Rabbits are the third most popular pet in the UK, but despite this, evidence suggest that the research that focuses on the welfare and mortality rates of hospitalised rabbits is minimal (Rioja-Lang et al, 2019; Benato et al, 2020). A lack of self confidence in veterinary proessional's knowledge of rabbit pain and analgesia is also evident and the requirement for increased understanding of the species is highlighted to improve welfare of rabbit patients (Fredholm et al, 2013; Benato et al, 2018).
Literature review
In human medicine, doctors can rely on their patient's ability to communicate where the pain is and how much pain they are in, however, we cannot communicate in the same language as animals and so we rely upon physiological parameters and behavioural observations to assess pain. Inaccurate pain scoring can lead to incorrect dosages of analgesics being administered to the patient (Sneddon et al, 2014).
(Leach et al 2011) found that the most accurate indicators of pain in rabbits were found when assessing the hindquarters as opposed to the face. As part of current practice, the ‘Rabbit Grimace Scale’ established by (Keating et al 2012) is the most used method to assess pain, however, there are limitations to this method of assessing pain. Breed specific considerations are not incorporated, for example lop-eared rabbits ear position cannot be used as an indicator of pain. Figures 1 and 2 show rabbits with differing ear positions.
Rabbits are prey animals and to survive, they have the ability to disguise signs of pain and will do so when faced with a stressful situation, making it difficult to carry out accurate pain scoring. Situations such as being handled in the veterinary practice can cause stress (Richardson, 2016). When examining the patient and providing treatments this stress is unavoidable, however, it can be minimised and managed. Pain leads to increased levels of stress (Richardson, 2016). In the opinion of Sibbald (2018), this can have a detrimental effect during recovery post anaesthetic, leading to gut stasis or even death. A study carried out by (Lee et al 2018) into the peri-anaesthetic mortality and gastrointestinal complications in rabbits concluded rabbits are at a much higher risk than cats and dogs to suffering from gastrointestinal complications post-anaesthetic. A wide variety of rabbit breeds were used in the study with male and females undergoing a variety of procedures. Of the total 210 cases being examined 38% of the rabbits that underwent anaesthesia suffered gastrointestinal complications within 72 hours of the procedure. Whether this is due to pain or stress cannot be identified through this research however, in the clinical notes of the rabbits that died following these procedures, it was suspected by the veterinary surgeons that the cause of death was cardiac related. Stress is known to increase the heart rate of an animal therefore stress could be a contributing factor.
Aim and objectives
The aim of this study was to explore the perceptions of RVNs in relation to veterinary professional's confidence when assessing pain in rabbit patients and to use the findings to inform improvements to rabbit welfare. There were three objectives of the project. Firstly, to explore the feelings and experiences of RVNs when pain scoring rabbits, secondly to identify aspects of rabbit pain scoring that RVNs feel less confident in, and thirdly to evaluate areas for improvement in current pain scoring methods used in practice.
Method
The project was inductive in nature and qualitative data was collected via individual online interviews with five participants using Microsoft Teams. A semi-structured approach to the interviews was taken, with a mixture of open and closed questions, to enable the collection of detailed data and to encourage the participants to elaborate on their feelings and experiences (McIntosh and Morse, 2015)(Appendix A).
A non-probability, purposive sampling method was used and participants were required to be RVNs in order to take part. To recruit participants, small animal first opinion veterinary practices were contacted and the RVNs they employed were invited to take part. All participants completed an opt-in consent form and pre-interview questionnaire. The questionnaire collected some key demographic data (Lopez and Whitehead, 2013)(Appendix B).
Ethical approval was granted prior to the data collection, reference number [ethics number: ETHICS2022-122-LR]. The Interviews were recorded via Microsoft Teams and then deleted once transcripts had been created. The data were stored on a password protected OneDrive in accordance with the GDPR (2018). The transcripts were anonymised, the participants were assigned pseudonyms (Nurse-1 to Nurse-5) and any contextual information, such as veterinary practice names were omitted (Cornock, 2018).
The seven-step model of thematic analysis described by (Clarke and Braun 2013) was used to analyse the data. Thematic analysis was selected because it provides a flexible framework which allows the researcher to gain an in-depth understanding of the data and to identify key themes (Braun and Clarke, 2006).
Results
The pre-interview questionnaire identified that the time the participants had worked in clinical practice ranged from five to 25 years. The participants also rated their understanding of rabbit behaviour which helped to explore their experience with rabbits in relation to their experiences assessing pain, with two participants rating their understanding as very good, two as fair and one as very poor.
Through the data analysis, of the semi-structured interview data five themes were identified (see Figure 3). The results have been presented by theme.
Results for theme 1: experience with rabbits
All participants currently owned or had previously owned rabbits and had varying experience with normal and abnormal rabbit behaviour. Owning a rabbit was not a criteria for participant selection as varying confidence levels were desired. Participants reported that rabbits were commonly seen in their practices. A shared experience amongst all participants was veterinary professionals general avoidance of rabbit patients and passing the responsibility to more experienced colleagues. Examples included:
‘Most of the vets try to dodge the bullet and pass it onto the other ones so umm the bunnies tend to get passed around … since none of the vets know what they're doing until the bunny vet is in.’ (Nurse-1)
Results for theme 2: pain assessment
The confidence levels of the participants when assessing pain in rabbits was varied. Those who reported feeling confident linked it to their experience with rabbits inside and outside of practice. All participants reported finding difficulties to differentiate between signs of pain and stress, despite some participants feeling confident using their chosen pain assessment method. The participants shared that they used the ‘Rabbit Grimace Scale’ to assess pain in rabbits, one participant reported also using the ‘Bristol Rabbit Pain Scale’ and found it useful for visual comparison, but also commented on the lack of other options. For example:
‘So it would be nice if there was … a pain scoring system in place, not just a chart with some pictures on that we can actually physically score their pain and see if they're improving or if they're deteriorating.’ (Nurse-2)
Results for theme 3: analgesia
Participants shared the view of analgesia being underutilised in rabbits especially when compared to the variety and frequency of pain relief being administered to cats and dogs undergoing similar procedures. One participant shared the view that most veterinary surgeons are unaware of the variety of pain relief available for use in rabbits and this leads to rabbits receiving insufficient analgesia.
‘There's so many different kind of pain reliefs that people think oh you could give a rabbit gabapentin, tramadol … actually yeah, we can do those things as well as like CRI's.’ (Nurse-4)
Results for theme 4: rabbit welfare
Participants discussed the attitudes of the veterinary industry towards rabbits as being not as important as cats and dogs and often not being treated properly due to the lack of care and understanding of the species. Participants shared the view that pain assessment is very important in rabbits in order to give the appropriate amount of pain relief. All participants believe that industry attitudes towards rabbits must be changed with some mentioning how we should no longer be seeing rabbits as an exotic species as we see them so often in practice. Examples included:
‘It's also it's been I don't do bunnies, you know, it's a rabbit … they don't matter as much as cats and dogs.’ (Nurse-2)
‘I think they're completely under like nursed, I guess, in regards to to pain and well, I say under nursed like I think vets as well can do a lot more in regards to pain in rabbits … I don't think we're doing enough in in general practice.’ (Nurse-4)
Results for theme 5: training and education
The participants shared the view that more education is needed in regards to rabbit behaviour and pain assessment. Some participants mentioned that owning a rabbit made them more inclined to learn more about the species and that continued professional developement (CPD) was very useful to them as well as the Rabbit Welfare Association and Fund (RWAF) website in terms of rabbit behaviour and husbandry, which has allowed them to give better care to their rabbit patients. An example of a point raised is:
‘Now that I have done CPD about doing the grimace scale, I certainly would like to try and do more of it in practice.' (Nurse-3)
‘Eventually caved and got a rabbit, and then we came a bit more interested in them and started doing more CPD about rabbits … and I've set up my practices rabbit savvy practice with the RWAF and I'm practice rabbit advocate now.’ (Nurse-5)
Discussion
Within the study, the confidence levels of RVNs with pain scoring rabbits were explored and the three objectives were addressed. The focus of objective one was to explore the feelings and experiences of RVNs when pain scoring rabbits. The participants who nursed rabbits more frequently seemed to feel more confident with pain scoring and nursing rabbit patients largely due to their familiarity to the species and feeling they had the knowledge to deliver an appropriate level of care. Unfamiliarity with the needs of rabbit patients seemed to be linked with avoidance of undertaking rabbit related procedures, this could be due to a lack of confidence in themselves and a fear of failure. (Zarrin et al 2020) researched the impact of procrastination and fear of failure. Their findings could explain the reasoning for veterinary professionals avoiding rabbit related procedures. The study was conducted with human nursing participants who reported avoiding tasks they felt would make them feel inadequate and tasks they felt they could not perform to the level they would like. To address these challenges, rabbit nursing and pain scoring could be covered in more detail in veterinary nurse training curriculum.
Another possible explanation for RVNs avoiding rabbit nursing could be a lack of interest for the species, this poses an ethical dilemma because it could suggest that patients are being prioritised by their species and not by their care needs. Research into veterinary ethics discusses relations in terms of animal ethics, this explores the social relations society makes to certain species and how this affects what we see in the veterinary practice and regard as a patient. This perspective on certain species can cause moral distress to other members of staff or owners who may have a stronger connection to that species (Huth et al, 2020).
Through objective two, the aspects, of rabbit pain scoring, that RVNs were less confident with were identified. A common theme identified regarding the limitations of pain scoring in rabbits is a lack of a composite pain assessment tool which is able to accommodate for all breeds of rabbits and provides more flexibility in terms of determining the amount of pain the rabbits are experiencing. Whilst the results show that the grimace scale can be good for identifying painful behaviours in rabbits, it does not show the degree of pain they are in or where this pain may be. The use of facial features originates from human medicine in order to establish pain in non-verbal patients, however, animals do not just rely on facial features to express communication. When communicating with others of the same species or even their owner's animals use their whole body to communicate including things like their tail, which a human does not have (Rault et al, 2020).
KEY POINTS
Areas for improvement in current practice where evaluated through objective three. Education is a significant part of the veterinary profession. It should be considered to include more about rabbit behaviour, anatomy and husbandry into the curriculum for veterinary professionals and changing the viewpoint within the industry of considering the rabbit as an exotic pet, as the results show, they are frequently seen in practice. Currently the consensus within practice is that rabbits are often undervalued. By increasing the amount taught about rabbits in veterinary training programmes it highlights the importance of this knowledge and will therefore make it more likely to be used in practice. For those who are already qualified, seeking out CPD in rabbit behaviour is a useful tool for gaining more experience within the area or speaking to those who own rabbits and spending some time observing rabbit behaviour (Price and Reichert, 2017).
Limitations
The online nature of the interviews could have limited the expression of the participants and restricted the ability of the researcher to assess the participant's body language, however, it was considered that the convenience and accessibility of online interviews outweighed the limitations (Oliffe et al, 2021). To mitigate against their limitations, all participants were required to have the cameras on during the interviews and the researcher took the time to talk to the participants at the start of each interview to put them at ease and to help them feel comfortable to talk openly about their experiences (Thunberg, 2021).
Conclusion
The confidence levels of RVNs when assessing pain in rabbits varied depending on the level of experience they had with rabbits, both within and outside of practice. The more exposure, to rabbits, the participants received the more confident they felt carrying out accurate pain assessment, suggesting that additional training with rabbit patients in all aspects of husbandry, anatomy and behaviour would increase the value that veterinary professionals place on rabbit patients and help to improve their confidence and enthusiasm for delivery care to the species.
The avoidance of rabbit patients could be reduced by the introduction of a composite pain assessment tool specifically designed for use in rabbit patients which caters for breed specifics and their ability to mask pain. The wider use of pain assessment tools could also increase veterinary professional's confidence with rabbits.