The concept of ‘out of hours’ veterinary care is not a new one. For as long as the industry has existed, provision has been made to ensure animals receive around the clock care. Currently, a number of different types of emergency provision are available, from individual practices providing care for their own clients, to specialist night service providers, who provide care around the clock for a number of practices. Moral, ethical and professional issues may arise centring on client expectation and the reality of inpatient checks which take place during overnight hospitalization.
Reasons for overnight hospitalization include: chronic illness; acute conditions; postoperative care; analgesia; and emergency admissions. Not all cases are necessarily comparable, nor need a similar amount of involvement or intervention overnight.
Client awareness
In order to ascertain information about client expectation, primarily relating to frequency of checks during hospitalization, a six item questionnaire was circulated among 50 individuals within Norfolk and Suffolk. All were pet owners, and none were involved in the veterinary industry, except as a consumer. Forty five completed questionnaires were returned, 8% of which were from participants directly known by the author, with responses being anonymous. The sample was randomized and included individuals located within the East of England only. Participation was optional and the reason for carrying out the survey and how the results would be published was explained in writing. The questions included were all open questions, to avoid leading the participants in any way. The findings are summarized in Table 1.
Table 1. Summary of key questions asked and responses given
| Question asked | Example response given |
|---|---|
| What do you know about the ‘out of hours’ provision provided by your veterinary practice? |
|
| If your pet was admitted for overnight care, how often would you expect your pet to be checked? |
|
| Do you know what guidance the Royal College of Veterinary Surgeons provide to veterinary practices on frequency of inpatient checks after hours | All respondents answered no to this question |
It was interesting to note that while some pet owners were aware of the emergency out of hours provision by their veterinary practice, and some had actually accessed this, none of those who completed the questionnaire had a clear idea of how often their animals were, or should be checked while hospitalized overnight, with a wide range of time intervals suggested (from 20 minutes to once a night). In terms of guidance given from the Royal College of Veterinary Surgeons (RCVS) on this issue, all respondents answered that they had no knowledge of this information.
However, it is worth bearing in mind that clients accessing emergency services may have been provided with this information, but could not remember or retain the information, which may be due to the stress of dealing with an ill or injured pet.
Background
The routine of carrying out round the clock veterinary care has implications for clients, inpatients and the veterinary team. A workable treatment plan which incorporates appropriate checks has to be arranged. Prioritization is usually given to patients who are most critically ill.
According to the Guide to Professional Conduct for Veterinary Surgeons 2012, ‘diferent levels of care required arise in differing circumstances:
- Intensive care
- Post-operative recovery
- RTAs and some orthopaedic procedures
- Whelping and kittening
- Stabilizing procedures, e.g. for diabetics
- Pending laboratory or other test results
- Refuge — awaiting re-homing or abandoned’
RCVS guidance also states that:
‘Clients are entitled to have their animals housed in a comfortable environment, monitored and treated by day and night, as appropriate to the animal's condition, by persons with the requisite knowledge and expertise’
(Royal College of Veterinary Surgeons, 2012a)
Guidance on out of hours provision is provided by the RCVS within the Guide to Professional Conduct for Veterinary Surgeons 2012, which stipulates that emergency care should be provided after normal clinic opening hours, although this does not have to be carried out by individual practices, as using an external provider is acceptable (Royal College of Veterinary Surgeons, 2012a). However, the Guide also advises that practices should ‘ensure that clear written information is provided about practice arrangements, including the provision, initial cost and location of the out of hours emergency service, and information on the care of inpatients’. Such knowledge is not refected by many of the participants of the questionnaire, with the clients who knew about the out of hours provision at their practice being those who had had to access it previously. A number of issues could arise from owners not being aware of the out of hours arrangements including: possible delay in animal treatment (due to travelling to an unknown practice), and distress and confusion to clients, who may have to make an unfamiliar journey late at night. These could be avoided by planning route/obtaining directions in advance. Reduced client satisfaction and confidence in a practice could also arise.
Different methods of communicating out of hours information should be considered, as studies have shown that individuals respond to a variety of communication materials to varying degrees ‘there is no single correct way to communicate’ (Pichler, 2010). Also, timing of the information should be considered. Ideally such information should be provided to clients prior to them accessing emergency care, as emotion can be a barrier to effective communication (Gray and Moffett, 2010). This is a barrier which potentially affects both the client and the member of veterinary staff (Quill, 2000).
Prior to leaving their animal at a veterinary practice, owners should be made aware of the level of supervision the animal will be given overnight (which could include the proposed frequency of checks, based on information at admission). It is possible that the proposed plan may change due to changes in the animal's health status during the night. This should be explained to the owner, with contact offered to update on the situation throughout the hospitalization period.
Another key element of communication regarding hospitalization should also include an explanation to the owner of the proposed cost. It is likely that intensive care cases could be more expensive than routine overnight hospitalization with minimal intervention, due to higher levels of consumables and other resources being used, as well as increased levels of involvement from members of the veterinary team.
Studies in human medicine have examined inpatient care, elements of which are relevant and can be applied to veterinary care. One such element which is important to consider is the lower staff to patient ratios which are usually present during out of hours services, which can be supported by use of monitoring devices (e.g. intravenous fluid pumps, set with sound alarms). Combining these elements has been shown to improve patient outcome (Esoga and Seidl, 2012).
The role of the night veterinary nurse
The role of the night veterinary nurse will vary from practice to practice, but can generally be summed up as providing assistance to the duty veterinary surgeon, supporting clients and providing care to inpatients.
Guidance for veterinary nurses
Veterinary nurses are given direction primarily by the duty veterinary surgeon. Since the non-statutory register of veterinary nurses opened in the UK in September 2007, registered nurses are required to consider moral, professional and ethical implications of a variety of situations encountered in veterinary practice, and act appropriately. Accountability is defined as ‘taking responsibility for an action’ (Killeen, 2001). Therefore registered nurses need to acknowledge responsibility for their actions, and ensure that they act in the best interests of the patients, clients and veterinary practice team that they are working with, or face possible complaints and disciplinary action. This has been refected within the updated Guide to Professional Conduct for Veterinary Nurses (Royal College of Veterinary Surgeons, 2012b), which provides information and guidance (via the booklet and online). More responsibility has now been placed on veterinary nurses, and it is important that all nurses are familiar with the guidance within this documentation.
There are a number of sections within the guide, those most relevant to out of hours provision being: 24 hour emergency first aid and pain relief; practice information and feeds; communication between professional colleagues and clinical governance. The relevant areas are discussed below.
Veterinary professionals are now advised to refect on any unexpected critical events which may occur, as well as on communication with other members of the work team and clients, learning from any outcomes, and making appropriate changes to practice.
In the case of concerns regarding provision of out of hours care, if duty nurses have any issues these should first be highlighted to the duty veterinary surgeon. It may be that if unresolved, whistleblowing may be an option, although this raises its own professional and ethical concerns (Welsh and Bayliss, 2012). Practice meetings involving the night team, which evaluate the service and client feedback could aid revision of protocols where necessary.
It is important for nurses to remember that their ‘primary moral and professional duty is to your clients and to the animal patients’ (Rollin, 2006). In a case study on out of hours care reported by Rollins, it is noted that a key element for consideration is if the animals are satisfied, this does not necessarily mean that the best patient care possible has been provided. While client satisfaction is vital, it should not be the only element for consideration.
Duty of care
Duty of care primarily applies to the client rather than the animal in veterinary practice (Donaghue vs Stevenson, 1932). Hendrick (2000) states a duty is owed to anyone who is reasonably likely to be affected by an act which is either carried out or omitted. If a breach in the duty of care is suspected, the injured party (in this case the client) must prove that the care or service that has been provided falls below a reasonable expected standard of practice. This can be defined as what an ordinary skilled professional would have done if faced with the same situation. It is not concerned with comparisons to the best possible treatment in a particular situation. The harm that is caused also needs to be foreseeable (e.g. giving an anaesthetic to a patient, without informing the client of the risks of this procedure, which then suffers an adverse reaction and dies, could be argued to be foreseeable harm). This could relate to inadequate frequency of inpatient checks, although the required frequency can only be determined by the information available for the patient at the time. In order for negligence to take place the harm must be foreseeable.
‘Client expectation should be a key consideration when dealing with admission of patients for overnight care.’
Client expectation
Client expectation should be a key consideration when dealing with admission of inpatients for overnight care. Perceived care for the animals may be unrealistic, or unnecessary, but intentions or care plans for the patients in their care should be made transparent to owners prior to gaining consent to treatment and also for payment to be collected. It may be worth considering educating clients regarding this element of overnight care prior to emergency events, to allow information to be fully processed.
Legal concerns
The Animal Welfare Act (2006) legislation was drawn up to promote the health and welfare of companion animals. The Act stipulates that the Five Animal Needs should be met by an animal's primary care giver, who could be argued to be the veterinary team while a patient is hospitalized. In the section on promotion of welfare the Act highlights five animal needs which are based on the Five Freedoms:
- Freedom from pain, injury and disease
- Freedom from hunger and thirst
- Freedom from discomfort
- Freedom to express normal behaviour
- Freedom from fear and distress.
It could be argued that without reasonably frequent checks throughout the night during hospitalization, one or more of these freedoms may not be met (as much as each is possible depending on the condition of the animal and/or reason for its hospitalization). Not all of the freedoms may be met even with constant monitoring, however the aim should be to incorporate these needs into the treatment plan wherever possible, e.g. walking dogs outdoors if condition allows to provide opportunity to urinate and defecate rather than soiling the kennel environment, which could be said to be a more natural behaviour, or providing intravenous fluid therapy to maintain hydration in an animal which is unable to drink, to avoid thirst where possible. How much each can be met will depend on each individual case.
The nature of the checks which are proposed to be carried out should also be considered. Physical and visual checks form part of inpatient care. While hourly physical checks (taking the patient out of the kennel, taking pulse, respiration and temperature readings) may appear desirable, this may not be advisable in all cases. Some species are prey animals (such as rabbits, guinea pigs) which may find frequent handling stressful. Also animals that are in pain, or find the hospitalization process stressful, could find frequent handling problematic. Care can sometimes be accomplished by visual checks, respiration rates can be monitored visually, as well as eating and drinking patterns, posture and ability to move around the kennel space. A consideration for planning inpatient checks should be the effect of stress on the body. Production of cortisol has been linked to delayed healing time and less efficient immune system responses leading to animals being more susceptible to attack from secondary disease (Moberg and Mench, 2000).
In addition, in entering into a contract with the client (consent form, agreeing to pay for services including overnight care) there is a degree of expectation of the level of service that is to be provided. This could be better established by increasing client communication about how frequently checks are proposed to be carried out, and what factors may lead this plan to change.
The nature of out of hours or emergency care is such that a full and frank discussion of these issues may not be appropriate at the time of admission, due to the urgent nature of the treatment of the animal, and the emotional state of the owner, as this is often a time of great distress. Communication is affected by a number of factors, emotion being a significant barrier to effective communication. Many owners will experience a number of emotions when bringing their pet to a veterinary surgery for possible hospitalization (stress, guilt) and these are all potentially obstacles when conveying information about patient care. It is important to note that some elements could be communicated to clients prior to the time of admission, e.g. waiting room posters displaying the out of hours provision for the practice, including contact numbers, location and cost, and general information about overnight provision of care. This could then mean that less information needs to be communicated to the client at a time when great distress may be experienced, but the client is still well informed.
Ethical considerations
There are a number of key ethical schools of thought, which can be applied when making decisions in veterinary practice. One key school of thought which was heavily influenced by Mill and Bentham (2000) is utilitarianism, which is concerned with creating a consequence which provides a positive outcome for the greatest possible number, with little regard to rules and regulations.
Deontology is another key branch of ethical thinking, which is less concerned with consequences, and more concerned with making a decision based on abiding by rules and professional guidance.
In terms of decision making in terms of planning inpatient care and checks, an element of each could be relevant. It would be desirable to provide the best possible care for all patients (utilitarianism), while abiding by relevant regulation and remaining professional (deontology). The consequences of following one school of thought without the other, would be possible negligence of inpatients, or disciplinary action being necessary against members of the veterinary team. Veterinary nurses should seek guidance from the duty veterinary surgeon as to frequency of checks, and which staff member is responsible for the check. There may be obstacles to completing planned inpatient checks (carrying out surgery, taking emergency phone calls, assisting clients at the practice, aggressive temperament of inpatients) but this should be communicated to other members of the out of hours team as soon as possible, to allow the check to be completed at the earliest possible opportunity.
When considering the best course of action, as registered veterinary nurses, understanding ethical and professional implications of situations encountered is vital. Dealing with ethical situations in practice can be stressful (Wisemann-Orr et al, 2007) and staff are not necessarily expected to have the answer to every situation they are faced with. If registered nurses are faced with ethical dilemmas, the Professional Conduct Department at the Royal College of Veterinary Surgeons can be contacted for advice and support.
The questionnaire: what owners should know
Ideally when responding to the questionnaire, clients would be able to identify out of hours provision for their practice, demonstrating an understanding of the provision available (e.g. staff on site throughout the night versus visiting the practice for scheduled checks). A proposed care plan could be outlined on admission, with an agreement with the client made on when to inform should the care plan change, and the relating costs. Information relating to out of hours arrangements could be displayed around the practice (contact telephone numbers and maps if an alternative location is used are vital). This can be in a variety of forms, as research shows no one method of communication suits all. Practice websites can also be used to display this information. Practice protocols could be used to guide staff, and ensure standardization (e.g. all patients are checked every 2 hours minimum) and may depend on the staff on shift (dedicated night staff versus those who work the following day), with follow-up meetings to discuss effectiveness of the protocol or any issues arising.
Conclusion
It is the moral, ethical and professional duty of veterinary nurses to provide a high level of care to the animals in their care, as well as effective communication to clients about the proposed care their animals will receive.
It could be questioned as to whether it is morally or ethically correct to take payment for a service which clients may not be fully informed about. Following on from this it is important that clients are well informed and pricing is as transparent as possible for each case.
Having knowledge and understanding of the issues surrounding patient treatment plans is vital in order for veterinary nurses to maintain professional behaviour. Examining the ethical and moral implications of cases encountered may not change the treatment that is carried out, but if applied correctly should lead to a number of positive elements, including higher standards of client communication, less cause for complaints, improved teamwork within veterinary practices and improved job satisfaction overall.
Key Points
- Out of hours provision is a key element of veterinary care.
- Client communication and understanding of this issue is varied, as illustrated by questionnaire findings.
- Frequency of overnight checks of inpatients can be based on a number of different factors.
- Guidance is provided on out of hours provision by veterinary practices, but this is not prescriptive in terms of intervals between inpatient observations, due to the individual nature of each case and practical provision.
- Further communication may be needed in order for clients to have an improved understanding of the provision given or available for their animals, which could be linked to improved client satisfaction and fully informed consent.