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https://www.wm-referrals.com/images/content/factsheets/pet-owners/post-op-airway-surgery.pdf

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https://www.vscdsurgerycenters.com/pdf/discharge-instructions/canine_cystotomy_discharge.pdf

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https://veteyecare.co.uk/for-owners/factsheets/

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Brachycephalic Obstructive Airway Syndrome (BOAS) Animation - The Ralph

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What is Brachycephalic Obstructive Airway Syndrome (BOAS), and how is it treated? Watch this short animation to learn more. Thank you to Team Ralph and…

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How to: look after your pet after abdominal surgery

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After any surgery, your pet is likely to be feeling unsettled and not themselves, due to both their initial condition and to medications. Read our 5 top tips.

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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

Background

It is not known how much information clients retrieve from discharge instructions.

Objective

To investigate client's understanding of discharge instructions and influencing factors.

Animals

Dogs and cats being hospitalized for neurological diseases.

Methods

Clients were presented questionnaires regarding their pet's disease, diagnostics, treatments, prognosis and discharge instructions at time of discharge and 2 weeks later. The same questions were answered by discharging veterinarians at time of discharge. Clients answered additional questions regarding the subjective feelings during discharge conversation. Data collected included: data describing discharging veterinarian (age, gender, years of clinical experience, specialist status), data describing the client (age, gender, educational status). Raw percentage of agreement (RPA) between answers of clinicians and clients as well as factors potentially influencing the RPA were evaluated.

Results

Of 230 clients being approached 151 (65.7%) and 70 (30.4%) clients responded to the first and second questionnaire, respectively (130 dog and 30 cat owners). The general RPA between clinician's and client's responses over all questions together was 68.9% and 66.8% at the 2 time points. Questions regarding adverse effects of medication (29.0%), residual clinical signs (35.8%), and confinement instructions (36.8%) had the lowest RPAs at the first time point. The age of clients ( P  = .008) negatively influenced RPAs, with clients older than 50 years having lower RPA.

Conclusions and Clinical Importance

Clients can only partially reproduce information provided at discharge. Only clients' increasing age influenced recall of information. Instructions deemed to be important should be specifically stressed during discharge.

Keywords: agreement rate, client communication, client conversation, communication, discharge instruction, questionnaire, reproducibility

Abbreviations

MCQ‐MA

multiple choice question-multiple answers

MCQ‐SA

multiple choice question-single answer

1.Q

first questionnaire

RPA/RPAs

raw percentage of agreement/agreements

SD

standard deviation

SEM

standard error of the mean

1. INTRODUCTION

Veterinarians usually focus on providing the highest level of medical care to their clients. That prioritization of the medical aspects of their profession largely ignores that educating and empowering the pet owner might have an influence on the therapeutic success., , , , The imbalance between those 2 parts of clinical veterinary medicine, animal care and owner communication, is reflected by a relative paucity of scientific literature in veterinary research investigating clinician and pet owner interaction in contrast to extensive publications in human medicine., , , , Even though there is growing interest in that research, studies specifically investigating comprehension and efficacy of discharge instructions are lacking in veterinary medicine.

In human medicine, clinician‐patient‐interaction and its effect on outcome has been more extensively investigated. Specifically, discharge instructions and their effects on comprehension and recall have been studied in human emergency departments. Complete recall of discharge instructions varies between 8% and 84% of human patients released from emergency departments., , Providing written discharge can improve comprehension of information provided. Written instructions instead of verbal instructions only increased the correct use of pain medication from 40% to 71% of patients. Another study in human patients concluded that recall of discharge information can be increased from 47% to 58% if written instructions are provided to patients.

There seems to be a need for similar investigations in veterinary medicine in order to improve communication between clinicians and pet owners. Therefore, the aim of this study was to investigate comprehension of discharge instructions in a veterinary neurological referral center.

2. MATERIALS AND METHODS

The study was performed using a prospective cohort design. Owners of dogs and cats being hospitalized as patients at the Neurology and Neurosurgery Service of the Department for Small Animals of Leipzig University were asked to participate in a study to improve owner instructions by answering a questionnaire at 2 time points after the animal has been discharged from the hospital. During the discharge conversation, owners were informed about their pet's disease, diagnostic tests and treatments performed, medication to be given by the owner, and necessary exercise restriction as well as the prognosis of their pet's disease. All this information was handed over to the owner as written discharge instruction as well. In addition, the owner received all medication, either as the complete package, as a bottle of liquid, or as a strip of tablets. In the latter, medication was placed in a separate bag being labeled with the name of the medication and additional instruction on how to apply it.

A questionnaire consisting of 3 parts was developed. Part I included questions characterizing the owner itself such as: age, gender, educational level, being a native German speaking person and having a medically professional background. Part II included questions regarding the owner's personal perception of the verbal discharge conversation such as: feeling informed, general atmosphere, personal emotions, understandability of clinician's explanation, clinician's empathy and others. Part III of the questionnaire addressed the diagnosis, performed diagnostic tests, treatment, follow up visits as well as the prognosis of the pet's disease. Part I and Part II questions were only answered once exclusively by the pet owners at the time of discharge. Part III questions had to be completed separately by the pet owners and the attending clinicians at the day of discharge as well as a second time by the pet owner only 2 weeks after discharge. The pet owners were not aware, that the questionnaire they will be asked to answer 2 weeks after discharge will contain exactly the same Part III questions they had already responded to on the day of discharge. There were the following types of questions: multiple choice questions (either single or multiple answers; MCQ‐SA and MCQ‐MA), open questions, and questions on a 6‐point Likert scale. The exact wording of questions, question types as well as response options were developed together with a human psychotherapist (Marie A. Harkenthal). All questions of all 3 parts as well as question types and response options are listed in Table 1.

TABLE 1.

Question

Question type

Response options/answers

Raw percentage of agreement in % at discharge and 2 weeks later

Part I:

Questions characterizing the owner

Answered by the owner only

How old are you?

MCQ‐SA

Years: 18‐29; 30‐39; 40‐49; 50‐59; 60‐69; 70‐79; 80‐89; 90‐100

What is you gender?

MCQ‐SA

Male, female, nonbinary

Is German your native language?

MCQ‐SA

Yes, no

Do you have a medical profession?

MCQ‐SA

Yes, no

What is your level of education?

MCQ‐SA

Secondary school diploma;

High school diploma;

Vocational training college degree;

Technical college degree;

University degree

Part II:

Questions characterizing verbal discharge instructions

Answered by the owner only

I have been sufficiently informed about the treatment of my pet.

Six‐point Likert scale

Part III:

Question regarding the disease, diagnostic tests, treatment and prognosis

Answered by the owner and the dischargeing veterinarian

What is name of the disease we have diagnosed in your pet?

Open answer

The following criteria had to be fulfilled in order to ask a pet owner to participate in the study: the pet was hospitalized, clinicians of that service had performed all owner communication once the animal had been hospitalized as well as provided all verbal and written discharge instructions. Owners were excluded if the pet died or was euthanized during hospitalization, if the clinician thought that the owner cannot be addressed with that request because of the general circumstances, if owners were not able to pay the bill, if the owners had a recheck appointment in less than 3 weeks after discharge and if verbal discharge conversation was performed under time constraint due to unforeseen circumstances. For participating owners, the attending clinician reported the following information regarding the verbal discharge conversation: duration in minutes, number of attending adults, number of accompanying children, number of accompanying pets and if the pet to be discharged was present during discharge conversation or was handed over after the conversation was completed, location of discharge (general examination area with incompletely separated booths, separate room, general reception area, outside of the hospital, and other). In addition, the following information characterizing the discharging veterinarian was collected: age, gender, number of years working as a veterinarian, level of specialization (no special degree, national degree of specialization, diplomate of the European College of Veterinary Neurology).

Owners eligible to participate were informed about the study after completion of the verbal discharge instruction and handing out written instructions. They were provided with additional written information regarding aim and design of the study as well as a declaration that all information provided would be handled as required by the European Union General Data Protection Regulation. Owners agreeing to participate signed a consent form.

Following the discharge conversation and after receiving the written discharge instructions, owners could participate in 3 different ways based on their personal preference: receiving a paperwork questionnaire to be mailed back to the hospital, receiving a weblink either in the printed discharge instructions or via email. Owners were asked to complete questionnaires at 2 different timepoints: 1 on the day of discharge (Parts I, II, III) and a second 2 weeks after discharge (Part III only).

Data were analyzed by determining the individual agreement between responses of all owners and all clinicians to every single Part III question. The agreement rate for every single question as well for every individual owner was expressed as raw percentage of agreement (RPA). It was calculated for every single owner by dividing the number of questions, where owners and clinicians provided the same response by the total number of all Part III questions. Similarly, the RPA was calculated for every single question. The total RPA was calculated as the mean of all individual owner RPAs. The total RPA was calculated for the 2 time points, when owners responded to Part III of the questionnaire, at the time of discharge and 2 weeks later. Further analysis included only answers to the questionnaire provided at the time of discharging the pet.

For the total RPA including all Part III questions, the influence of answers to Part I questions (owner characteristics), Part II questions (subjective assessment of verbal discharge instructions characteristics provided by the owner) and objective data of the discharge conversation (duration, present persons and pets) as well as data characterizing the discharging clinician (age, gender and level of expertise) on the RPAs between owners and clinicians were analyzed. Furthermore, the influence of the same factors on RPAs between owners' and clinicians' responses was determined looking only at the following 2 questions of Part III separately: "What is the name of the disease we have diagnosed in your pet?" and "If you have to give medicine to your pet, to which category do those belong?" Responses were rated as in agreement if exactly the same answers were chosen by clients and clinicians in MCQ‐SA and MCQ‐MA. For the open answer question regarding the diagnosis, decision about agreement between clients' and clinicians' responses was achieved by consensus among 3 authors (Thomas Flegel, Katharina Dobersek, and Sabrina Bayer). If consensus was not achieved between those 3 authors, agreement was classified as "unclear." Unclear agreement was treated similar as responses without agreement during statistical analysis. MCQ‐MA questions were classified as in agreement if all the same answers were selected by owners and clinicians. A response was considered as partial agreement, if a client selected only some of the answers selected by the clinician or if the client selected more answers than the clinician. Responses with partial agreement were treated as no agreement during statistical analysis.

2.1. Statistical analysis

Statistical analysis was performed using the software IBM SPSS Statistics 27 (SPSS Inc, New York, USA) and Microsoft Excel 2019 (Microsoft Deutschland GmbH, Munich, Germany). Continuous data were visually tested for normal distribution as well as by using the Kolmogorov‐Smirnov test. Data are reported as mean or median with the SD, range or 95% confidence interval, depending on their normality. The difference between the total RPA at the 2 different time points was tested by the paired t test for dependent samples. The differences of RPA between the 2 time points for every single question was calculated using a paired‐sample sign test. The influence of factors on the total RPA was tested by linear multivariable regression analysis with forward selection.

The Mann‐Whitney U test and the Kruskal‐Wallis test (depending on the number of groups to be tested) were used to detect differences in the total RPA of Part III questions between groups for the following variables: animal species, number of years working as a veterinarian, level of specialization of the veterinarian, gender of the veterinarian, location of the discharge interview, number of people present at the discharge interview, presence of the animal at the discharge interview, native language of the animal owner, level of education of the animal owner, medically professional background of the animal owner gender, and age group of the animal owner.

Furthermore, it was tested if there are differences in the total RPA between groups for the following variables using the Mann‐Whitney U test and the Kruskal‐Wallis test (depending on the number of groups to be tested): animal species, number of years working as a veterinarian (≤4 years; ≥7 years), level of specialization of the veterinarian, gender of the veterinarian, location of the discharge interview, number of people present at the discharge interview, presence of the animal at the discharge interview, native language of the animal owner, level of education of the animal owner, medically professional background of the animal owner gender, and age group of the animal owner. An influence of the duration of the discharge interview on the agreement on the 2 subquestions was tested using the Kruskal‐Wallis test.

Part II questions regarding the owners' personal perception were analyzed with the nonparametric Mann‐Whitney U test.

Significance values were adjusted using the Bonferroni correction for multiple tests where applicable. A value of P  < .05 was considered significant for all analyses.

3. RESULTS

A total of 230 clients agreed to take part in the study by signing the consent form, of which 151 (65.7%) responded to the first survey immediately after discharge and 70 clients (30.4%) performed both surveys. Nine clients (3.9%) performed the second survey only. Those 160 responders are included in the further analysis. The majority of clients used the web‐based questionnaire (60.8%).

Thirty clients owned a cat (18.7%) and 130 a dog (81.3%). The 11 most frequent diagnoses in both species together were: intervertebral disc disease (37.2%), idiopathic epilepsy (8.2%), intoxication (6.5%), vestibular syndrome (3.9%), intracranial neoplasia (3.5%), meningoencephalitis of unknown origin (3.5%), peripheral neuropathy (2.2%), lumbosacral stenosis (2.2%), spinal luxation/fracture (2.2%), infection (1.7%), and steroid responsive meningitis arteritis (1.7%). Some more specific diagnoses have been grouped together in the list provided above. For 14.3% of cases, no definite etiological diagnosis could be established. For the latter, a more descriptive diagnosis was provided to the owner.

One hundred seven clients were female (71.3%), 42 were male (28.0%), and 1 was nonbinary (0.7%). For 5 clients (3.4%) German was not their native language. One hundred twenty‐eight clients (18.7%) had a profession related to medicine or veterinary medicine. The age and the educational level of all clients are presented in Figures 1 and 2.

Nine different veterinarians performed the verbal discharge instructions, 7 were female and 2 were male. Three discharging veterinarians were board certified neurologists. Discharging clinicians have practiced veterinary medicine for 6 months to 29 years. The median duration of the verbal discharge conversation was 16 minutes (n = 153; range: 4‐42 minutes). For 7 cases, clinicians forgot to measure the duration of the discharge conversation. The following locations were used for discharge conversations: general examination area with incompletely separated booths (8.1%), separate room (18.8%), general reception area (62.5%), outside of the hospital (8.8%), and other (1.8%). There was a single client present in 100/152 cases of discharge conversations (65.8%), whereas in the other cases there was at least 1 additional person. There were children of the clients present in 4 more cases (2.6%). The animal to be discharged was present during the discharge conversation in 12/153 cases (7.8%). The responses describing the subjective impressions of clients regarding discharge conversation are presented in Figure 3.

The general mean RPA between clients' and clinicians' responses to questions regarding the animal's hospitalization was 68.9% (SD: 21.9; SEM: 4.13; range: 29.0‐98.0) and 66.8% (SD: 35.4; SEM: 4.9; range: 19.3‐98.9) for the questionnaire at discharge and 2 weeks later, respectively. The total RPA of the first set of answers at discharge is significantly higher than the second set 2 weeks later ( P = .03). The distribution of the total RPA at the 2 time points is shown in Figure 4. The RPAs to the following 3 questions were significantly lower 2 weeks after discharge compared to the day of discharge: "Should you give any medicine before feeding your pet?" ( P = .017), "What are potential adverse effects of the medicine you have to give your pet?" ( P = .035) and "If your pet has to live permanently with signs of the disease, which are those?" ( P  = .008).

Lowest RPAs were obtained for MCQ‐MA. For the 6 MCQ‐MA with RPAs below 50%, agreement could be increased to 78.4% by accepting questions as answered correctly even if 1 correct option of the multiple correct options was not selected by the owner. Similarly, RPA could be increased to 77.4% by accepting questions as answered correctly if 1 wrong option was selected in addition to all correct answer options. All RPAs for every single question are shown in Table 1.

The only factor influencing the total RPA between clients' and clinicians' responses including all questions was the age of the client, with older age being associated with lower agreement ( P = .008, corrected R ²: .041; F value: 7.21, t value: −2.685, regression coefficient: −1.64, beta coefficient: −.217). The RPAs in different age groups are shown in Figure 5. Significant differences were seen between clients of 30 to 39 years and those of 50 to 59 years of age ( P = .034; Cohen's r = .25) and between clients of 30 to 39 years and those of 60 to 69 years of age ( P = .038; Cohen's r  = .27). There was no significant difference between the age group 70 to 79 years and any other age group. However, the latter included 3 individuals only and therefore reliable statistics could not be applied to this group.

There was not any factor influencing the RPA, when not the total RPA over all questions was evaluated, but if the RPA was selectively evaluated for responses to the specific questions "What is the name of the disease we have diagnosed in your pet?" and "If you have to give medicine to your pet, to which category does it belong?"

4. DISCUSSION

The total RPA between clients' and clinicians' responses to questions regarding the disease, diagnostic and treatment of pets discharged from a veterinary neurological referral center was 68.9%, when questions were answered on the day of discharge and 66.8% when answered 2 weeks later. However, there was a large variation of individual RPAs, ranging from 28.4% to 98.0% and from 19.3% to 98.6% for the first and the second Part III questionnaire, respectively. Those RPAs are within the wide range of discharge recall rates reported for humans of 8% to 84%., , ,

There was a significant, but small decline of the total RPA 2 weeks after discharge compared to the total RPA on the day of discharge which is barely clinically relevant. Only 3/28 questions were answered significantly different at the 2 time points. Those were questions regarding giving medication before feeding, adverse effects of the medication, and residual clinical signs. That could imply that misremembering over time is not a major problem, at least not in the immediate post discharge time period. However, we do not know how many clients responded to the Part III questions 2 weeks after discharge just based on their memories and how many used the written discharge instructions to respond. We would argue that this question is irrelevant, since it is only important that clients can reproduce the information provided, while it does not matter which resource is used for that.

Veterinary studies for direct comparison are lacking to the best knowledge of the authors, though there are several studies investigating other aspects of the client‐veterinarian communication. A few of them are exemplarily mentioned here. The adherence of clients to their veterinarians' recommendations in dental practice was found to be 30% only. However, the odds of adherence were 7 times as high if clients were provided with clear instructions rather than options. Another study assessed the communication between veterinarians and horse owners about the zoonotic risks of the Hendra virus. It was found that 24.9% of owners were initially unreceptive, emotionally overwhelmed or denied the potential risk. Those findings emphasize the importance of providing comprehensible explanations in order to increase client understanding. Authors concluded that veterinary communication skills should be further investigated. In addition, animal directed talk using utterances addressing the pet itself might facilitate many tasks that have to be achieved during client‐clinician interaction. Such animal directed talk was not possible in most cases of the study presented here, since pets were intentionally usually not present during discharge conversation, since we felt it would distract clients. Furthermore, client communication expectations were evaluated in a veterinary oncology referral center. The authors concluded that not only the content but the way information is provided to the owner is crucial. It does not only facilitate comprehension of medical information, but it generates a psychosocial environment that supports the client in dealing with their diseased pet.

Written instructions seem to have an influence on the recall since adding those to verbal instructions increased the correct use of pain medication from 40% to 71% in human patients. Another study in human patients concluded that recall of discharge information can be increased from 47% to 58% if written instructions are provided to the patients. Those recall rates are probably suitable for comparison, since pet owners of the study presented here received combined verbal and written instructions. Therefore, RPAs achieved in this study are in a similar range as reported in human medicine.

Some MCQ‐MA had relatively low RPAs. That applied for instance to questions regarding the adverse effects of medication (RPA 29.0% 1.Q), residual clinical signs (RPA: 35.8%, 1.Q), instructions for confinement of the pet to a certain area (RPA: 36.8%, 1.Q). Obviously, the RPAs are naturally lower in multiple answer questions if only those answered were accepted as correct, where all correct options were selected. Accordingly, by accepting 1 wrong selection, the RPAs could be increased to 77.4% for those answers. The question addressing the potential risk to die from the disease was with 57.4% (1.Q) close to the total RPA of 68.9 (1.Q), but one would expect or would hope for a much higher RPA for such a fundamental question. It is not clear if that is caused by a natural reluctance of the clinicians to touch that rather difficult topic in the moment of discharge or if the clients block such unpleasant information out of their minds. In addition, the high variation between RPAs for different questions (range from 19.3% to 98.9%) might partially reflect a different focus of clinicians and pet owners. Similarly, human patients are more interested in diagnosis and prognosis, whereas clinicians tend to focus on treatment in a general practice setting.

Only 1 factor influenced the total RPA. Specifically, subjective factors on the individual perception of the discharge atmosphere did not have any influence. The study was conducted during the time of the COVID‐19 pandemic, where access of clients to the hospital was strictly limited. Therefore, many discharges had to be performed in the relatively noisy general reception area (62.5% of all discharge conversations). That was recognized by the owners by reporting that discharge was performed in an undisturbed surrounding in only 60.7%, surprisingly however, that did not influence the RPAs. The clients' age was the only factor influencing the total RPA, with clients being at least 50 years having lower RPAs. Therefore, communication should probably be tailored to the clients' age.

Having a medical background of the clients did not have a significant influence on RPAs. That can be interpreted in different ways. On 1 hand, it could be an indication, that the way the clinician communicates is more important than the clients' education or profession. Medical knowledge might not be able to compensate for poorly structured or even confusing explanations by the clinicians. More positive explanations would be that the information was provided in a generally comprehensible way in this study, so that medical understanding did not add any value to it or clinicians did tailor their explanations to the clients' needs. There were no instructions in the study design to provide information to all clients in the same way, so that clinicians were free in their way of addressing the educational level or professional background of clients. On the other hand, it is possible that all clients independent from their educational level or profession are nervous enough to experience difficulties to follow the clinician's explanations, even though 59.7% of the owners did declare not to be stressed. However, there might be a gap between the personal perception and the objective level of stress during discharge.

Even though not specifically investigated in this study, the style of communication might influence clients' recollection of information. Pet owners appreciate a partnership‐centered communication expressing empathy and understanding for their fears and concerns., This communication style might be used differently by clinicians of different age. A study found a negative correlation between veterinarians' years practicing small animal medicine and the degree of involving clients in the shared‐decision making process. Authors argued that more experienced clinicians might use a more directive communication or that clinicians might develop a more paternalistic communication style over time. In the study presented here, however, the number of years practicing small animal medicine did not influence the RPAs of answers provided by clients and clinicians.

The main limitation of this study is the nonblinded study design. While clinicians were instructed not to change their usual discharge habits, it is safe to assume that the knowledge of the ongoing study influenced the way animals were discharged. We could not think of any study design without the clinicians being aware of it. Therefore, the true agreement rates outside of this study could potentially be lower than presented here. In addition, excluding some clients from the study (if the pet died or was euthanized during hospitalization, if the owner was subjectively considered to be a challenging person, if owners were not able to pay the bill) could have added a bias to the results. Including the responses of those clients which are potentially more stressed would probably have decreased RPAs and might have resulted in valuable findings in that subgroup. However, we felt that clients cannot be asked to take part in a study if they are in such exceptional emotional state.

In summary, clients are only able to recall correctly about two thirds of the information provided on discharge. Therefore, discharge instruction that are deemed to be critical should be stressed specifically and should potentially be repeated. That applies particularly if clients are elder people.

CONFLICT OF INTEREST DECLARATION

Authors declare no conflict of interest.

OFF‐LABEL ANTIMICROBIAL DECLARATION

Authors declare no off‐label use of antimicrobials.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC) OR OTHER APPROVAL DECLARATION

Data collection was carried out in accordance with the General Data Protection Regulation 2016/679 of the European Parliament. This research project was approved by the Ethics Committee of the Faculty of Veterinary Medicine at Leipzig University (EK 18/2021).

HUMAN ETHICS APPROVAL DECLARATION

Authors declare human ethics approval was not needed for this study.

ACKNOWLEDGMENT

This publication has been supported by the Open Access Publishing Fund of Leipzig University. Results were presented as an abstract at the 35th ESVN/ECVN Symposium, Venice, Italy, September 21‐23, 2023. We express our sincere thanks to all clients who supported us in conducting this study. Open Access funding enabled and organized by Projekt DEAL.

Flegel T, Dobersek K, Bayer S, et al. Client's understanding of instructions for small animals in a veterinary neurological referral center. J Vet Intern Med. 2024;38(3):1639‐1650. doi: 10.1111/jvim.17085

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Articles from Journal of Veterinary Internal Medicine are provided here courtesy of Wiley

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Client's understanding of instructions for small animals in a veterinary neurological referral center

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It is not known how much information clients retrieve from discharge instructions. To investigate client's understanding of discharge instructions and influencing factors. Dogs and cats being hospitalized for neurological diseases. Clients were ...