In 2016 the first graduates of the New Zealand Certificate in Animal Technology (Veterinary Nursing Assistant) (NZCAT-VNA) (NZQA, 2015) emerged giving New Zealand veterinary businesses the opportunity to expand the practice team. The integration of veterinary nursing assistants (VNAs) into practice has the potential to alleviate stress experienced by veterinary staff.
While studies of stress in this sector have predominately centred on veterinarian wellbeing, recently studies have emerged with a focus in veterinary nurses (VN) (Huggard and Huggard, 2008; Foote 2020; Harvey and Cameron 2020). ‘Compassion fatigue’ and ‘burnout’ are the types of stress most reported in the veterinary workforce. They may occur in conjunction or independently and are implicated as major contributors to poor staff outcomes. These include high risk of suicide in veterinarians (Bartram et al, 2009; Bartram and Baldwin 2010) and harmful coping mechanisms such as increased medical/recreational drug use in VNs (Overfield, 2012). While compassion fatigue is a consequence of direct involvement in traumatic events or interaction with those suffering from traumatic events (Figley and Roop, 2006), ‘burnout’ is related to conflict between roles (Dale, 2019; Harvey and Cameron, 2019), overwork, or conversely, insufficient workload (Rizzo et al, 1970).
Identifying and addressing causes of stress can lead to improved staff wellness and performance, which in the veterinary industry is associated with improved animal welfare outcomes (Moore et al, 2014; Dale 2019). Integration of VNAs into practice staffing structure could reduce stress from high workload, positively impacting staff wellbeing and animal welfare. Crucial elements for smooth assimilation of VNAs into practice include clear job expectations and responsibilities for all staff (Brogdon, 2014; Dale, 2019). Avoiding role conflict is important, with balancing workloads between veterinarians, VNs, veterinary technicians (VTs), VNAs and reception staff fundamental to this.
Gardner and Hini's (2006) study on management of work-related stress highlighted the importance of identifying hazards posed to staff wellness along with response. Setting a scope of practice (SP) which defines the bounds of the role, and delegation guidelines (DG) during development of a new qualification could mitigate role conflict and contribute to stress management within veterinary teams. Additionally, it could provide a platform from which to build career identity for VNs and for VNAs. Career identity is recognised to be a crucial part of how individuals perceive themselves and the world, and is the core of their motivations, autonomy, belonging and wellbeing (Bell and Cake, 2018). It influences the behaviour, values and principles applied to practice (Allister, 2015).
SPs and DG are ubiquitous in human healthcare professions and woven into health legislation. Despite the availability of a VNA qualification since 2016, a formal SP was only released in 2020 for utilisation by veterinarians, VNs and VTs managing VNAs in New Zealand practice. Internationally, several projects are underway to standardise and clarify the role of VNs and VTs including in the UK through ‘Vet Futures’, and in America via the ‘Veterinary Nurse Initiative’. SPs and competences for veterinary paraprofessionals are utilised in some states of America (American Veterinary Medical Association (AVMA), 2021; Georgia Veterinary Medical Association (GVMA), 2021; Veterinary Nurse Initiative (VNI), 2021). In New Zealand, the recently released SP is a necessary first step in clarifying roles in veterinary practice teams.
This study examined veterinary professionals' practice experiences of integrating VNAs into practice teams. Their accounts enabled evaluation of the VNA SP and development of DG. This can be used by practice management along with the VN SP to set clear and appropriate job descriptions for VNs, VTs and VNAs. Additionally, decision-making about delegation to the VNA by veterinary professionals was investigated. This informed the development of a framework to guide veterinary professionals in task delegation within the practice team.
Materials and methods
Qualitative methods were used to explore the utilisation of VNAs with the potential to share and compare practices, generate, and develop ideas and learning which leads to richer data underpinned by attitudes, beliefs, and values (Vogt et al, 2012). Aspects of good choice design according to Vogt et al (2012) are met. That is subjective knowledge, in-depth information is more important than generalising a wider population and when informants need time to think about and elaborate on answers.
Participant recruitment
This study involved three mini-focus groups, two multiple person interviews and 13 individual interviews involving 30 participants overall. Recruits were invited to participate via social media and email. Focus group design accounted for power-imbalances inherent in veterinary practice hierarchical structure by arranging the groups into tiers of organisational structure (VNs/VTs, VNAs, veterinarians and practice managers) providing a safe forum for open discussion. Informed consent and non-disclosure statements were obtained prior to participant engagement. All interactions were recorded.
Data collection
A semi-structured interview and focus group approach was taken using open questions. Sessions were audio-visual, or audio recorded and conducted face-to-face, through online conferencing and by telephone.
The question content covered three sections. The first centred on participant context. This included experience or observations of practice organisational structures. The second was practice based on experiences of VNAs themselves and reflections and observations of their colleagues. The third section focused on delegation. Participants were asked to discuss and categorise reception and clinical tasks according to staff roles drawing richer data on the decision-making process. Finally, veterinary nurse and VNA job descriptions were requested to further examine expectations, responsibilities, and the degree of role definition in practice. The themes were saturated at study completion.
Data analysis
Inductive thematic analysis was performed to extract information and define relationships between variables ensuring data were effectively represented in the three themes generated (Braun and Clarke, 2006; Nowell et al, 2017). Triangulation was utilised to promote rigour. Specifically, consideration of disparities in study findings from literature, inclusion of multiple views and reflexivity by researcher and assistant. Kahneman's (2011) categories in decision-making was utilised for deductive analysis of veterinary staff delegation processes to ascertain the effectiveness of decision making for staff wellbeing and positive animal outcomes.
Results
Demographic analysis
In total 30 veterinary staff participated in the study (Figure 1a–f; Table 1). Three participants had moved from less technical roles starting as receptionists and moving on to the VNA role with formal training. In addition, one participant had also completed study to gain the National Certificate in Veterinary Nursing (level 5) prior to availability of the VNA role, however, has elected to practice as a VNA on grounds of improving animal welfare within a multi-disciplinary team.
Table 1. Other locations of participant work experience n=16
| United Kingdom 38% |
| Bermuda 6% |
| Japan 13% |
| Pacific Islands 6% |
| India 6% |
| Australia 25% |
| South Africa 6% |
Utilisation of veterinary nursing assistants
The participants were asked to discuss experiences of task delegation to VNAs. Variation in this was vast. Practices ranged from VNA utilisation in all clinic areas, to limited roles with VNAs most commonly performing reception and hospital (kennel) duties. Most tasks delegated crossed-over with VN and receptionist responsibilities. The degree of cross-over varied between practices, with team size being a significant determining factor. The differentiation between receptionist, VNA and veterinary nursing roles was more clearly defined in larger teams, however, increased workload changed expectations of practice, with VNAs asked to perform more technical tasks in busy periods. This was consistent with the employment contracts analysed.
Participants were asked to reflect on the appropriateness of clinical tasks delegated to the VNA. Majority consensus was reached for many tasks perceived as suitable for delegation to the VNA (Table 2). A substantial number of participants believed the tasks related to active management, and those requiring higher level of knowledge and/or technical skill, to be outside the scope of the VNA and a risk to the patient. However, competing participant perspectives were evident relating to both reception and clinical tasks requiring greater technical skill and knowledge (Table 3).
Table 2. Tasks appropriate for delegation to the veterinary nursing assistant (VNA) by majority consensus and those currently being performed by other staff in the practice
| Area of practice | Task of the VNA as agreed by majority consensus | Alternate staff responsibility (as experienced by participants in practice) |
|---|---|---|
| Reception | Restraint of animals to assist veterinarian with examination and procedures | Veterinary nurse |
| Customer service, sale of food and pet products.Where client enquiries are beyond the VNA's scope of practice, refer on to veterinary nurse or veterinarian | Receptionist | |
| Manage appointments, take payments | Receptionist | |
| Restock the consultation room | Receptionist | |
| Follow stock ordering systems and maintain stock levels in reception | Receptionist | |
| Follow stock ordering systems to maintain stock levels of Registered Veterinary Medicines (excluding ordering and recording the use of controlled drugs) | Veterinary nurse | |
| Pharmacology | Dispense un-restricted veterinary medicines | Receptionist |
| Follow protocols to maintain a hygienic environment in all areas of the veterinary facility | Receptionist in reception area or cleaner in non-surgical areas | |
| Clinic hygiene | General cleaning and tidying. Laundry, kennels, and cages cleaned and prepared | |
| Follow veterinary care plans to provide basic inpatient care under the direction of the veterinary nurse | Veterinary nurse | |
| Medical nursing | Provide appropriate food and water as directed by the veterinary nurse and veterinarian | Veterinary nurse |
| Administer prescribed registered veterinary medicines — oral and topical (ocular and aural) — under veterinary nurse and veterinarian's direction | Veterinary nurse | |
| Follow protocols to maintain the hygiene of surgical equipment and instrumentation | Veterinary nurse | |
| Surgical nursing | Prepare theatre and surgical equipment | Veterinary nurse |
| Provide non-sterile assistance in theatre | Veterinary nurse | |
| Instrument cleaning, packaging, and sterilisation | Veterinary nurse | |
| Preparation of the surgical site | Veterinary nurse | |
| Follow protocols to maintain the hygiene of anaesthetic machines and equipment | Veterinary nurse | |
| Anaesthesia | Monitor patients in anaesthetic recovery, record parameters and report the veterinary nurse or veterinarian | Veterinary nurse |
| Follow protocols to maintain hygiene in the dental theatre | Veterinary nurse | |
| Dental procedures | Prepare equipment for dental procedures | Veterinary nurse |
| Clean package and sterilise dental equipment | Veterinary nurse | |
| Prepare equipment for diagnostic tests | Veterinary nurse | |
| Laboratory diagnostics | Collect basic diagnostic samples, e.g. free flow urine | Veterinary nurse |
| Run in-house laboratory tests | Veterinary nurse or veterinarian | |
| Prepare diagnostic imaging equipment for use | Veterinary nurse | |
| Diagnostic imaging | Assist with diagnostic imaging procedures | Veterinary nurse |
Table 3. Tasks for which consensus regarding delegation to the veterinary nursing assistant was not met
| Area of practice | Tasks |
|---|---|
| Reception | Managing client records |
| Discharge of routine cases, e.g. uncomplicated spay and neuter surgery | |
| Pharmacology | Dispense restricted registered veterinary medicines |
| Medical nursing | Monitor routine fluid therapy. Record and report to the veterinary nurse or veterinarian |
| Monitor patients with dressings, bandages, and casts. Record and report to the veterinary nurse or veterinarian | |
| Anaesthesia | Prepare anaesthetic machines and equipment |
| Monitor sedated patients, record parameters and report to the veterinary nurse or veterinarian | |
| Monitor routine medical and postoperative patients. Record and report results, to the veterinary nurse or veterinarian | |
| Dental | Assist with dental procedures |
Animal welfare and sustainable practice
Participants were asked to describe their decision-making process. Decision making for task delegation involved considering a range of factors including legal, business model, financial, patient condition, complexity, staffing levels, time constraints, trust in the individual, and influence on patient outcome, along with the VNA's interest in progression and level of responsibility in relation to the task. Discussions revealed several factors were considered to some degree, determined by scenario, and underpinned by animal welfare, personal/social and/or business sustainability (Figure 2).
‘These are the things that we run out of time to do, but what would really improve our monitoring of our patients… I think you could always need an extra pair of hands and I think it means that the nurses can be more efficient, focusing on different tasks.’
(Interview, Veterinary nurse, female, small animal practice)
Many participants perceived that the cross-over of tasks requires careful consideration of staffing levels as an influence on efficiency of the multi-disciplinary team. If the number of staff at each level of the organisational structure is imbalanced, the welfare of the animals, staff wellbeing and financial sustainability may be compromised.
‘So, we're looking at efficiencies for our vets, and our nurses give us that. The VNA gives the nurses their efficiency.’
(Mini-focus group, practice manager, small animal practice)
A substantial number of participants voiced a need for change of staff utilisation believing greater delegation to VNs, and in turn utilisation of VNAs would promote personal/social and business sustainability including contributing to solving the shortage of veterinarians in New Zealand. Currently the process toward formal registration of the VN is underway and many participants believed that this would increase delegation by the veterinarian resulting in greater utilisation of the VN and recognition that the VN is a skilled team member.
Qualification confusion
Inconsistent understanding of the difference between the NZCAT-VNA (level 5), its predecessor the National Certificate in Veterinary Nursing (level 5) and the New Zealand Diploma in Veterinary Nursing (NZDVN) (level 6) qualifications contributes to heterogenous utilisation of the VNA in practice.
Some participants were unaware of the difference between VN and VNA qualifications. Because of this they may have inappropriately delegated tasks to a VNA. This raised concerns relating to animal welfare, as well as risks to job satisfaction, team harmony, and reputational risks for the industry, clinic, VNA and training providers.
‘It is not clear to each clinic of what that role is. There's a lot of concerns about staff safety and animal safety and even staff morale I would say as well because for a vet nurse who has completed a diploma or a bachelor, they're performing the same skills as the vet nurse assistant.’
(Interview, veterinary nurse, and lecturer)
Discussion
This study reveals that the utilisation of the VNA in New Zealand veterinary practice varies widely. Practices range from having no clinical and client facing tasks delegated to them, to VNAs performing complex clinical duties and having reception responsibilities. This is driven by the diverse mix of factors that inform decision making regarding the employment of VNAs and the delegation of tasks to them.
Qualification knowledge in industry
The principal factor is poor industry understanding of the structure of the veterinary nursing education framework, and the content of the NZCAT-VNA programme. With 11 educational providers delivering 11 independently developed NZCAT-VNA and NZDVN programmes, guided by the outline approved by the New Zealand Qualifications Authority (2015) and only recently, availability of a SP, there has been a lack of clarity for the veterinary industry in the scope of each qualification. The open interpretation of some areas in the qualification overview are not unique to the New Zealand scene. In the UK, the qualifications are accredited by an independent entity, however, comparison of Veterinary Care Assistant/Animal Nursing Assistant qualifications exhibit training discrepancies particularly in anaesthesia and its practical application. Furthermore, the guidance provided for the Code of Professional Conduct for Veterinarians in the UK (CPCVUK) is not explicit in delegation of anaesthesia-related duties for ‘lay staff’, and has potential to negatively affect animal welfare and personal, social, and business sustainability.
Delegation decision making
Kahneman (2011) is renowned for his work on the impact of decision making, he divides decision-making processes into two groups. ‘System one’ decisions are made quickly with limited thought and often based on prior experience, gut instinct, and pattern recognition. ‘System two’ decisions are evaluative and demand more time. Applying this theory to the process of delegation to the VNA utilised by veterinary staff suggests that ‘system one’ is often relied on, commonly driven by time constraints. Downfalls of this system as identified by McKay (2011) are bias, misplaced confidence, lack of information and thus potential to compromise animal welfare, personal/social and business sustainability. For example, the administration of medicines for which majority consensus was attained (Table 2), would not be supported under the CPCVUK. Subtle differences in legislation between countries may easily be overlooked by team members creating risk of disparity in veterinary staff expectations and team harmony.
NZ legislation, NCNZ scopes of practice, American Nursing Association (ANA) definition of SP (encompassing ‘Who’, ‘What’, Where’, ‘When’ and ‘Why’) and practice staff experience were utilised to evaluate the Allied Veterinary Professionals Regulatory Council (AVPRC) SP. The AVPRC SP is broad and satisfies the definition provided by the ANA while remaining within the bounds of the Veterinarians Act 2005 (Box 1).
Box 1.Areas of the Allied Veterinary Professionals Regulatory Council (AVPRC) scope of practice (SP) that satisfy the American Nursing Association (ANA) definition of SPsAreas of the AVPRC VNA SP that satisfy the ANA definition of SPs:Who: States qualifications required to practice under this scopeWhere: Relevant locations including those outside of the practiceWhen: Under the direction and delegation of a registered professional and when there is need for care of an animalWhy: Intended role in supporting animal healthcare in partnership with families and multi-disciplinary veterinary teamsWhat: Areas of contribution in practice including care assessment, implementation, and evaluation of care for animal patients
However, the degree of the VNA contribution to care within the SP is not dictated, allowing for individual interpretation. This is supported by the mixed and varied participant responses relating to numerous factors influencing decision-making identified in this study. In response, a DG has been developed (Box 2) to promote animal welfare and practice team sustainability through a consistent and efficient process. The development of case study examples and a day-one competences and skills list would further clarify decision making. This is an area for further research and development in the profession. Clear communication between the AVPRC, educational providers and industry regarding the SP and DG is required as identified by Robinson (2017) and Orpet (2018) who found boundaries of roles continue to be blurred despite availability of a SP and DG for veterinary practice teams overseas.
Box 2.The Three Rs of delegation: a guide to delegation to the veterinary nursing assistant (VNA)R esponsibilityIs delegation possible?
- Is the procedure considered significant under the Code of Professional Conduct for Veterinarians?
- Have you gained client consent to care for the animal?
- Do you have recent personal knowledge of the patient condition?
R isksHave you identified risks associated with the specific patient and the impact delegation may have on the patient, VNA and client?
- How difficult is the procedure?
- How likely is it that a problem will arise?
- Will the patient condition and/or procedure pose a risk to VNA health and safety?
R eadinessHow prepared is the VNA?
- Has the VNA been trained to carry out the procedure? — refer to day-one competences and skills list when developed
- Have you checked with the VNA you are delegating to that they are comfortable with carrying out the procedure? Do they wish for support?
- Is the VNA familiar with the species?
- Would the VNA recognise a problem and respond appropriately?
This delegation guidelines (DG) is informed by the themes of this study and aligns with Schedule 3 (RCVS, 2019)
Role clarification
The significant cross-over of responsibilities between VNAs and VN/receptionist increases risk of poor jobsatisfaction generated through lack of role definition and recognition crucial to career identity and consequently animal welfare and business success (Page-Jones and Abbey, 2015). The use of a SP and DG clarifies roles and helps to prevent conflict. Role definition is a key factor in strengthening veterinary practice teams, however, development of case study examples like those produced by the RCVS (2018) and further exploration into how best to disseminate this information to veterinary practices is required (Robinson, 2017; Orpet, 2018). Other elements that promote a healthy work environment and team efficiency identified in this study include clinical coaching with potential to build leadership in the veterinary nursing profession. Additionally, formal registration of VNs is strongly supported in this study stepping toward protection of title and acknowledging the VN's responsibility and contribution to positive patient outcomes, as is presently under review in the UK (VN Futures, 2020; BVA and BVNA, 2021; RCVS, 2021).
Study limitations
Had timing of similar research being undertaken by the New Zealand Primary Industry Training Organisation aligned, findings could have informed this study.
Conclusion
The present uncertainty of the level of competence of the VNA and crossover of tasks support the implementation of AVPRC SP and a clear process to assist in sound decision-making in task delegation to VNAs in practice. The variable utilisation of VNAs highlights the need to strengthen communication between the New Zealand Veterinary Nursing Association (NZVNA) and AVPRC, education providers and industry, particularly with the planned introduction of new qualifications. In addition to the SP and DG, a clinical coaching scheme like those available internationally could strengthen practice teams and offer clearer guidance. Other elements such as registration of VNs, day-one competences for VNs and VNAs could further assist in role definition promoting sustainability and reducing risk of negative patient outcomes.
Entwined within the development of career identity through registration of the VN, is the potential for further development of career identity for the VNA, which may increase utilisation. Therefore, future investigation is warranted to establish if this will benefit the veterinary industry. Although day-one competences and skills of the VNA could be partly informed by this project, further research to clarify the expectations of the new graduate VNA by veterinary clinic staff in New Zealand is required. This should inform qualification development.
At the individual/group practice level, periodic engagement in conversations within veterinary practice teams to review the clarity of contractual job descriptions and staff expectations regarding their own role and the role of their colleagues could serve to strengthen career identity and team harmony. Use of teaching and learning methods such as ‘talking walls’ as a team building exercise to enhance interprofessional learning has been effective in other healthcare professions (Parsell et al, 1998). Integration of this process into new staff induction could also assist those who have been abroad and may overlook subtle differences in the legislation between countries.
Overall, this study has shown it is crucial to develop guiding documents for existing and new animal-related qualifications and strengthen communication between professional organisations, educational providers, and industry. Forging ahead, individual practices can act to promote team harmony, career identity and animal welfare through periodic and collaborative review of job descriptions and individual staff expectations.
KEY POINTS
- The utilisation of the veterinary nursing assistant (VNA) in New Zealand is broad and variable between practices owing to numerous factors, most significantly poor understanding of the qualification.
- There is cross-over of responsibilities held by the VNA and other staff which can compromise team harmony and sustainability.
- The decision-making process in delegation is complex and can influence outcomes in animal welfare and personal/social and business sustainability.
- Communication of clear guidelines from the professional organisations (New Zealand Veterinary Nursing Association (NZVNA) and Allied Veterinary Professionals Regulatory Council (AVPRC)) to veterinary practices is a key requirement for the planned veterinary nursing qualification framework changes.
- Opportunity exists for further evolution of multi-tiered practices, through clear communication of expectations between staff coupled with regular review, thereby, improving patient outcomes, team wellness and business success.