The VN Futures scheme set up by the British Veterinary Nursing Association (BVNA) and the Royal College of Veterinary Surgeons (RCVS) has identified several issues in veterinary nursing today. These are organised into themes affecting the profession, which have produced a number of ambitions for the future (VN Futures Action Group, 2016):
- Creating a sustainable workforce
- Structured and rewarding career paths
- Confident, resilient, healthy and wellsupported workforce
- Proactive role in One Health
- Maximising nurses' potential
- Clarified and bolstered veterinary nurse's (VN) role via a reformed SIII.
The VN Futures working groups are aiming to address these. You may have seen the issue being referred to as the three ‘Rs’, as the below are the initial factors that were raised as issues in veterinary nursing:
- Recruitment
- Returning to work
- Retention.
As discussed in part one, the ambitions appear to show a hidden theme. In many senses, veterinary nurses are not a visible profession to clients, to veterinary colleagues and sometimes even to each other in the veterinary nursing community; veterinary nurses are invisible.
Part one discussed the issues of appearance, uniform and the impact of television's portrayal of the nurse's role (Davidson, 2017). These individual issues combine to create a role that can be hard to identify.
In this article the lack of veterinary nursing's visible identity the issue of financial invisibility is discussed and set into context within the issues of recruitment, returning to work and retention.
Missing financially
It would appear that the income generated by veterinary nurses is hidden within the practice's income (Davidson and Marsh, 2017). Within the VN Futures Report 2016 (VN Futures Action Group, 2016) it has been suggested that clients should pay for nursing time when attending nurse clinics. But, how can veterinary nurses expect clients to suddenly start paying for nurse clinics if they have never paid for veterinary nursing skills before?
This is another contributing factor to the ‘hidden’ role of the veterinary nurse, if employers cannot invoice for veterinary nursing time and skills, how do they know how much income veterinary nurses bring into the practice? How can a veterinary practice as a business run without knowing who does what and how much it costs?
Salaries are often referred to by accountants as variable costs, but most practice managers know these are actually fixed costs and treat them as such (Girotti, 2011). For veterinary surgeons, salaries are often offset against fees earned. If no fees are accrued to balance against costs of a veterinary nurse salary, it is possible they could even be seen as a financial burden to the business.
Figure 1 shows a veterinary invoice for surgery for a 5 kg dog from 2016. Members of the profession, veterinary surgeons and veterinary nurses will likely recognise the tasks that would be apportioned to them in practice, but a client receiving this may not be aware of the specific roles the veterinary nurses had in their pet's care, leaving the veterinary nurse role invisible. This invoice also had all the income apportioned to the veterinary surgeon. The pricing column has been removed as it would have shown information that could identify the veterinary surgeon. When asked, the practice principle did explain that the monitoring fee was intended as a nursing fee, yet he admitted that the costs would go to whoever had priced it up and that the nursing aspect of the role was only for internal use. Leaving the income generated by the veterinary nurse invisible for this patient.
A profit centre is an area of the practice where the same income-earning activity takes place every day. Thus, a small animal practice may be split into the following profit centres:
- Consulting
- Surgical suite
- X-ray
- Laboratory
- Pharmacy
- Procedures room
- Dentistry
- Wards and hospitalisation (Coates, 2014).
In some of the sections above the veterinary nurse will carry out the greater work load (wards, hospital, laboratories) and will carry out the majority of the fee making tasks, yet it is rare to see ‘vet nurse’ listed on a client invoice. Veterinary nurse skills that could easily be itemised include:
- Placing an IV
- Monitoring anaesthesia
- Starting and monitoring fluids
- Administration of medication
- Nursing care
- Bandage care
- Physiotherapy
- Consultations.
This creates an issue for the business as well as the client. How do employers and employees truly know what tasks veterinary nurses are carrying out and what skills they bring to the practice, how much these cost and how much profit is made? Running a business without being able to cost accurately what a large part of the team do would suggest a business is not working as efficiently as it could.
The client will see the veterinary surgeon in the consulting room and then at patient discharge, and they will see the veterinary surgeon listed on the invoice. Anecdotal evidence and personal experience suggests it is unusual to see the veterinary nurse title or a named veterinary nurse listed on an invoice. This could be seen to confirm the myth to the client that the veterinary surgeon has been with their pet 100% of the day, and that every procedure is performed by the veterinary surgeon.
Recently a veterinary invoice was reviewed by a veterinary surgeon and a veterinary nurse to see if they could agree on how much on the invoice was carried out by a veterinary surgeon or veterinary nurse. The result was interesting as the veterinary surgeon actually apportioned more of the invoice to the veterinary nurse than the veterinary nurse did (Marsh, 2017). Yet the invoice was made out solely in the veterinary surgeon's name with no mention of the word ‘nurse’.
It does raise the question — do we charge appropriately for veterinary surgeons' (and veterinary nurses') time?
Coates (2014) has noted:
‘It has become anecdotal that veterinarians in the UK tend to undervalue themselves and often undercharge for their services. To make matters worse, there is a lack of suitable benchmarking data to enable comparisons to be made in order to inform pricing decisions’.
If veterinary surgeons are not charging appropriately for their own time then how can they charge appropriately for veterinary nursing time? How can veterinary nurses be a financially viable and recognisable part of the veterinary care team without invoicing tasks to their role?
The issues associated with being ‘hidden in full view’ (where the veterinary nurse clearly exist but what they do in practice is hard to identify) may seem not to be linked; however, what veterinary nurses wear, how they are viewed on TV, and how they are missing financially impacts hugely on the issues facing the industry today — recruitment, returning to work and retention.
Clear career progression and longevity of career
Gender equality and recruitment There are a number of problems that are associated with the lack of visibility of veterinary nurses, and it would not be possible to complete these articles without commenting on the gender issues facing the profession. The industry needs more veterinary nurses (VN Futures Action Group, 2016), and as a career that uses many science, technology, engineering and maths (STEM) skills that are traditionally seen as male, it would seem that recruiting from across the genders would be key, as attracting more males to the role would double the potential pool of students. Yet this is challenging. The nursing role has been historically a female one and this image persists today; the image in the first part of this article of a nurse call button shows the commonly used ‘universal’ image of a nurse. The same is true in veterinary nursing and this can make attracting male veterinary nurses hard. The lack of recognition for the role can make it hard for all, but few men are going to be attracted into a profession where the monetary incentive is limited and the status of the role aligned with feminine attributes (McLaughlin et al, 2010).
The continued use of females in dresses as the ‘veterinary nurse image’ on practice websites and social media will only add to this problem. Efforts to make the profession more visible should be combined with tackling gender-associated issues, and gender neutral uniform options must be considered.
In communicating the veterinary nurse's role the industry must use positive role models and communicate these to the public. Posters showing veterinary nurse uniforms and veterinary nurses performing appropriate veterinary tasks would promote the role and increase awareness. Simply producing posters of a female nurse in a bottle green dress is not enough to promote the role, and is confusing as not all practices have green uniforms for veterinary nurses, not all nurses are female, and a dress is not a practical uniform option for many.
Returning to work
In the author's experience, veterinary surgeons are more able to return to work than veterinary nurses on flexible or reduced hours after maternity leave. Some practices may employ lay people and require veterinary surgeons to undertake tasks usually completed by nurses, such as administering medication or placing IV catheters; this puts pressure on the veterinary surgeons. This is made easier if the practice dresses staff in similar uniforms irrespective of the roles they perform — visually the team looks the same to the public, yet the skills they are capable of may be very different.
If a veterinary nurse was more financially visible, as discussed earlier, it would be easier to see the financial benefits resulting from his/her employment whether on a full or part time basis.
When considering a return to work, veterinary nurses could benefit from knowing what tasks and roles will be of most financial benefit to the practice. This would provide the information for both veterinary nurse and employer to make informed decisions about the benefits of part time veterinary nurses. In an industry that has a huge flexibility in the hours that can be worked, every effort should be made to utilise the skills of experienced veterinary nurses and this includes all parties acknowledging the positive financial impact the veterinary nurse role has on a practice.
Career progression and retention
If there is no scale of fees for veterinary nursing skills how easy is it to decide what skills to learn and improve to advance a veterinary nursing career? It is clear which skills and surgery make the most money for veterinary surgeons and so they can plan continued professional development (CPD) and career advancement with this is mind.
The recent RCVS Schedule 3 survey results have provided evidence that veterinary surgeons and veterinary nurses agree the veterinary nurse role can expand. This is both within the current guidance and also with a view to reviewing tasks in the future (Robinson et al, 2017). If veterinary nurses are to undertake more training and carry out more skilled tasks there needs to be a way to trace the improvement in patient care and increase in income created by those individuals.
As a veterinary nurse would it not be amazing to know which skills would earn them more money? What CPD would boost their career? While some practices pay more for further qualifications it seems to be given whether they use their skills or not. Perhaps an incentive for using their new skills and improving patient care would make veterinary nurses more motivated to undertake advanced and structured CPD? If there is only one veterinary nurse in the practice placing naso-oesophageal feeding tubes, for example, should they not get the financial recognition for this, as their skill base is more advanced than their colleagues? If there are only veterinary nurses managing feeding tubes should this not be noted on the clinical records and the invoice?
While many do advance their skills, it is hard to chart the progress. This seems to be because they do not always get to write up their cases and patient notes, or apply fees to their new skills. They often rely on other people's perceptions of their skills and their role in a team rather than hard evidence of what they have done, and this evidence is not always recorded in the clinical notes.
The vet blogger Nick Marsh, wrote a blog about the veterinary nurse's financial lack of identity. Nick's words speak for the veterinary nursing situation:
‘seeing an invoice go out with the vet's name next to every one of these items is further evidence that nurses have a long way to go to achieve the recognition they truly deserve: recognition for their training, their knowledge, their support, and their indispensability in the veterinary world’ (Marsh, 2017).
Lessons from human nursing
In their book The Profession of NursingJones and Bartlett (2014) have an informative chapter — The image of nursing. What it is and how it needs to change. This is written about human nurses but can be applied to the veterinary nurse role. Jones and Bartlett give practical advice for the employer and employee to promote the role of nurse, but their most important piece of advice is that each RVN is a powerful advocate for the profession and should realise their power and use it.
Conclusion
The conclusion to the issues described in the two articles on visibility of the nursing profession could be — what do veterinary nurses and the profession do about this? Do they design new uniforms? Appear on TV? Demand equality in billing rights? All of these could raise the veterinary nurses profile, but are these options the correct way to do this?
While some aspects of these actions may help, veterinary nurses have perhaps a greater power. What veterinary nurses choose to do individually and for their practice will be down to the different roles they have and the places of employment.
Each veterinary nurse can make a difference in their own way. The way veterinary nurses are perceived and how they promote their role is down to each one promoting themselves. There are some 13 500 RVN voices in the UK (VN Futures Action Group, 2016) would the best move forward for their profession be to utilise every voice?
Every veterinary nurse can wear an appropriate uniform that is clean, wear their RCVS badge, promote their image in their practice through posters explaining who they are. Get their skills on the client invoice and get the income from nursing skills apportioned to the nursing team and to individuals. If veterinary nurses appear in the media they should wear appropriate clothing and their badge. Remember to speak to clients professionally and politely and speak about veterinary nursing in a positive fashion and promote their role wherever they are.
If veterinary nurses achieve these small changes they are moving towards a visible profession which will bring its own rewards in improving recruitment, returning to work and retention.
KEY POINTS
- The veterinary nurse's role is hidden in many ways and these need addressing to allow the role to be visible.
- Financially the veterinary nurse is lost as there is rarely an invoice with nursing skills specified. This creates an image for the client that the veterinary surgeon is involved with all aspects of the patient's care and relegates the nurse to the role of handmaiden.
- The veterinary nurse also then suffers as any income generated is not identifiable as being from the veterinary nurse, relegating the salary of a veterinary nurse to a cost to the business and not a balance between salary and income.
- The recent RCVS S3survey results have supported an increase in delegation to the veterinary nurse. This needs to be in conjunction with an increased recoginiton for the role
- Each individual has the power to promote their own vet nurse role. Use the S3 survey results to start the conversation to promote your role where you are.