Studies such as Roshier and McBride (2013) suggest that many veterinary staff do not feel fully confident in offering clients behavioural advice and are often reluctant to do so during consultations. Many veterinary staff may not wish to specialise in behaviour or may find it difficult to devote the time to supporting clients through modifying their pet's behaviour. However, considering the links between behavioural change and medical conditions, it should be a basic requirement of all veterinary practices to be willing to discuss behavioural changes in companion animals, and to be able to offer first aid behavioural advice prior to specialist treatment (Zulch, 2019).
Enhancing animal welfare and improving practice profitability
Annually, more pets are euthanased, abandoned or rehomed for behavioural reasons than as a result of medical problems (Overall, 2013); and the majority of these animals are under 3 years of age. This suggests that the introduction of behavioural support in the form of preventative and first aid advice, will not only enhance the welfare of veterinary patients, but it will also enhance the practice's financial health. Every animal lost from the practice due to behaviours, which result in a breakdown in the owner–pet bond, results in the loss of practice income for annual vaccinations, routine parasite control, routine surgery and the medical support that would have been required during the animal's senior years. In addition, timely advice and owner education prevents owners from repeating the same animal welfare mistakes (also resulting in owner misery) with subsequent pets — a win/win situation for everyone.
Improved welfare: pets, owners and staff
‘Inability to effectively cope with fearful and stressed animals in the clinic was preventing adequate care being given and compromising health and welfare,’ stated Jonathan Bloom, a speaker at the 2018 SPVS Veterinary Management Group Congress (Kernot, 2018). Dr Bloom went on to explain that over half of the patients treated at a veterinary clinic are stressed and, hence, helping animals to arrive and remain in a clam state is half the battle to ensuring that adequate veterinary care can be provided.
However, to enable animals to remain calm, they must be able to cope (Mills et al, 2013). Veterinary staff therefore need to be aware of the ethology of the individual species that they handle, understanding and providing for their natural coping requirements. If different breeds of a species are treated within the practice, breed-specific differences must also be taken into account. Such competency from the entire veterinary team enables the development of consistent practice strategies that protect patient, owner and staff. Not only will the provision of sensitive handling and enhanced opportunities for patients to cope prevent unnecessary negative learning regarding those attempting to handle the animal (both within and outside the practice premises), it will give opportunities to educate owners. In addition, sensitive treatment of patients helps to ensure that owners are more willing to present their pets at the practice as soon as health problems are spotted — rather than presenting patients as a ‘last option’ choice, either as a result of having observed distress in their pet at the practice or following embarrassment regarding difficulties that their pet may have previously caused for the staff.
Many practices have already experienced advantages for their feline patients through following the guidelines created by the International Society of Feline Medicine (ISFM) (Box 1) for ‘Cat Friendly Practice’. A similar ‘Dog Friendly Practice’ scheme has been initiated by the British Veterinary Behaviour Association (BVBA) (Box 1), and this may be of interest to practices that would like to improve the welfare of their canine patients.
Box 1.Useful information and contacts
- Association of Pet Behaviour Counsellors (APBC): www.apbc.org.uk (includes free-to-download advice sheets for clients)
- The Association for the Study of Animal Behavious (ASAB) register of certified clinical animal behaviourists: www.asab.org/ccab-register
- The Animal Behaviour and Training Council (ABTC) register: http://www.abtcouncil.org.uk/index/abtc-members-by-region.html
- Advisory Council on the Welfare Issues of Dog Breeding: http://www.dogadvisorycouncil.com/puppy/index2.html
- Blue Cross – Dog: https://www.bluecross.org.uk/pet-advice/choosing-right-dog
- Blue Cross – Muzzle training: https://www.bluecross.org.uk/pet-advice/dogs-and-muzzle-training
- British Veterinary Behaviour Association – Dog Friendly Practice: www.dogfriendlypractice.com
- Cat Protection – Kitten Socialisation: www.cats.org.uk/kitten-socialisation
- Dogs Trust – Buying a Dog or a Puppy: https://www.dogstrust.org.uk/help-advice/advice-for-owners/buying-a-dog/buying-a-dog
- RSPCA Buying a puppy: https://www.rspca.org.uk/adviceandwelfare/pets/dogs/puppy
- International Cat Care – International Society for Feline Medicine: icatcare.org/advice
- Rabbit Welfare Association: rabbitwelfare.co.uk/rabbit-housing
- Sound Therapy for Pets: www.dogstrust.org.uk/help-advice/dog-behaviour-health/sound-therapy-for-pets
Behavioural awareness adds value to the practice
By becoming the ‘go to’ place for behavioural advice (even if the practice then refers cases on), clients will appreciate that your practice is doing all that it can to enhance the welfare of their pets (Zulch, 2019). However, to maximise the behavioural health of pets, it is important that all practice staff are able to make a consistent, evidence-based response to client queries, so that if an owner speaks to different staff members on different occasions, they always receive consistent advice.
Behaviour-based pamphlets and newsletters from sources such as the Association of Pet Behaviour Counsellors (see Box 1 at the end of the article for details) and the strategic use of simple questionnaires (e.g. for all owners of adolescent pets or pets that are entering their senior years to be completed prior to a consultation) can then form the basis of appropriate veterinary questioning that can track behavioural health. This can help owners to realise, for example, that age-related changes are not inevitable and that the practice can assist and support the ageing pet.
Additional roles for nurses
Of over 800 000 puppies entering the UK dog population annually (Laurence, 2019), only 250 000 of them result in Kennel Club registration. There are thousands of accidental or hobbyist breeders, most of whom would benefit from advice regarding the developing legislation surrounding the breeding of dogs, as well as how to avoid prosecution under the ‘sale of goods’ and animal welfare acts through failing to produce puppies that have sufficient resilience to cope with their role as domestic pets.
Therefore, the nurse's role of educator should extend to both breeder and potential purchaser, as well as the new dog owner who welcomes a puppy (especially if the source has inadvertently been one that is illegal or ‘farmed’) or a re-homed dog into their home. However, this level of care and advice for prospective owners should extend to all companion animal species. In particular, prospective owners should be warned of the dangers of sourcing a pet through the internet, a system that allows a wide array of illegal commercial and welfare practices to proliferate and continue — not least the flourishing trade in breeds of species with breed-specific physiological problems (Laurence, 2019). However, under-recognised is the misery experienced by many of the foreign pets that are ‘rescued’ and brought to UK — not to mention the distress of the new owners who try to rehabilitate them (Bacon, 2019). Realistic discussions between prospective owners and veterinary staff regarding the needs of such pets can prevent their inappropriate placements (and potentially educate the public regarding supporting better solutions for the needs of such pets within their home countries).
As legislation starts to close the loop holes surrounding animal welfare, the veterinary nurse remains an essential link in educating the public (Figures 1 and 2). Sadly, it is unlikely that the majority of prospective pet owners will pay for such advice, so free nurse-led advice sessions or individual nurse consultations would appear to be the most likely way forward. Such sessions could be species-specific or they could cross species, potentially drawing in those who already consider themselves experts in their own pet's species. This would enable nurses to tackle emotional and behavioural welfare issues arising from anthropomorphism that often forms a barrier to owners recognising the species- and breed-specific welfare needs of their pets.
Link between pain and behaviour
‘The inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment’ (Self, 2019). However, many of the patients presented in behavioural clinics are communicating their pain through behavioural change. This places a responsibility on the veterinary professional to thoroughly investigate owner reports of behavioural change, as not all animals will demonstrate the classical signs of pain that veterinary professionals would traditionally expect to observe. Animals with muscular/skeletal/renal pain, for example, will be extremely reticent to move from a resting position, potentially resulting in aggressive responses towards family and other household pets who disturb them.
The anticipation of pain results in an animal learning to initiate distance, creating communication in response to the approach of animate stimuli. It also results in other household animals learning to predict such responses, altering the social dynamics within the home. Such pain-related problems can be anticipated in older pets; but in young pets, even a temporary injury may result in instant learning, creating long-term aggressive responses to stimuli present at the time of the pain experience, both when the injury was sustained and for the duration of recovery from the acute incident (or potentially during ongoing chronic discomfort). Even relatively short-lived painful episodes can result in considerable behavioural change, resulting in, for example, learned defensive aggression, sound sensitivities and separation-related problems
Although the associated learning can be long-term, requiring behavioural modification, timely and sensitive questioning of owners can enable appropriate veterinary investigations and the initiation of analgesia. An awareness of ‘pain faces’ for specific species and alternative, species-specific behavioural signals of pain and discomfort are essential in such cases (Table 1).
Table 1. Examples of common behavioural changes that may be signs of discomfort and unwellness (Zulch, 2018)
| Behavioural change | Potential associated conditions |
|---|---|
| Dogs | |
| Anxious and aggression around resources |
|
| Aggression to people or other dogs in situations where movement may be necessary | |
| Aggression to people on handling or towards approaching dogs | |
| Anxiety, reduced sociability in senior dog | |
| Constant chewing/scavenging | |
| Excessive licking at surfaces (especially if also occurring during owner absence), pica or stone eating | |
| ‘Prayer’ position | |
| Repetitive behaviours e.g. fly-biting | |
| Destructive behaviour or distress during separation | |
| Licking of joint areas | |
| Balance/proprioception | |
| Puppies | |
| Random urination (not due to excitement or lack of opportunity) – especially close to meal times |
|
| Anxious behaviours | |
| Cats | |
| General over-grooming |
|
| Licking/grooming throat/front legs | |
| Licking lower limbs | |
| Excessive grooming of lower abdomen/inner flanks | |
| Urine spraying, urinating outside litter tray | |
| Defecating outside litter tray | |
| Generalised grumpiness in older cat | |
Unwellness and behaviour
If behavioural management and modification strategies are to be successful in resolving behavioural problems, it is essential that any initiating or maintaining medical problems are resolved prior to behavioural intervention. If a behavioural change is not obviously, directly associated with the sensitive periods of an animal's emotional development (e.g. early social and environmental referencing, puberty or social maturity) or with an obvious exposure to a stimulus or trigger (and hence the change is not consistent with learning opportunities), it is highly likely to be associated with a medical problem.
Lincoln University's Behaviour Clinic found that more than 23% of their caseload had a medical component, with 27% of those animals expressing their distress through aggression (Zulch, 2019). Relying on obvious signs of discomfort in a companion animal may be an unreliable indicator of pain and discomfort. Many dogs are incredibly tolerant of human handling and hence stoical regarding their lack of response to inept or uncomfortable handling techniques; responses such as these can make it difficult to detect the site of discomfort. Other species (e.g. small prey animals) may have an ethologically-based reticence to responding to discomfort, as indicators of pain may result in detection by predators.
Medication and behavioural change
Other than in response to the restricted number of psychotropic medications licensed for use in companion animals, do veterinary professionals always consider the potential for ongoing medication to alter the behaviour of patients? Cortisol is recognised as resulting in behavioural change and negative bias towards stimuli within the stress response (Mills et al, 2013). However, the potential for corticosteroid-based medication to result in an animal's brain being exposed to cortisol concentrations that are hugely in excess of those experienced during a stress response is under-considered (Notari et al, 2015; 2016). In addition, prolonged or excessive exposure of the brain to cortisol can have a neurotoxic effect on the areas of the brain associated with memory (Mills et al, 2013); this can result in animals losing competency with stimuli they have previously encountered, leaving patients vulnerable to sensitisation to situations with which they could previously cope.
Basics of behavioural first aid
The first step in providing behavioural support involves being a good observer and listener, by watching your patients and listening to conversations that occur between clients in the waiting room, over the reception desk and within the consulting room. Although many owners will approach the practice with direct requests for behavioural support, many may not realise that their pet's behaviour indicates a welfare problem, nor may they realise that you can help. By listening to ‘throw away’ comments about toileting, destructive vocalisation and handling issues, for example, and by observing a pet's responses within the practice, you can initiate a conversation that may have a substantial impact on the welfare of both pet and owner.
Unfortunately, when owners initiate behaviour queries, it is often at the end of a consultation and pre-fixed by, ‘while I'm here ….’; by then, professional time may be severely limited. If there is insufficient time to offer constructive or sufficient first aid advice, immediately make an appointment for the client to return for a more in-depth chat, ensuring that you're allowing sufficient time to address the animal's immediate needs. If you have already identified that the problem is too complex or potentially dangerous for the practice to deal with, an immediate referral should be organised but first aid advice will still be required.
Behavioural support
When considering how behavioural support should be provided, it is important to consider a number of factors (Zulch, 2019):
- Will the client be able to afford an extended consultation appointment slot to discuss a behavioural problem? If this is going to pose a difficulty, it may be essential that a nurse can offer the required advice
- Can the owner email you a summary of the problem and its development? This will enable you to save consultation time, do some research and tailor advice
- Will further referral be needed? If so, have all of the information available so that a referral can be made while the owner is still feeling positive about the outcome
- Is the owner likely to be able to cope with compliance with a behavioural modification plan? If not, as long as the pet is not a danger to itself, the public, the family or other animals, consider whether a succession of relatively short ‘in-house’ support sessions that create very small, successive goals, may be of more assistance to client and pet. Your usual clinical behaviourist may be able to help you with creating such a package.
Physical examination
Regardless of which of the above strategies is found to be most appropriate, the next step should be a thorough physical examination of the animal. If a thorough examination is impossible due to the animal's behaviour or the client's financial situation, this should be noted so that it becomes clear to anyone offering behavioural support that information may be missing from the medical history. If the animal is likely to pose a danger to the safety of the person designated to offer further behavioural advice, owners should be given appropriate information to enable them to reduce the threat, e.g. advice regarding muzzle-training a dog (see ‘Blue Cross’ in Box 1). Owners should expect to be responsible for ensuring that veterinary staff, behaviourists and members of the public remain safe from injury caused by their pet.
If I haven't studied behaviour, what can I do?
There are three main priorities when offering first aid advice for behaviour problems (Zulch, 2019):
- Managing risk
- Preventing the problem from becoming worse
- Reducing the incidence of the problem.
The importance of common sense should never be underestimated; what appears obvious to you may not be obvious to a client that is struggling to cope. Therefore, there is no embarrassment in suggesting what may feel like really obvious management strategies. If the client says they have already tried them, talk them through how they've implemented the strategy, as there may be obvious flaws that you can spot (Zulch, 2019).
Something as simple as closing a door to prevent a family member (or other household pet) and the pet with the behavioural problem from coming into contact, may have been overlooked during the distress surrounding incidents. Suggesting the use of barriers and secure baby/dog gates may make all the difference between an owner continuing to manage while waiting for a referral appointment, and failing and releasing the pet. It is also important to check that owners are not punishing the pet (merely creating confrontation and distress) or implementing inappropriate or counterproductive advice, which they may have received from friends or through internet searches. The website of the Association of Pet Behaviour Counsellors (Box 1) has a range of free-to-download advice leaflets, which may help owners to manage problems in the short term (e.g. the introduction of a muzzle to a dog or the continuous use of a lead). In addition, a family that is disappointed in the behaviour of their pet may consider the use of food lures in management to be ‘rewarding bad behaviour’ and they may need to be persuaded of the advantages of such a system.
Managing risk
To effectively manage risk, you will need to:
- Ensure that the pet cannot damage itself
- Ensure the pet cannot damage family members or members of the public
- Ensure the pet cannot cause damage to other family pets
- Ensure the pet cannot damage the family home.
Preventing trigger exposure
One of the most obvious solutions to preventing a problem behaviour worsening, that is often overlooked by owners, is preventing the animal from having to encounter the ‘trigger’. Management may require the short-term confinement of the pet in a separate environment that meets its welfare needs. In some cases, management may extend to finding alternative, short-term, accommodation for the pet, e.g. in a kennel or cattery.
Usually, it is accepted welfare advice that all pets require appropriate exercise. However, when being placed in the garden is the source of a cat's distress, or when being taken for a walk and having to encounter novel or frightening social and physical stimuli is the source of a dog's need to bark, lunge and potentially bite, it becomes far more welfare-appropriate to ensure that movement and mental stimulation occur within the safe environment of the home.
This advice may be very difficult for owners to accept, but acceptance may result in the animal remaining within the family in the long term, as opposed to re-homing. Families will need to understand that repetition of the problem behaviour is not just likely to strengthen the pattern, but it is also likely to result in the behaviour being exhibited in a wider range of circumstances and at lower levels of exposure to the trigger — once this is understood and an owner has been given ‘official’ permission, e.g. to not walk the dog for a few days or weeks, both the pet and owner can start to re-evaluate their situation.
Consistency and predictability
Many owners are unaware of how important it can be for an animal to be exposed to a consistent routine and predictable social relationships (Zulch, 2019). As part of this consistency of approach, all attempts to punish the animal should cease and owners may need to have it explained that this includes the harsh use of the voice and even finger wagging (which, for some animals, may be predictive of further punishment or lack of owner predictability). In addition, it will be highly beneficial to encourage owners to start to encourage the behaviours that they would like their pet to express (Zulch, 2019), offering something that the pet enjoys (e.g. using quiet praise and gentle attention when the pet is resting or entertaining itself by playing with its own toys or giving a small food treat when the pet responds appropriately to a social stimulus).
Knowing a pet's species and breed
Above all, know your species and know the breed. Problem behaviours can be a sign that a pet's needs are not being met (Hedges, 2017), and further articles in this series will give basic guidance in this matter. However, before offering emergency/interim behavioural management and first aid advice, it is important to be aware of the ethology of a patient's species and, if appropriate, the specific needs of the breed. In particular, animals that naturally live in social groups will have very different needs to those that live a more solitary lifestyle. Similarly, the needs of animals belonging to predatory species will differ from those of prey animals or animals that are both prey to some but predatory on other species, and nocturnal animals will have different needs to those of a diurnal lifestyle (Figures 1 and 2).
Hence, after giving emergency advice (such as separating animals whose social relationship has either broken down or has never existed), it is often sensible to allow a short period prior to a nurse appointment, not only for owners to collate useful information, but for staff to do some research of their own. Such research may result in practice staff realising that the ‘problem’ is actually the pet's natural coping strategy within its current environment, and informed conversations regarding this issue will help the family to initiate management and environmental changes.
Referring on
It is a basic requirement of the veterinary role to understand when the complexities of a case surpass practice expertise. Due to a lack of veterinary behaviour specialists within the UK, it is often necessary to refer cases to non-veterinary behaviourists. In such cases, the duty of care for the patient remains with the referring veterinary surgeon and every member of practice staff who is likely to come into contact with clients should know where to find registers of appropriately trained animal trainers and clinical behaviourists (see ABTC, ASAB and APBC in Box 1) (Heath, 2018).
However, it is also essential that every member of the practice can offer welfare-appropriate first aid advice that will keep the pet, client and members of the public safe during the period between practice recognition of a behavioural problem, and the clients actually attending a consultation with a clinical behaviourist. In some cases, such timely behavioural support may resolve the problem or reduce it to a level that removes the immediate need for specialist advice. In other cases, referral may become essential (Zulch, 2019) (Tables 2 and 3).
Table 2. When to refer a behavioural case
| Immediate referral required | Later referral in addition to first aid advice likely to be required |
|---|---|
| There is a high welfare risk to the patient, other household pets, family or general public | The owner requires more detailed and time-consuming advice than the practice can provide |
| Immediate advice, exceeding the competencies of practice staff, is essential | The problem is worsening despite the implementation of immediate management and first aid advice |
| The animal is young (less than 12 months) and the problem is severe | The problem is not worsening, but there is insufficient improvement to warrant the future potential welfare risks to patient, other household pets, family or public |
| The limitations on available advice will only act as emergency support and further advice will be essential | – |
Table 3. Referral routine
| Routine procedures prior to referring a behaviour case |
|---|
| Follow the guidelines of your professional organisation by ensuring that the behaviourist is registered as a clinical animal behaviourist either by the Animal Behaviour and Training Council, Association of Pet Behaviour Counsellors or the Association for the Study of Animal Behaviour |
| Ensure that any medical cause of behavioural change or enhanced social or environmental sensitivity such as pain, sensory or endocrine problems have been adequately investigated and treated |
| A professional referral should be prepared and ideally, this should include the animal's medical history |
| The practice should be willing to discuss the patient's ongoing health issues and medical history with the behaviourist |
| The practice should be open to discussing health concerns that may come to light during a behavioural consultation; owners may mention matters that they have not previously discussed with, or thought relevant to, their veterinary professionals |
| Veterinary professionals may need to be open to discussing the potential need for the use of psychotropic medication. Although non-veterinary behaviourists cannot discuss medication with the client or with the veterinary surgeon, unless invited to do so by the client's veterinarian, they may request that the client returns to their veterinarian to discuss medication |
| Encourage your client to collate any supplementary evidence that may be useful during the behaviour consultation. If it does not pose a welfare problem to animal or human, a video diary of behaviour is useful and, in some cases (e.g. separation issues), essential. A log of incidents and pre-empting patient, family and environmental activity may also be helpful |
| Expect a full copy of your client's report and be ready to liaise with the behaviourist regarding follow-up progress and support |
The referral of behaviour cases should follow the same routine as those of other veterinary disciplines (Heath, 2018). Providing the clinical animal behaviourist with a patient's full medical history can be overlooked by referring practices, as the link between medical events and behavioural change can be missed; this is particularly the case if they do not appear to occur concurrently (Heath, 2018). Yet, associative behavioural changes can occur months after a physical event, making a full medical history important to the timeline that the behaviourist will need to create. It is also important that, when there is any doubt as to whether physical problems may be involved in behavioural change, haematological, biochemical and imaging investigations occur prior to referral. Also, if considered necessary, referring practices should remain open to providing further physical investigations following referral (Heath, 2018).
A genuine behavioural role for nurses
The RCVS has formalised the skills that veterinary nurses require within the Day One Competences and Skills (RCVS, 2014; 2016; Hedges, 2017). These skills include a knowledge of:
- The patient's normal behaviour and environmental, behavioural and emotional needs along with the application of these to patient care
- Species- and welfare-appropriate handling techniques
- How to support the owner whose pet has recognisable behaviour problems
- Behavioural implications of the procedures undertaken
- Behaviour-related products sold by the practice(Hedges, 2017).
However, although many nurses have a strong interest in the behavioural welfare of their patients, the RCVS Code of Professional Conduct for Veterinary Nurses requires them to ‘keep within their own area of competence’ and ‘not hold out themselves or others to have expertise they cannot substantiate’ (RCVS, 2017). For decades, American veterinary practices have embraced the role of the ‘animal behaviour technician’ as an independent specialism or as one held as an adjunct to the veterinary nursing role (Landsberg et al, 2013). However, such a role has been missing within the British veterinary framework. This may be partly a result of veterinary and nursing degree courses continuing to give only limited opportunities for undergraduate training in veterinary behaviour.
Some years ago, the Animal Behaviour and Training Council (ABTC) (Box 1) identified the academic requirements and experience that would support a role of Animal Behaviour Technician within a UK veterinary context — a role that would support the provision of preventative and first aid behavioural advice to clients while auditing and advising on the prevention of stress-related animal welfare infringements within the practice environment. Recently, some of the recognised professional behaviour organisations (e.g. Association of Pet Behaviour Counsellors listed in Box 1) have expressed an intention to support a membership level for animal behaviour technicians.
Conclusion
Pet behavioural problems threaten the pet–owner bond and hence threaten the entire ethos on which general veterinary practice depends. Every practice should be able to take a proactive approach to offering early life education and training that will enhance their clients' pets' capacity to cope with the complex human environment in which they will co-exist with their owners. Similar attention should be given to the owners of re-homed pets and adult pets that join the practice, along with helping owners with the challenges faced by elderly pets and those facing hospitalisation and postoperative restrictions upon their normal routine. In addition to ensuring that the practice can offer such services, they should obviously and enthusiastically advertise their willingness to spend the necessary time discussing and helping with behavioural issues.
Although behavioural medicine may not be a specialism that your practice can invest time in, just as with every other aspect of veterinary medicine, behavioural welfare support and first aid advice should be key to your practice's daily routine.
KEY POINTS
- The provision of behavioural first aid advice should be part of every veterinary nurse's skill set.
- Behavioural first-aid advice may be essential to preventing the relinquishment or euthanasia of an animal.
- Pet behaviour and physical health are intrinsically linked and physical health should always be investigated when behaviour change is mentioned by owners.
- Although first-aid advice may be adequate to resolve some problems, if a nurse is not a clinical animal behaviourist (CAB), the nurse should be ready and willing to arrange a referral to an appropriately skilled clinician.
- Nurses who are not CABs but who wish to take on a role in managing and maintaining the behavioural welfare of patients may now train as Animal Behaviour Technicians.