There has been a recent move towards creating positive patient experiences during veterinary visits. Various initiatives aspiring to achieve this are creating awareness amongst veterinary professionals (Box 1). The aim is to build knowledge and confidence in caring for patients' behavioural health and emotional welfare, while attending to their clinical needs.
These initiatives are generating growing awareness of the concepts and ethics of patient-friendly practice (PFP) amongst the veterinary community. Resources such as those detailed in Box 1, along with peer-reviewed articles, such as those by Rodan et al (2011), Hetts et al (2004), Mills et al (2014), Hemsworth et al (2015), Hammerle et al (2015); and texts such as Overall (2013a) and Hedges (2014a), advocate for PFP, maintaining that it is achievable in day-to-day veterinary practice. They agree that PFP is beneficial for veterinary patients, staff and pet care-givers; and that educated, confident veterinary professionals are perfectly placed to provide and advocate for PFP. Overall (2013a) explains that the veterinary team should: care about behaviour and embrace behaviour as a core discipline, advocating staff to identify, understand and respond to emotional signals; modify the environment to improve the patient experience; and moderate human behaviour when handling patients.
What is PFP?
The concepts, aims and goals of the PFP initiatives, texts and authors reflect a similar ethos: i.e. of building knowledge, understanding and care for the patient's ethology and its individual emotional and behavioural needs while under veterinary care. These practices aim to improve patients' veterinary experiences within the clinic, throughout preparation for visits (e.g. at home, including periods of training), as well as during transport to, and on arrival at, the clinic.
Box 2 describes the concept of PFP, taking into account the composite ideas, aims and strategies of all of the above-mentioned professional organisations, education providers and course/resources. This is with the aim of reducing patient stress, promoting positive veterinary experiences and, above all, doing no harm.
The alternative to the above-described patient-friendly approach is based on enforced physical handling and restraint, which may range in levels of force used. These techniques often force animals into positions, sometimes for extended periods, and impose procedures which may be mildly to moderately stressful and/or painful in and of themselves. Handling techniques such as this restrict patient choice, often necessitating patients to use escape/avoidance, or distance-increasing behaviours. Distance-increasing behaviours are those aimed at making a threat stop or move away. The use of these behaviours may be missed, or misinterpreted — inducing the use of more force as staff attempt to control the patient and avoid injury to themselves or the patient.
While stressful patient interactions are rarely carried out with the intention of doing harm, historically, behavioural health and emotional welfare has been an area of veterinary medicine that has been given minimal attention, with the focus being far more on the clinical skills and training of staff, and therefore staff may be under-prepared to implement PFP efficaciously (Overall, 2013a).
How should PFP be implemented?
Hetts et al (2004), Rodan et al (2011) and Overall (2013a) explain that clinical behaviour and PFP (as defined above) is not extensively taught as part of many veterinary curricula. This commonly results in veterinary professionals having a lack understanding and confidence in the area of PFP, largely due to insufficient education during qualification and in their ongoing professional development. Although this is improving, examination of the majority of syllabi of UK veterinary and veterinary nursing courses show that behaviour makes up a small proportion of most curricula. These authors identified key areas in which veterinary professionals could develop their knowledge and skill to promote PFP, and these are detailed in Box 3.
In-depth look at the specifics…
The focus of the discussion will be on the aspects of PFP that relate to emotional signals, body language and the function of patients' behaviour in the context of the veterinary environment. Visits to the veterinary clinic are potentially stress-inducing for many reasons. Stress and distress have potentially problematic physical and emotional impacts on patients, short and long term, both in health and disease (Mills et al, 2104).
Stress is a physiological manifestation of emotion, often resulting in observable behaviour (Notari, 2009; Panksepp, 2012). Notari (2009) explains that the physiological stress response is designed to be useful in the acute phase, i.e. when an individual's homeostasis and/or environment is perceived to be under threat, triggering the animal to act in order to restore its normality. It is important that the animal is able to perceive threat, make decisions on a course of action and respond. This response is always within the animal's physical and emotional capabilities, and facilitates survival and adaption in the face of danger/change. If patients cannot fulfil this natural response, e.g. when forceful handling is employed and patient choice is restricted, intensification of escape behaviours with or without behavioural shut-down may occur. Attending to the patient's emotional state, as well as the outward physical and behavioural manifestations of stress and distress, therefore matters on many levels including to its clinical condition, which may be exacerbated by the physiological sequellae of stress (Mills et al, 2104).
Recognition and response to body language
Animals use behaviour and body language to express internal feelings, maintain safety, escape aversives and gain desired outcomes. Negative emotions experienced by cats and dogs in the veterinary setting are likely to cause anxiety, fear and/or frustration (Overall, 2013b,c). In the veterinary context, body language and behaviour arising from one or more of these emotions may be aimed at:
Sometimes both fear and frustration are at play, or one leads to another. Learning to observe and respond to a patient's behaviour and understand the significance of body language can help patients to remain emotionally comfortable, prevent undesired behavioural sequellae, as well improving staff safety (Overall, 2013b,c; Becker et al/Fear-FreeSM, 2016).
Canine and feline body language is a visual communication system, used instinctively/involuntarily, and/or offered intentionally to another in order to impart information and/or change the other's behaviour (i.e. it may simply express an emotion, but it may also change the recipient's response to that signal) (Overall, 2013b,c) — Figure 1. Communication may be aimed at distance-increasing, or distance-decreasing, i.e. intended to invite desired interactions with a conspecific/human/other animal (Luescher, 2105; Shaw, 2015).
Emotionally-driven behaviours and body language are frequently seen in the veterinary setting. These may be instinctive, or learned, based on experience, and are an individual-specific, moment-to-moment response to the environment, the situation, and the response of the intended recipient of the communication (Overall, 2013b,c; Hedges, 2014b).
Dogs are obligately social, co-evolving to successfully live within groups and are therefore able to use their body to communicate effectively in social interactions, so as to build relationships and/or collaborate, avoid conflict and/or appease, and to gain desired outcomes (Luescher, 2015).
Cats differ from dogs in that they are selectively social, having evolved from solitary hunters. Cats may therefore choose to avoid social interactions, rather than communicate/risk conflict, which may pose dangers to their survival (International Cat Care, 2015).
In dogs, signals are subtle, in cats often more so. Signals are relatively easy to observe by trained staff. Many body gestures that are frequently used socially by dogs and cats have been identified, including those involving:
Observations for and response to these gestures is important. It can affect how patients behave within the clinic, i.e. they may try to communicate discomfort at the proximity of a person/stimulus and may or may not try to escape if possible, but may escalate their communication attempts in emotional conflict, when their choices are removed, when the perceived threat intensifies, etc. This may result in an animal showing defensive or offensive aggression.
Body language may be categorised under its functional and morphological behavioural descriptions. Some canine examples are shown in Table 1.
| Appeasement (active submission) |
| These gestures, e.g. jumping up, nuzzling, licking, lowering of the body, pawing/paw-lifting, grinning, etc. may be emitted by dogs showing active submission. This is thought to be a defensive strategy which lowers arousal levels, diffuses conflict/aggression, showing that the signaller is no threat. These are often part of friendly greeting rituals, as part of play routines, during et-epimeletic (care-seeking), or allelomimetic (group) activities (Overall, 2013b) |
| Deference (passive submission) |
| These signals are emitted in response to perceived threat, regardless of the intention of the concerning individual. Examples could include turning away, freezing, avoiding eye-contact, rolling over, urination, slow movement, stillness, low tail carriage, etc. These are aimed at showing that the dog is not meeting a challenge, i.e. passively disengaging so as not to escalate a situation they are uncomfortable in (Overall, 2013b) |
| Displacement |
| These signals are aimed at conflict avoidance, and often manifest as incongruous, or out-of-context behaviours. The internal/emotional conflict/cognitive dissonance may result from stress situations such as anxiety, fear, frustration, or motivational conflict — where the animal wants to do something it cannot do/cannot do something it wants to. They may be thought of a ‘self-soothing’ (as opposed to intended to calm another). Examples of displacement behaviours could be shaking off, stretching, yawning, grooming/scratching-self, ground-sniffing, as well as many types of vocalisation, and even aggression (Luesher, 2015) |
| Stress signs |
| These may be any/all of the above emitted in a context in which the dog is emotionally stressed/conflicted. Often the physiological signs of stress are the most obvious in this context — often seen when the more subtle signs have gone unnoticed/are already over/dropped out of the repertoire, e.g. elevated respiratory rate, shivering, increased muscle tension, blinking/squinting, flat ears, rapid/frantic panting, dilated pupils, etc. Usually these overt physiological signs are seen in cases of fear, phobias, especially when combined with a loss of choice/control, and/or there is a perceived threat to safety/survival (Luesher, 2015) |
| Threat displays |
| These are emitted by the signaller to convey warning for various reasons, e.g. defence — itself, or a valued resource, are perceived to be under threat; more subtle conflict-avoidance behaviours have not yielded the expected result; the dog has lost control of its options to escape; the dog has learned these signals through experience and grown confident in the expected outcome (e.g. distance-increasing, resource-gaining); and they may be seen in offensive aggression to gain a desired resource/outcome. These may take the form of slow stalking, hard stare, piloerection, showing of teeth, growling, snarling, lunging, snapping, biting, etc. (Overall, 2013b) |
Like dogs, cats may use instinctive visual signals when anxious, fearful, frustrated, etc. to avoid conflict and maintain control of their situation. Cats are more understated — they may use distance-increasing displays, e.g.:
Within the veterinary clinic, these strategies may fail to be effective, so cats may show more obvious signs such as:
Depending on the individual's temperament and emotional state, its freedom to make choices, as well as the learning history at the clinic, the cat may either: attempt to flee — move away/hide, etc.; or fight — this could include struggling/escape behaviours with or without offensive aggression (Neilson 2009; Rochlitz 2009; Overall, 2013c)
All patient communication signals must be viewed in context as they can change in a second, i.e. escalation/deescalation, allowing a real ‘conversation’ to take place to effect a change in the patient's emotional state if the veterinary professional is able to ‘listen’ and act appropriately, making the situation better for the patient, and safer for staff. When an animal cannot obtain the safety/resource that it needs, it may necessarily escalate defensive strategies to offensive actions to be able to achieve its goals. Overall (2013b) discusses a continuum, where animals move from between stages of emotion, with body language expression reflecting this. As the purpose of communication is to affect change in the recipient's behaviour, response to signalling will change how the signaller responds. This means that the progression of defensive-offensive body language may be, but is not necessarily, linear. Not only will the animal's next move depend on the environmental response to its signalling, but it will also depend on what has previously worked for that individual. For instance, dogs that ‘bite with no warning’ may not have demonstrated a linear ‘ladder-style’ (Figure 2) set of signals, but may skip any previously-ineffective signals so as to ‘get to the point’. This may be seen in situations where the patient feels the need to protect itself from threat (Luescher, 2015; Shaw, 2015).
Knowledge is power — keeping the patient and team safe
When an animal's choices are restricted it may be forced to use its behaviour to help gain safety, if its body language does not work to prevent/remove the threat. Instigation of stressful handling initiates the physiological stress response, which may result in various behaviours including sympathetic freeze-flight-fight behaviours. This may lead to staff injury, as well as a lower workrate efficiency, which may potentially be detrimental to the patient's emotional and physical wellbeing, as well as its clinical condition (Rodan et al, 2011; Overall, 2013a; Hammerle et al, 2015).
Using enforced/forceful handling to ‘just get things done’ can result in flooding (response-blocking), where the animal is presented with a fear-inducing stimulus at excessive intensity and has no choices to employ avoidance strategies. This is likely to be aversive/punishing to patients, causing patients significant stress in that moment, and at future visits because of the learned experience (Rodan et al, 2011; Hammerle et al, 2015). While some patients may attempt flight, or resort to fighting, others may freeze. This may be a temporary conflict-avoidance strategy, but prolonged application of aversives may lead to behavioural shutdown, or learned helplessness. Freidman (2014) states that ‘learned helplessness occurs when an animal learns that its behaviour has no effect on the environment. As a result, even when the power to escape is restored, animals often remain apathetic.’ This shut down animal can be a real concern, but often goes unnoticed when the patient is subjected to accidental anthropomorphism, e.g. ‘oh, look — she's calmed down/being good, she knows we are trying to help her/it's for her own good’ — whereas the animal is silently suffering, potentially resulting in unwanted behavioural, emotional and clinical sequellae.
Hammerle et al's (2015) review article noted that ‘manual restraint increases the likelihood of struggle and risk of injury to staff and patients'. Enforced handling can pose risk of injury to staff, which impacts not just on the individual veterinary surgeon/veterinary nurse, but may have knock-on effects on other staff, and the practice work-flow.
Punishment, even inadvertent, may exacerbate fear and/or frustration, with the potential for dangerous behaviour, thus worsening handling problems. It is damaging to the veterinary-patient/client relationship, and will invariably become associated with the person and/or environment in which it occurs (Pryor, 2002; Price, 2015).
Learning to approach patient care in a way that offers the patient at least the illusion of choice can help with all of the above scenarios (Figure 3, Box 4).
According to Rodan et al, 2011; Overall, 2013a; Hammerle et al, 2015; Martin and Martin, 2015, as well as reading and responding to body language, ideas for positive, successful veterinary experiences for cats and dogs could include:
Proactive use of anxiolytic medications with or without sedation in PFP
Confidence in reading and responding to body language can also be an indicator of when to consider the use of medication. Rodan et al (2011), Overall (2013a), Becker et al/Fear FreeSM (2016) , and others, advocate for prompt, or preferably pre-emptive, administration of an anxiolytic medication with or without the use of a sedative to prevent, rather than alleviate, stress whenever possible. Many of the cited authors discuss the ‘two try rule’, i.e. if an intervention is not easily achievable within two easy attempts, then psychogenic medications should be considered. Anxiolytics can be an important part of PFP, both to prevent and alleviate stress while facilitating necessary handling and/or a procedures, as well as in many behaviour modification plans to teach anxious patients how to cope better at the clinic. In pre-emptive/preparatory training protocols, drugs may also part of a multifaceted approach to help the patient relax, feel less anxious and to prepare it to be able to learn, so that behaviour modification can take place (Bennet and Sparkes, 2015). While this will always be a veterinary decision, and extended discussion of medication is out with this article's remit, the use of anxiolytics is rarely clinically contraindicated. It is usually considered preferable to the physiological effects of stress on the patient, as well as the injury risk to patient and staff — anxiolytics are best used pre-emptively where possible to facilitate PFP (Rodan, et al, 2011; Becker et al/Fear FreeSM, 2016).
Conclusion
Regardless of the patient's species or clinical presentation, recognition of conflict-avoidance signals may help to identify escalating/de-escalation stress levels. This, in conjunction with environmental arrangement and preparation, as well as caregiver education, can allow measures to be taken that will:
Objectively assessing the efficacy of PFP may be difficult, i.e. prospective studies comparing the effects of PFP on patients, versus enforced/forceful handling would be ethically difficult to justify. However, there are many measurable behavioural parameters, including body language that may help veterinary staff assess effectiveness of their efforts. Becoming adept at this should help veterinary professionals to tailor their approach to individual patients, preventing escalation of problematic/dangerous behaviours, and allow decisions on appropriate anxiolytic medication to be expedited.