Veterinary nurse (VN) led diabetes clinics will create more available veterinary time, increasing capacity for revenue from VNs and veterinary surgeons (VS), use VN knowledge and skills to promote job satisfaction and staff retention. They will also address real concerns of diabetic pet owners through provision of personal support. Two surveys from Niessen et al (2010; 2012) found that many of the most significant negative considerations for owners related more to the owner's quality of life than to the pet's: concerns around injecting insulin did not feature in the top 15 in either study (Table 1). Both surveys highlighted the lack of veterinary advice or support, with respondents feeling their veterinarian had a poor understanding or knowledge, particularly around diet and home monitoring of blood glucose (BG). A more recent study by Albuquerque et al (2020) also found advice lacking regarding how to recognise an unstable diabetic, diabetic remission, dietary change, hypoglycaemia or home blood glucose monitoring (HBGM), and some owners received no training or supervision around injection technique. The authors highlighted the importance of involving the entire veterinary team in the education of owners, with more use of veterinary nurses to address these gaps. Niessen's study (2012) concludes that there is no ‘average diabetic pet owner’, reminding veterinary professionals to take a tailored approach to each individual pet owner about the specifics of managing this disease, rather than relying on a standard protocol to suit all.
| Diabetic dogs and owners | Diabetic cats and owners |
|---|---|
| ‘worry’ (−5.92 ± 4.27) | ‘boarding kennels’ (−4.67 ± 5.3) |
| ‘friends and family’ (−5.68 ± 5.07) | ‘more control’ (−4.34 ± 4.7) |
| ‘worry vision’ (−5.58 ± 4.63) | ‘friends and family’ (−4.21 ± 4.7) |
| ‘boarding kennels’ (−5.18 ± 5.21) | ‘worry’ (−4.10 ± 3.9) |
| ‘worry hypo’ (−4.95 ± 4.26) | ‘worry hypo’ (−3.67 ± 3.5) |
| ‘social life’ (−4.82 ± 4.41) 7. | social life’ (−3.48 ± 3.9) |
| ‘costs’ (−4.11 ± 4.74) | ‘costs’ (−3.04 ± 3.8) |
| ‘future care’ (−4.07 ± 4.62) | ‘working life’ (−3.03 ± 3.7) |
| ‘working life’ (−3.88 ± 4.48) | ‘pet's moods’ (−2.87 ± 2.88) |
| ‘restrict your activities’ (−3.88 ± 3.85 | ‘restrict your activities’ (−2.81 ± 3.09) |
| (Niessen et al, 2012) | |
Initial considerations
A diabetes diagnosis can put an emotional, financial and physical burden on the owner, but veterinary nurses can play a vital role in client support. The VS remains responsible for clinical decision making, but can delegate history taking, clinical examination and diagnostic tests through clinic protocols, equipping VNs with structured plans to follow. Protocols should state how often the patient is to be seen, which monitoring tests to perform, what the VN should and should not discuss with the client. Clinic checklists then provide a framework for each VN to conduct a thorough and consistent diabetes consultation, including history taking and patient care areas to discuss. The VS should set client expectations regarding revisits, tests and associated costs, whilst tailoring the plan to suit the client's capability and budget.
VN involvement should begin at diagnosis with an introductory clinic, continuing through stabilisation and into long-term patient monitoring. VNs should be familiar with the aetiology of diabetes mellitus (DM) in dogs and cats; a refresher can be found in Table 2. The goals of treatment are the same for both species: to reduce clinical signs, optimise quality of life and minimise complications. However, the management can vary between species. Cats with ‘type 2’ diabetes can potentially achieve remission, as many continue to produce endogenous insulin. Behrend et al (2018) suggest that remission can be considered as a possible goal in cats, but not in dogs; cats may revert to clinical diabetes as a result of the permanent β-cell damage. Reported remission rates vary, with relapse common; a retrospective Australian study by Gottlieb et al (2024) found that 47% of newly diagnosed cats achieved remission, although 40% subsequently relapsed.
| Canine | Feline |
|---|---|
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(adapted from Buishand, 2024)
Introductory clinic
The case VS should designate a case VN with an early introduction to the client and pet. A cooling-off period after diagnosis, allowing the client 48–72 hours to digest the news before agreeing and starting the treatment plan, can be helpful if the pet is relatively well. Book the clinic to start insulin therapy when support is available in case of complications, such as in the morning, unless the practice provides easily accessible out-of-hours care. Prepare resources and equipment in advance: gather the medication, sharps disposal if needed, syringes/needles if applicable, create a discharge letter with an information pack containing guidance on DM and a monitoring diary (Figure 1). Also, be aware of the importance of internet research and provide websites that offer accurate and useful information on disease management, such as www.vetprofessionals.com or icatcare.org (Albuquerque et al, 2020).
What is diabetes mellitus?
Explain the pathology of DM, describing insulin as a door key which allows glucose to pass into tissue cells, which can be useful. There can be either a lack of door keys (insulin deficiency) or changed locks (insulin resistance), which causes a build-up of glucose in the circulation. Discuss how the clinical signs of polyuria/glycosuria, polydipsia, polyphagia and weight loss arise, regarding the renal threshold for BG, osmotic diuresis, compensatory thirst, persisting hunger because of the lack of negative feedback loop activation in the brain and the resulting catabolic state as they break down fat and proteins into energy. Convert jargon into layman's terms and confirm the owner's understanding – this will allow them to appreciate their significance in monitoring the stability of DM.
Current common treatments include insulin, such as lente and protamine zinc, as well as the more recent oral sodium-glucose co-transporter 2 (SGLT-2) inhibitor, Senvelgo. Behrend et al (2018) recommend protamine zinc as the first-choice insulin for cats because of its longer duration of action compared to lente insulin, which is recommended for dogs. Whichever option has been prescribed, describe its mode of action and how it contributes to controlling the clinical signs.
Medication
The key points to cover about medication are:
Complications
Diabetes-related complications should be explained to the client, including hypoglycaemia, hyperglycaemia, diabetic ketoacidosis, urinary tract infections, diabetic peripheral neuropathy and cataracts (Figure 2), which are discussed further in Table 3. These complications may indicate poor diabetic control and may require treatment or further management considerations, so the client should monitor them at home.
| Complication | How this occurs | Consequences |
|---|---|---|
| Hypoglycaemia | True or relative excess of insulin is given (relative caused by lack of food intake, or vomiting) | Early signs: quiet, lethargic or sleeping Progresses to weakness, shivering, muscle twitching, disorientation and incoordination, seizures and unconsciousness |
| Urinary tract infections | Bacteria thrive with glucose (glycosuria) | Infections can be subclinical, with or without cystitis signs, so it is recommended to screen regularly as underlying infection contributes to insulin resistance |
| Diabetic ketoacidosis | Fat breakdown involves oxidation of fatty acids into toxic ketone bodies (usually removed by insulin) | Clinical signs: vomiting, anorexia, dehydration, rapid breathing, with diabetic clinical signs, pear drop scent on breath, leading to collapse, coma and death Be aware of euglycaemic diabetic ketoacidosis (eDKA) with SGLT-2 inhibitors (insufficient endogenous insulin produced by the cat to prevent ketones from forming, normal BG because of the mode of action) |
| Diabetic peripheral neuropathy | Products of glucose breakdown attach to nerves and cause a plantigrade stance (lowering of the hocks) | Seen in about 10% of diabetic cats (Hughston, 2014) |
| Diabetic cataracts | Glucose in the eye broken down by an enzyme into sorbitol, increases water in the lens, disrupting clarity and forming a cataract. | Most common in dogs and rare in cats. Dogs often develop them within 6 months of diagnosis, irrespective of diabetic control. Onset is usually gradual but can appear sudden once the sight is more significantly affected. Cataracts can be surgically removed, with an artificial replacement lens fitted, but success rates vary |
(Buishand, 2024)
Nutrition and feeding
Consistent and appropriate nutrition is necessary to manage postprandial hyperglycaemia. Feeding the same type and same quantity of food at the same time each day, in relation to their medication, will aid in managing overall BG levels. For dogs receiving twice daily insulin, 50% of their daily food requirement should be fed at each injection (or ideally, a short time after the injection), with minimal caloric intake in between. If insulin is received once daily, a second meal may be given 7–8 hours after injection, roughly at peak insulin activity. In cats, clinically relevant postprandial hyperglycaemic peaks are less likely, so grazing through the day is acceptable if fed an appropriate diet. With a higher protein requirement and slightly reduced ability to digest carbohydrates, cats will generate glucose through amino acid breakdown in the liver, so it is important for them to eat regularly and continue to eat. Sparkes et al (2015) advise that the regular feeding routine is maintained, provided it involves at least two meals per day.
Nutritional factors for diabetic dogs and cats are outlined in Table 4, with two potential options for nutritional balance in cats. The author is most familiar with the low-carbohydrate/high-protein approach. Once diagnosed, a low-carbohydrate diet is needed, but feeding a high-carbohydrate diet to cats and dogs has not been found to increase the risk of diabetes occurring (Laflamme et al, 2022). A diet low in simple carbohydrates can increase the remission rates by 50% in cats by reducing the demand for insulin (Bennett et al, 2006), and this should be continued into remission to reduce the chance of relapse. Feeding a high-protein diet (≥40% metabolisable energy) to cats will reduce the risk of hepatic lipidosis and maximise the metabolic rate, improve satiety, prevent lean muscle mass loss and maintain palatability (Behrend et al, 2018). Good fibre content is recommended in dogs – insoluble fibre reduces postprandial hyperglycaemia by delaying glucose absorption, and soluble fibre delays gastric emptying, keeping them feeling full when not being fed frequently. High fibre is not typically recommended in cats (Behrend et al, 2018).
| Factor | Dogs (increasedfibre/highcarbohydrate food) | Cats (increasedfibre/highcarbohydrate food) | Cats (low-carbohydrate/high-protein food) |
|---|---|---|---|
| Water | Fresh, clean water should be available at all times. Avoid digestible sugars | Fresh, clean water should be available at all times | Fresh, clean water should be available at all times |
| Digestible | Provide foods with no more than 55% digestible carbohydrate | Avoid simple sugars and starch Provide foods with less than 40% digestible carbohydrate | Avoid simple sugars and starch Provide foods with less than 20% digestible carbohydrate |
| Carbohydrate | 7–18% | 7–18% | |
| Fibre/fet | <25% | <25% | <25% |
| Protein | 15–35% |
28–55% |
28–55% |
| Food form | Avoid semi-moist foods | Avoid semi-moist foods | Avoid semi-moist foods |
*Nutrients expressed on a dry matter basis.
Diabetes is easier to regulate at an ideal body condition score (BCS), as obesity contributes to insulin resistance and requires higher doses of medication. Fatty acids released by adipose tissue stimulate the liver and gluconeogenesis, increasing BG and insulin levels, causing islet cell exhaustion. Therefore, it is important to address obesity from the outset in patients with BCS 7 or above, based on the 9-point BCS system (WSAVA, 2020). In dogs, it is appropriate to transition to a weight loss diet immediately, which can be continued into maintenance. Cats requiring weight loss could also start a therapeutic diet immediately, but using a diabetic diet first may achieve quicker initial stabilisation, before moving onto a weight loss diet once glycaemic control has improved (Burke, 2024). Cats can then maintain a weight loss diet or return to a diabetic diet when they reach their ideal weightt. The suggested weekly weight loss aims are 1–2% in dogs and 0.5–2% in cats, while closely monitoring BG and insulin requirements (Behrend et al, 2018).
Comorbidities such as renal disease, pancreatitis or adverse food reactions should take nutritional priority, but diabetic patients must eat, so the choice must be palatable, as well as nutritionally appropriate. If diabetic patients are inappetant and depressed with nausea/vomiting, pancreatitis should be considered and treated early. With any new diet, clients should be advised on a slow transition and the daily feeding amount. Underweight patients feed around 10–15% more than their resting energy requirement. They should be fed a high-quality palatable maintenance diet or a diabetic diet with soluble and insoluble fibre, which is not designed for weight loss.
Wet formulations often contain fewer simple carbohydrates than dry ones if a veterinary therapeutic diet is declined. Wet diets have lower energy density than dry food, so the patient can eat more in volume and obtain the same energy intake as smaller volumes of dry food. The client may choose to feed a life stage diet, suitable for the pet's body condition score, ideally from a company that at least meets the World Small Animal Veterinary Association guidelines (WSAVA, 2021).
It is not essential to eliminate treats if they are reduced to suitable items given occasionally. In dogs, these should be given close to their feeding time if possible. Encouraging the client to be open and honest about treats will help diabetic stabilisation, where the vet can consider everything when assessing the response to treatment. Consider using green vegetables high in water content (low in calories) for enrichment.
Polydipsia must be managed with constant free access to fresh water. Using running water sources (including fountains and taps) does not result in a superior level of water intake, although personal preferences vary across individuals (Grant, 2010; Robbins et al, 2019). Water receptacles should be:
Exercise
Exercise uses energy and helps reduce hyperglycaemia, while increased blood flow may increase insulin absorption, helping to lower BG further. A moderate level of exercise performed consistently each day is appropriate, as too much will result in hypoglycaemia. Consider the timing of exercise and whether the period around the glucose nadir should be avoided.
Client monitoring of clinical signs
As reducing clinical signs is a treatment goal, accurate monitoring by the client is essential. Pharmaceutical companies produce client diaries to record medication doses, drinking, feeding, appetite and demeanour, urine output and ketones. The client may also record BG readings. VNs can create a bespoke diary for each client, dependent on what is monitored. Decide whether the client will record ‘increase’, ‘decrease’ or ‘normal’, or values by measuring water intake, either physically or with a Felaqua. Advise clients of the targets and when findings should be flagged with the team, either urgently or non-urgently. The The International Society of Feline Medicine Consensus Guidelines (Sparkes et al, 2015) detail what they recommend recording daily and weekly.
To round off the clinic, provide time for any questions and ask where they see potential problems arising – try to solve these as early as possible. Book in the next visit or advise the client of the next point of contact, ensuring they know how to make contact, the VN's availability, who should be contacted in the case VN's absence, and when/how to report an emergency.
Stabilisation clinic
The first stabilisation clinic can be booked 3–7 days later for dogs and 7–21 days for cats (insulin resistance takes time to overcome). Insulin dosing should not be changed earlier than this, unless hypoglycaemia is occurring. Book an early morning appointment if possible so the client can feed the pet at home and then inject them in clinic under observation. The client should bring their monitoring diary to each appointment. Costs associated with monitoring methods should be discussed and agreed by the VS with the client in advance.
Clinical history
History should include the clinical signs (refer to the diary), bodily functions, demeanour/behaviour, general activity levels, comfort and signs of nausea. Review medication administration and storage, nutrition and feeding routine, any hypoglycaemic episodes (when, any pattern, whether any first aid was given) and any other client concerns. Quality of life and/or pain scales may also be useful as many diabetic patients have comorbidities.
Clinical examination
Measure and record bodyweight, BCS and muscle condition score (WSAVA provide guides for this), calculating percentage weight change at each visit. Record parameters including heart rate, respiratory rate, hydration and mucous membrane colour (temperature is not necessarily required unless concerned). Review the whole patient, including their coat, dental health, mobility and any lumps, having brushes, nail clippers and dental charts available. Check for signs of diabetic complications (peripheral neuropathy, cataracts, diabetic ketoacidosis) or comorbidities such as pancreatitis.
Tests and monitoring
Daily glucose trends are often variable, so trends of polydipsia, polyuria, polyphagia and bodyweight change should always be considered when reviewing test results. DM is likely well-controlled when the patient has no clinical signs and the body weight is steady or increasing.
Point-of-care can be easily checked with a glucometer, but it only provides a snapshot of the current level. Many factors can affect BG, such as insulin dose, the animal's ability to respond, eating patterns, and levels of activity and stress, since adrenaline is an insulin antagonist. A single reading could indicate a need to reduce an insulin dose if the BG is low, but it should not automatically trigger a dose increase if the reading is high. However, point-of-care glucose monitoring can benefit patients on SGLT-2 inhibitors because of their mode of action.
Glucometers are calibrated for capillary blood. Calibrate the device for a dog or cat, then warm the ear to dilate the marginal ear vein if needed, before using the lancing device to obtain a sample (Figure 4). Do not squeeze the vessel, as this will dilute the sample with interstitial fluid. Clipping fur will prevent blood dissipation and loss. Applying petroleum jelly can also help pool the sample. Sampling location should be consistent, as BG may vary at different locations. If measuring venous BG, continue this each time.
Serial glucose readings taken every 1–2 hours create a BG curve. Frequency of readings may depend on patient stability and the likelihood of hypoglycaemia and consequential Somogyi overswing. Hormones are triggered to increase BG sharply during a hypoglycaemic episode, with the patient remaining hyperglycaemic for up to a few days, leading the vet to believe an increase in insulin is needed.
Glucose curves reflect the efficacy of treatment (does the BG fall), the onset of action (when does it start to fall), the peak effect (time to nadir), the glucose nadir (the lowest it reaches) and once there is an acceptable nadir, the duration of action can be determined (how long the insulin works for). Behrend et al (2018) suggest repeating a curve every 1–2 weeks until stable and 1–2 weeks after any change in insulin dose at a later stage.
In-practice glucose curves can be inaccurate because of potential stress hyperglycaemia and difficulty maintaining a regular routine and appetite. HBGM has many benefits, provided it does not increase the owner's burden or lead to clients altering their pet's dose independently. However, cats are not always affected by stress hyperglycaemia. Casella et al (2005) found BG was lower in the clinic than at home, assumed to be because of a lack of food intake. In 38% of cases, treatment based on hospital curves would have differed from home curves.
The above studies not only identified owner concern over hypoglycaemia but also found HBGM increased owner confidence in managing their pet's diabetes. Albuquerque et al (2020) found that 71% of cat owners performed HBGM, with many owners taking readings at least once a day, finding the marginal ear vein the easiest site. Most owners found information on the internet about HBGM but would have preferred that their vet had recommended it. HBGM has been shown to improve remission rates, reduce the need for clinic visits and improve the quality of life of owners and cats, mainly by reducing owners’ concerns (costs and hypoglycaemia) (Hazuchova et al, 2018).
HBGM can be performed with continuous glucose monitoring devices, such as the Freestyle Libre human sensor, which measures glucose in interstitial fluid (Figures 5, 6). This follows the same trend as BG, just slightly delayed, so a glucometer would be a useful backup to more quickly and reliably assess for hypoglycaemia (the sensor is also less accurate at low glucose levels). Sensors can provide up to 14 days of data, if they do not fail or detach, allowing identification of hypoglycaemia and overshoot with extended monitoring time, while the patient experiences their normal routine at home. A client agreement form can be valuable, explaining the pros and cons while agreeing to understanding and consent. A smartphone app is required to scan the sensor; the data can be synced to be viewed online in practice. The sensors are easy to apply, and clients can be trained to apply them at home. However, they can be inaccurate in dehydrated patients.
Urinalysis can include biochemistry, specific gravity and sediment. Dipsticks can underestimate glucose in dogs and only reflect the glucose level while the bladder was filling, but weekly trends showing consistently low readings could indicate insulin doses might be too high. Culture and sensitivity may be performed as urinary infections cannot be ruled out by the absence of an active sediment and clinical signs. When using an SGLT-2 inhibitor, frequent ketone monitoring is required during the first few weeks. Urine samples should be collected at home to reduce the effect of stress, or the client may perform dipsticks and record results.
Other monitoring tests may include blood pressure (screening for primary or secondary hypertension), haemoglobin A1C (reflects average BG levels over past 2–3 months), biochemistry panels and pancreatic lipase. Fructosamine is debatable as the result does not answer the questions answered by a glucose curve. Sparkes et al (2015) mention fructosamine for monitoring but recognise its limitations and variability: well-controlled cats can be high, and uncontrolled cats can be normal, while cats with hyperthyroidism, reduced plasma proteins or high protein turnover may have lower fructosamine, or it might be elevated in sick, hyperglycaemic, but nondiabetic cats. Trends may hold greater significance; for instance, low fructosamine levels may indicate chronic hypoglycaemia and potential remission in cats.
The VN can report test results to the owner at the time, such as a spot glucose reading, and state whether this is high/low/normal without indicating how this might impact treatment, unless this is specifically detailed in a diabetic management policy delegated from the VS. However, Niessen et al (2010; 2012) suggested avoiding blanket policies, meaning veterinarians should consider test results as one part of the whole patient assessment.
Advice
If needed, provide guidance on medicating, feeding, exercise, obtaining samples, home monitoring and general care, such as comfort, toileting and resources, providing websites or handouts for reference. There are online support groups, International Cat online videos and Behrend et al (2018) created an emergency checklist for clients. Dispense any repeat medication or consumables needed.
When closing the consultation, summarise and consider any immediate concerns that require intervention by the VS. If not, book the next appointment or confirm the next point of contact, reminding the client how to make contact if needed. Taking things step by step and being available for frequent check-ins to answer new questions, including by phone, email or text, as well as the planned in-person consultations, will aid compliance.
Maintenance clinic
The maintenance clinic will follow the same pattern as above, dependent on the monitoring techniques used, performed at an interval determined by the case VS. Sparkes et al (2015) suggest in-clinic monitoring every 2–4 weeks to start with, then every 1–4 months depending on the stability of the cat and level of HBGM.
Making diabetes more manageable
Routines and holidays
Provide details of local boarding facilities that accept diabetic pets, or offer medication training for a family member, neighbour or friend in the case of client absence or inability to tend to their pet. Agree on a medication administration window to allow some flexibility to the routine and set realistic expectations – it may be acceptable to miss a very occasional dose if necessary. Recommend clients are equipped with a first aid pack when the pet is out and about, containing their glucometer and test strips, glucose gel/honey, and veterinary contact information, including out-of-hours.
Medication administration
Revisit medication administration as many times as necessary until the client is confident. The Ebbinghaus Forgetting Curve (Figure 7) (Clearwater, 2024) illustrates an exponential loss of memory immediately after learning, where, as time passes, more and more information is lost. However, repeated exposure over time reduces the curve as information is retained, so key points of diabetic management should be revisited frequently. Clipping fur between the shoulder blades can facilitate improved visibility when injecting insulin. Consider whether the client is better suited to syringes or an insulin pen and whether VN support at home may help to address issues.
Costs
VN consultations often cost less than VS, reducing costs during stabilisation. Review their insurance policy (if applicable) and use the funds wisely. For a 12-month policy, the funds could be used for more in-depth testing or monitoring, such as screening for other underlying endocrinopathies. Arrange a direct claim if possible. Check if the policy covers pet food, if this would aid a diet transition, or advise on any palatability and loyalty schemes available. Some practice health plans include consultation fees or offer discounts on medication.
Ordering medication (via a written prescription) and consumables online can be more cost-effective – highlight the types of syringes/needles used as these must be correct (U-40). The VS should prescribe and dispense appropriate medication volumes, considering the daily dosage and product shelf life, minimising wastage and maximising affordability. Depending on their capability and budget, the VS should tailor the treatment and monitoring plan to the client and pet. If the owner is confident, recommend home monitoring of clinical signs, BG (potentially applying their own sensors), weight change and urine dipstick results – the VS would then review the data and consult over the phone when needed.
Pet factors
Make gradual changes to dog feeding times by adjusting them every few days. Establish a treat routine with the owner, allowing for honest discussion. Reduce stress by optimising cat carriers and travel routines. Consider each pet's temperament – minimise clinic visits whenever possible and use anxiolytics (either POM-V or over the counter) before visits and/or injections. Pets may learn the pre-injection routine and become evasive, so clients should aim to be less predictable when possible.
Key consulting skills
Time is vital for thorough support, so nurse consultations should be as long as is practical to address client concerns and questions to facilitate better diabetes management. Being supportive and flexible will help achieve the overarching goal of improving quality of life.
The VN should practise active listening, maintain open body language and exhibit patience to create a warm, relaxed atmosphere that encourages discussion. Booking future consultations with the same VN will build rapport and foster a trusting relationship, allowing clients to share more. Avoid making assumptions and stay curious; for example, do not assume that those with clinical experience will find injecting easier – encourage every caregiver to be open with their thoughts. When providing advice and recommendations, the VN can share information and hope the client agrees or inspire them to see that the recommendation is right, reasonable, for the best and worth doing – this is the art of persuasion. When more in-depth questions are posed, take time, if needed, to find the answers and inform the owners when they can expect further information. If the subject is medication or treatment related, the VN can speak generally about how this works in the species, without implying any changes to the pet's current management before consulting a VS.
Appreciate the client's emotions and personal reactions, using a consensus mindset to reach an agreement with them, rather than a contest mindset, which enforces the VN's view as the only option. Always assume difficult clients are not being so intentionally – their behaviour is likely a result of their experience and emotions, rather than relating to the individual VN. Being engaging and understanding means the VN is no longer a target to attack. Approach a dissatisfied client as an opportunity to explore mistakes and make improvements. Enquire, ‘in your opinion, what went wrong?’ and apologise if there has been an error. Regarding cost issues, try to establish whether they cannot afford the proposal or perceive it as too expensive for what they will receive. Educate by explaining the benefits and be flexible with options.
Conclusions
Diabetic nurse clinics are valuable to the practice, team, pet and client. Knowledge of the pathology of diabetes in dogs and cats allows the development of consultation protocols and checklists, allowing the case VS and VN to deliver tailored management plans alongside excellent client support. Clients should be empowered to feel more involved in their pet's condition, understand their stability and be confident to decide when interventions are needed, which will reduce worry and help them feel freer.