving narcotics are less likely to produce bowel movements (Papich 2011) on a regular basis for a short period after discharge. This is generally not a medical concern. Providing clients with this information allays their concerns. However, patients that are unable to urinate require special attention. Often following spinal surgery, patients cannot voluntarily urinate. Carefully explaining the need to monitor urination and demonstrating bladder expression is essential in these patients. When clients are unable to express their pet's bladder, it may be advisable to continue hospitalization for expression or catheterization. Alternatively, repeat visits to the clinic may be required. Non-steroidal anti-inflammatory medications may cause vomiting and diarrhea. Clients are warned to contact the clinic if these occur, as it is imperative to stop the NSAID before the gastrointestinal condition worsens.

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Instructing and preparing clients for home care is essential for patient healing and return to well-being. This includes verbal and written discharge instructions as well as hands-on demonstrations of wound care, medication, and rehabilitation. Patient care, however, does not end when the animal walks out of the door. Following-up with clients within a few days of discharge provides an opportunity to monitor the patient's condition, answer clients' questions, assure compliance, and allay concerns.

Clients must receive home care instruction to provide their pet with the optimal healing experience. Communication is essential to patient care. Verbal instructions are important, but as with preparing for surgery, visual aids are helpful along with written instructions. Engaged clients retain and understand more information. While clients are anxious to be reunited with their pet, talking to them without this distraction is beneficial. Bringing a client to a quiet area such as an exam room eliminates other distractions and provides a private setting for a conversation. While providing oral instructions, it is beneficial to emphasize important points in the written instructions. Using a highlighting marker to stress certain aspects of the discharge underscores their importance for the client. When providing instructions for medications, asking the client to repeat the dosing schedule assures their understanding. It is important to provide information on when the next dose of medication is due after the patient is discharged.

Many studies, in human medicine, compare the appropriate reading grade level for discharge instruction comprehension and the actual reading level created (Bukata 2012). Studies indicate that the appropriate level of instructions be at the level of sixth grade reading (Somes 2003). While using medical terms is common knowledge for veterinary professionals, the general public may not understand them. Defining terms provides client education and understanding. For example, using the term "medial patella luxation or MPL" in a sentence is clear to the veterinarian and technician; however, a client may not recognize these words. Explaining this in layperson terms states this condition to be "the kneecap dislocates or moves to the inside of the knee." Use of acronyms, "MPL" in the above example, is also confusing and in need of explanation. Discharge instructions must be clear, concise, and free of errors. Creating a defined format for all clinic personnel provides consistency. When using a template, assure all pertinent information is correct for the individual patient. Include the following information:

Patient and client names

Client contact information

Caregivers: veterinarian and technician

Clinic/hospital/emergency contact information

Diagnosis - medical and layperson terms

Procedure-medical and layperson terms

Medication(s)

name of drug (brand and generic)

dose (size in milligrams and quantity per dose)

route of administration (oral, transdermal, injection, topical, etc.)

frequency (how often to give)

number dispensed

special precautions (give with food; do not mix with other medications, etc.)

example: Rimadyl® (Carprofen) 25 mg, give one tablet by mouth - with food, twice daily

Duration of medications - as needed, use all medications, etc.

Feeding instructions - usual diet or special needs, when to start feeding

Exercise - normal or restricted

Tests and results - laboratory tests, imaging, etc

General instructions for wound care, bandages, rehabilitation, etc.

Follow-up - call, appointment, suture removal, bandage change, etc.

Using a larger font size (14 pt.) aids in readability. Break down the instructions into short paragraphs and bullet points for clarification. Providing extra space allows the client to make notes. Printing on a special color paper may help the client to find the discharge instructions when needed (Day 2012).

Not all clients are proficient in or knowledgeable about medicating their pet. Providing a demonstration is important for client compliance. Asking the clients to also perform the task helps them to perfect their technique. Empty gel caps for oral medication and saline-filled syringes are great teaching aids. When bandaging is required at home, it is imperative to explain all steps and materials to the client as well as have them practice. Figure 8.1 shows a patient requiring slight compression on a neck incision. Using stretch stockinette as a "hood and shirt" allows the client to replace the gauze covering the wound.

Figure 8.1 Patients may go home with a stockinette bandage, like this Yorkshire terrier following neck surgery. The bandage requires monitoring and changing by the client.

Providing photos or videos helps clients who are visual learners. Anatomical models, electronic images, and hard copy books are additional aids to enhance client learning and understanding. Offer clients images of scoping procedures and radiographs. Explaining the images to clients enhances their experience. Reviewing charges with the client gives them a perception of all aspects of the surgery and its related costs. Through all stages of the discharge process, encourage and provide the client an opportunity to ask questions.

Patients may require special diets following their procedure. Short- or long-term needs are explained to the client. This information includes details of how to handle situations immediately after going home when food may need to be restricted to avoid vomiting due to anesthesia or pain medication-induced nausea. Patients are returned to their normal diet as soon as possible to avoid gastrointestinal upset. Some animals benefit from moistening dry kibble to be more palatable. Crushing the kibble prior to soaking in water hastens its water uptake. Patients reluctant to eat need coaxing with special foods such as commercially available canned pet food, baby food, boiled hamburger or chicken, water based tuna, and so on but not a high fat content food.

Long-term needs may include diet changes to comply with a specific medical condition, for example liver and kidney disease, degenerative joint disease as well as obesity. Pet obesity is on the rise in the United States. Recent studies indicate veterinarians classify 53% of dogs and 55% of cats as overweight (Association for Pet Obesity Prevention 2012). This study also shows that most pet owners are unaware of their pet's obesity. Providing clients information on weight-related conditions is imperative. These include kidney disease, breathing difficulties, hypertension, osteoarthritis, and type 2 diabetes. Showing and providing a body condition score and chart gives clients a visual aid in determining their pet's current and optimal fitness ( Figures 8.2 and 8.3).

Figure 8.2 Canine body condition system scoring chart.

(Courtesy of Nestle-Purina Petcare Company.)

Figure 8.3 Feline body condition system scoring chart.

(Courtesy of Nestle-Purina Petcare Company.)

Clients need instruction on measuring food intake, determining calorie content, and finding healthy treat alternatives such as raw vegetables. Advice is given on adverse foods not to be given as treats including products containing the artificial sweetener Xylitol, grapes and raisins, chocolate, avocados, garlic, onions, and macadamia nuts (Vetlearn 2011).

The stress of hospitalization alone may cause gastrointestinal upset. Clients are warned to watch for vomiting, anorexia, constipation, and diarrhea and to contact the veterinarian or technician if these occur. This is especially true for patients prescribed narcotics and non-steroidal anti-inflammatory drugs (NSAIDs). Patients deprived from food in the perioperative period and receiving narcotics are less likely to produce bowel movements (Papich 2011) on a regular basis for a short period after discharge. This is generally not a medical concern. Providing clients with this information allays their concerns. However, patients that are unable to urinate require special attention. Often following spinal surgery, patients cannot voluntarily urinate. Carefully explaining the need to monitor urination and demonstrating bladder expression is essential in these patients. When clients are unable to express their pet's bladder, it may be advisable to continue hospitalization for expression or catheterization. Alternatively, repeat visits to the clinic may be required. Non-steroidal anti-inflammatory medications may cause vomiting and diarrhea. Clients are warned to contact the clinic if these occur, as it is imperative to stop the NSAID before the gastrointestinal condition worsens.

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Macdonald. J., (2020) As with admission procedures, it can help to follow a consultation structure when discharging pets. Whilst the elements of ‘gathering information’ will not really apply, except to confirm the identity of the client, all other aspects may be relevant, including: preparation, gathering information, physical examination and giving information.

Macdonald. J. 2020. Small animal surgical nursing. In: B. Cooper, E. Mullineaux and L. Turner, eds. 2020. BSAVA Textbook of Veterinary Nursing 6th edition. Gloucester: BSAVA. Chapter 9.

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Improving your clinic’s ability to provide detailed postoperative instruction helps to ensure a more smooth recovery.

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Owner-assisted recovery and early discharge after surgical treatment in dogs with brachycephalic obstructive airway syndrome - PubMed

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Corrective surgery for brachycephalic obstructive airway syndrome was associated with lower postoperative respiratory complications when dogs were discharged on the same day after recovery with the owners. Owner-assisted recovery and early discharge are possible and safe and may decrease the inciden …

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ABSTRACT: There has been limited formal teaching of the process of consulting, for veterinary nurses. This article covers the processes required to convert 'the art of consulting' into a structured format.

Veterinary nurses often undertake the role of'clinic nurse' with little or no training on the delivery of a consultation. This, coupled with the requirement of the new nursing award, necessitate that both students and qualified veterinary nurses receive training in these very important skills.

Although there are several frameworks for consulting in medical education, none had been developed specifically for veterinary use. The Cambridge-Calgary consulting model has been adapted by the National Unit for the Advancement of Veterinary Communication Skills (NUVACS) as the most relevant framework for the veterinary profession (Figure 1).

Figure 1: Adapted Cambridge-Calgary model of veterinary consultation skills
1.Preparation
Any equipment required for the consultation should be prepared in advance, the consulting room needs to be clean, and the nurse should be familiar with the clinical history of the patient, in particular any relevant details (Figure 2). iMake a note of the animal's name, sex and age, and use these when talking about the patient. Your appearance is also highly important as it governs the client's perception of you (Figure 3).

Figure 2: Ensure that the consulting room is clean and tidy

Figure 3: Personal appearance is important, note the clean uniform, tidy hair and name badge
2.Initiating the Consultation
Whether or not the consult is regarding the previous clinical history of the animal, if you mention or ask how the pet has been since the incident, the client will feel that you care about their pet.

The consultation should also be started by confirming the name of the client, when calling them through from the waiting area. Always introduce yourself, and confirm the nature of the appointment at the outset. Clients often make an appointment for one cat, and then bring the other one instead, as they could not locate or catch the initial one!

If there is a delay, keep the waiting clients updated as they don't like to be kept waiting - not acknowledging increased waiting times will lead to frustration on the client's part, which will make your job worse once you do see them.

Spend a few minutes becoming acquainted with the patient. Dogs should be patted and spoken to and cats interacted with, prior to removal from their basket. Use of the pet's name is vital. If cats are unwilling to leave their baskets, then remove the top, if possible, and then either examine them in the bottom half of their basket, or lift them out on their blanket onto the consulting table. This stage is very important for creating rapport with the client and their pet. Remember to use the client's name too, and consider whether it is appropriate to shake hands. But most importantly involve the pet.

In order to create good rapport, nurses should empathise with the owners; indeed empathy is an essential trait for all the practice team - not just the VN that they see during the nurse consultations. In the majority of cases, the pet is an integral family member, and this special bond needs to be respected.

When children are brought into the consulting room, involving them can prove to be useful (Figure 4). Getting them to weigh the pet, or to read off the weight, are good examples of this, especially in weight loss clinics as it helps compliance with the children feeding the pet. Colouring books and pencils are useful for distracting children - and remember to put their completed pictures on the wall in your consulting room.

Figure 4: Puppies are often bought for children and. therefore, inclusion of children in the consultation process is important
3.Information gathering
Background information will be gleaned from the clinical history, but additional information can also be obtained through carefully focussed questioning. Many clients are more than happy to offer information whether it is relevant or not.

Some need specific questioning in order to retrieve the required information.

The use of 'open' and 'closed' questions should be utilised, as different types of answers can be gained. Questioning also helps provide information regarding the clients expectations and specific concerns. If conducted appropriately, this part of the process allows you to demonstrate your professionalism and knowledge, whilst helping to build rapport with the client.

Questions also help to give you time to think and time to focus. Use communication cues - such as nodding your head - to demonstrate interest in what the client is saying. Listen to what the client is saying, and, in some cases, repeat back to the client what they are saying in order to confirm details (Table 1).

This is a very important stage of the consultation, and one that is often overlooked or not completed to the full. In many situations, when the consultation has finished, the client often adds, "... and another thing"! This can be pre-empted by focused questioning of the client at the outset.

In some cases the client may have a very long list of queries or tasks. Prioritise the most important ones for the patient - by negotiation with the client if necessary - as they may have a different perspective to you as a veterinary professional.

For example, you may decide that the dramatic weight loss and polydipsia are the most important factors to be considered; whereas the client may be more worried about overlong nails or an increase in vocalisation for no apparent reason. If this situation is experienced, then the client should understand why you feel that these clinical factors need to be prioritised over the clipping of the patient's nails.

In situations where the client has a long list of non-emergency questions or procedures, it is important to hold a dialogue at the outset as to which things are to be completed first; and then a subsequent appointment can be made in order to complete the outstanding requirements. Reasons for suggesting more than one appointment may include: insufficient time
to correctly cover all the items, too much information for the client to retain in one appointment, the pet becoming stressed - for example if its coat is matted - or to aid in compliance.
4. Physical Examination
When initiating the physical examination, it is important to be aware of the clinical history of the animal. If the animal is known to have a tender abdomen, or arthritic joints, care must be taken not to exacerbate any discomfort. With larger dogs, or those that don't like being on the consulting table, the physical examination can be conducted on the floor.

Whilst performing the clinical examination, it is important to talk through with the client what you are doing and looking for. Work systematically from the head backwards - having a set routine will help to ensure that things are not missed out.

Start by looking at the symmetry of the head and jaw. This is important when animals are presented with dental disease, because lumps or bumps on the mandible or maxilla can be an indicator of tooth root problems. Any nasal discharge should be noted, along with its colour and whether it is lateral or bilateral. When examining the eyes, the size of the pupils and their symmetry should be noted. The conjunctiva surrounding the eye should be examined too, in order to check for infection, and any discharge. Ears should be checked for discharge, wax, dirt and smell.

Examination of the mouth will depend on the co-operation of the animal being examined. If it is known to be difficult to handle, in some circumstances asking the owner to lift the animal's lip up so that you can look at the teeth can be appropriate, provided that you are confident that this will not put the owner at risk of being bitten. If any disease is present, then it should be noted and graded (Table 2).

When palpating the animal's neck and shoulders, the lymph nodes should be checked and, if palpable, this needs to be noted and referred to the veterinary surgeon. The condition of the coat and skin should be accessed and checked for parasites. The range of movement in limbs should be assessed; and careful questioning about mobility should be instigated with cat owners because most arthritic changes are put down to old age rather than reduced mobility in this species.

Examination should also include measuring and assessing the heart and respiratory rate. Finally, the overall condition of the animal should be noted, including body condition score (BCS), muscle condition score (MCS) and body weight.
5.Explanation and Planning
Once all the information has been gathered and the animal examined, your initial findings need to be explained to the owner and conveyed to the veterinary surgeon as appropriate. If your consultation is primarily aimed at dealing with issues such as weight reduction or care of the geriatric patient, veterinary intervention may not be required. It will be your responsibility as a veterinary nurse to plan and explain the next steps in such a way as to ensure that the information is conveyed in a form that the owner understands. This can be oral or written, and in some cases educational DVDs can be utilised. Some points will need to be reiterated, and a useful tip is to do so in a different form.

When planning the next step the owner must agree with the decisions that are being made and be able to comply with the instructions given. If these steps are not complied with, the risk of non-compliance increases dramatically.

There are three elements involved in the implementation of care: the veterinary professional, the client and the pet. All parties need to be in agreement in order to make a plan work. The owner may agree to administration of oral medication on a daily basis, but the pet may resist this, thereby resulting in non-compliance.

Breaking down the information into 'digestible' chunks can be helpful for the owner. During lengthy consultations, it can be useful to ask the owner if he or she wants to take notes - have a pen and paper ready in order to allow them to do so. Asking the client to identify any challenges associated with the implementation of the proposed plan at home is important too as it not only identifies potential pitfalls, but also encourages the client to feel a degree of ownership of the process.
6.Closing the Consultation
When closing the consultation the aim is to summarise the decisions that have been agreed, and to arrange future appointments, as necessary. It is important to confirm that the owner is happy with any agreed protocols, such as medications that have been dispensed or diets recommended (Table 3).

Also ensure that the client is provided with contact details. These may be either telephone or e-mail, indeed both are recommended; and don't forget to reinforce your name by either writing it on any documentation provided or giving a card with your details. Whilst primarily considered a tool of 'the business person', business cards can be produced very cheaply for all clinical staff and are appreciated by clients.

Nicola Ackerman BSc(Hons)RVN CertSAN A1 V1 C-SQP MBVNA

Nicola works as senior medical nurse at The Veterinary Hospital Group and has been one of the emergency night nurses since 2005. She is a graduate of Hartpury College with an Honours Degree in Equine Science, specialising in animal nutrition; and qualified as a VN in 2002. She has subsequently gained a post graduation Certificate in Small and Exotic Animal Nutrition.

She is also the Head Assessor in practice for a team of four other assessors, and is currently studying for the internal verifiers award [V1|. Nicola was part of the BVNA Council for four years and held posts of Treasurer and Executive Editor of the VNJ during this time.

Nicola is part of the Pet Obesity Taskforce and has written a book on animal nutrition for veterinary nurses and technicians.

To cite this article use either

DOI: 10.1111/].2045-0648.2011.00097.x or Veterinary Nursing Journal Vol 26 pp 368-371.

* VOL 26 * October 2011 * Veterinary Nursing Journal

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Consultation skills for veterinary nurses by Nicola Ackerman - British Veterinary Nursing Association

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ABSTRACT: There has been limited formal teaching of the process of consulting, for veterinary nurses. This article covers the processes [...]