Cross-sectional study of perceptions of competence and confidence in feline handling

Despite their popularity as a pet, cats are perceived to be notoriously difficult patients to manage (Biggle, 2016). As territorial creatures, they require a sense of control to feel safe and the clinical environment can be hyper-stimulating and stressful for these patients who are sensitive to sights, sounds and smells (Dawson et al, 2016; Mariti et al, 2016; Cannon, 2018). As a predatory species, felines are inclined to show fear and defensiveness in unfamiliar or uncomfortable environments (Rodan et al, 2011; Dawson et al, 2016); behaviour that can be misinterpreted by veterinary staff as a natural compulsion for aggression. As such, there has historically been a tendency to use rough handling or ‘scruffing’ to conduct necessary treatment procedures (Dawson et al, 2019); practices which can lead to patient stress, and frustration for staff (Reeve and Hibbert, 2022) Recognising and reducing stress in feline patients is imperative as fearful cats may be presented less frequently to vet practices by their owners (Mariti et al, 2016). Supporting the welfare of these patients by using handling and restraint practices that meet an individual's specific needs can help reduce or prevent negative experiences, thus creating more cat-friendly practices (Nibblett et al, 2015; Fielberg et al, 2020). Patient low-stress guidelines and standard operating procedures can also support veterinary professionals to work confidently and with patient welfare in mind (Moody et al, 2020; Kendall, 2021).

Despite the current varied veterinary nurse training models that exist in the UK, with different academic levels of qualification, there is a consistent requirement for all students to meet the Royal College of Veterinary Surgeons (RCVS) Day One Skills and Day One Competences to be eligible to enter the register (RCVS, 2023a). Professional competence is determined through a combination of observation in clinical settings and practical and written assessments, and the RCVS defines competence as ‘a concept that integrates knowledge skills and attitudes, the application of which enables the professional to perform effectively, including being able to cope with contingencies, change, and the unexpected’. Theoretically, meeting the Day One Skills and Day One Competences requirements should mean that all student veterinary nurses, and consequently registered veterinary nurses, have the necessary competences across a spectrum of clinical skills, including feline handling. However, barriers to animal handling experiences during training have been identified (Dunne et al, 2015; Reeve and Hibbert, 2022), and the RCVS and others have acknowledged that competence is a relative term and is an attribute that will develop over time and with experience (Dunne et al, 2020). A time-frame of around 2 years has been suggested as being required to develop registered veterinary nurse competence in the workplace (Dunne et al, 2020).

Fu et al (2017) noted that competence and confidence are often misaligned, which can result in poor working practices. It is therefore possible for veterinary nurses to be competent in feline handling but lack the confidence to execute these skills reliably; or to feel confident but lack the competence to perform tasks correctly. Although all veterinary nurses should have achieved similar competence by the point of registration, they must evoke their own confidence in their abilities. Confidence in feline handling has been shown to be variable and dependent on many factors such as patient amenability, handling experience and perceived levels of competence (Reeve and Hibbert, 2022). A recent small survey study by Hill (2023) found that confidence in assessing feline behaviour and adapting handling techniques according to patient preference was significantly related to length and route of qualification; however, limited data were shown to support these claims and no sample size was reported. As such, these results should be interpreted with caution. Another small survey study by Goins et al (2019) revealed that of the 53 Irish veterinary nurses that participated, confidence was generally perceived to be high when advising clients about feline behavioural issues, with length of time qualified having no significant effect. However, the small sample size in this study may have reduced its reliability.

It is imperative that veterinary nurses develop attributes of both competence and confidence across diverse feline handling scenarios (Gottlieb et al, 2022) as they have an integral role in supporting the development of feline friendly practice and ensuring that the advances in feline care are translated into clinical practice (Little, 2016). Anecdotally, there are often individuals who are actively sought to handle difficult cats, and there are those veterinary nurses that enjoy nursing cats despite the challenges that some patients present. These self-proclaimed ‘cat whisperers’ appear to be more empathetic to the feline patient and naturally work well with this species (Dawson et al, 2019). It is not clear whether this phenomenon can be attributed to them holding a specific skill set or having a personal interest and desire to be a feline advocate. It is also not clear what sets these individuals apart as seemingly having an innate ability, when veterinary nursing training sets out standardised competencies. With increasing popularity of the cat as a domestic pet, accounting for around 40% of veterinary admissions (Carozza, 2018), it is important to better understand how veterinary nurses feel about working with cats to ensure these patients are receiving optimum care from this body of professionals.

Aims

The main aim of this research is to investigate the relation-ship that competence has to confidence and determine what factors in the registered veterinary nurse experience enable or disable competent and/or confident feline handling.

Methods

This study used a cross-sectional concurrent triangulation mixed methodology. The population of interest was RCVS registered veterinary nurses currently working in UK small animal clinical practice. Eligible participants were recruited using the RCVS research email database and the authors' corporate intranet, with further snowball sampling via social media (Facebook, Meta Platforms Inc.). A sample size of 305 was required to ensure a 95% confidence interval (CI) and 5% margin of error, calculated using an estimated population size of 17 168, where 72.3% work in small animal practice (RCVS, 2019).

The survey was administered using the Online Survey (Jisc) platform and comprised 33 questions: single or multi-option questions collecting personal and professional data (participants could select ‘other’ and provide a free text answer if no pre-determined option applied), 10-point Likert scale questions (where 0 = least and 10 = most) to score their perception of their competence and/or confidence in a range of scenarios, and open-ended questions allowing participants to explain their responses or provide their opinions. The survey was piloted with four registered veterinary nurses to ensure comprehension and the final version was open for 5 weeks across March–May 2022. The study was conducted with full institutional ethical approval.

Data were extracted into Excel (Microsoft Corporation) for cleansing and descriptive analysis. ‘Other’ free-text responses were re-coded to existing or new groups. Descriptive statistics were presented as frequency and percentage of the total sample. Likert-scale data were presented as median and interquartile range (IQR) as these ordinal data were not normally distributed. Correlation between competence and confidence scores were statistically analysed using the Spearman's rank correlation test. Univariate analysis of median competence and confidence scores was conducted across a range of categorical variables using the non-parametric Mann–Whitney and Kruskal–Wallis tests. To determine between which groups significant differences existed, posthoc pairwise comparisons were conducted with adjustment by the Bonferroni correction for multiple tests. Groups that were too small for analysis (<5) or those who answered ‘unsure’ were excluded from the analysis. Incomplete data sets were included in the analysis if >75% complete. Inferential statistical analysis was conducted using SPSS 28 (IBM) and significance was set at 0.05. Free-text comments were qualitatively coded using an interpretive framework where similar codes were combined into categories, from which overarching themes were identified (Creswell and Clark, 2011), and frequency of occurrence of categories and themes (n) were reported.

Results

The survey was completed by 153 participants, and one was excluded as they were a student, leaving 152 eligible responses for inclusion in the analysis. Based on this sample size, there is a 95% CI and a 7.08% margin of error.

Demographics

Most participants were aged 25–34 years (n=54, 35.5%) and qualified with a Level 3 Diploma (n=77, 52.0%). The median length of qualification was 11.0 years (IQR 18.0 years), with the largest group qualified for 16–25 years (n=44, 29.1%). Table 1 gives full demographic information. The majority (n=131, 86.8%) currently or previously owned or lived with a cat, and of these, 119 (90.2%) believed that this influenced their understanding of feline behaviours. When asked why, the themes that arose were that it improved their understanding of cats (including normal behaviour, body language, and individual needs; n=84), it provided opportunities to observe cats in a normal and relaxed environment (n=37), it improved handling and interaction with cats (n=17) and it provided personal benefits such as improved empathy and reduced fear (n=6).

‘I learned more about their normal behaviours outside a stressful environment. It made me appreciate their complexities more and improved my handling of them.’

Work experience with cats before veterinary nurse training was varied (Figure 1), with veterinary work experience the most common (n=44, 28.9%), followed by voluntary work/rescue centres (n=23, 15.1%). No prior feline work experience was reported by 55 (36.2%) participants.

Factors that influence veterinary nurse perceptions of cats

Most (n=135, 88.9%) participants stated they enjoyed working with feline patients, with influencing factors stated as having confidence (n=114, 15.1%), positive experiences working with cats (n=106, 14.0%), a love of cats (106, 14.0%), and cat ownership (n=102, 13.5%) (Figure 2). Of the 11 (7.2%) that did not, and 6 (3.9%) that were unsure of whether they enjoyed working with feline patients, they were influenced by previous bad experiences (n=9, 20.5%), fear (n=8, 18.2%), and lack of confidence (n=7, 15.9%) (Figure 3). Most (n=109, 72.2%) self-identified as the person commonly asked by colleagues to handle difficult or aggressive feline patients, hereafter referred to as a ‘cat nurse’.

Three main themes arose to describe the qualities of a ‘feline friendly’ nurse: personal traits (n=194), knowledge and skills (n=119) and effective practice (n=68). Table 2 shows the categories which informed these themes.

‘Patience, understanding, kindness, confidence and bravery. Also the ability to speak out when something isn't working and the ability to recognise better methods to succeed.’

Confidence in assessing feline behavioural cues was high, with a median of 8.0 (IQR 2.3) and was described to be influenced by experience gained at work or as a cat owner (n=72), and from completion of continuing professional development and training (n=17), with courses in behaviour, ISFM diploma and Fear Free certification cited.

Competence and confidence in feline nursing

Participants felt moderately prepared for feline handling from their initial training as student veterinary nurses (competence: median score 5.0 (IQR 4.0); confidence: median score 5.0 (IQR 5.0)). Some participants described receiving little or no training in feline handling (n=38) or a basic level of training only (n=29). This skill was described to have been learnt during time spent in practice (n=33), either as an employed student veterinary nurse or on clinical placement, though the quality of this learning was sometimes influenced by colleagues (n=4).

‘Little specifics or practicals involving live cat handling at college except when in practice – not always therefore taught best practice.’

Only three participants reported learning about feline friendly approaches, whereas more (n=23) reported being taught less cat-friendly and outdated restraint techniques.

‘Theory for restraint and consideration towards reducing stress, but there was less emphasis on an empathetic and understanding approach.’

Most participants believed their current competency made them confident in feline handling (n=133, 88.2%) and that veterinary nurse confidence in feline handling affected patient care (n=145, 96.1%). Explanatory themes encapsulated how it affected patient behaviour (n=77) and impacted on patient care (n=61) and on staff (n=23). Table 3 shows the categories that informed these themes. Respondents described that cats could ‘feel fear’ and responded positively to individuals who were calm and confident. This was stated to help facilitate accurate clinical assessment, administration of treatment in a timely manner, and prevention of the patient or handler coming to harm. When veterinary nurse confidence was low, concerns around overuse of firm restraint, staff avoidance of patients and substandard care were described.

‘I think that cats are very sensitive to a person's confidence, in that they can tell if you are nervous or unsure. This can agitate them, and cause a more aggressive response to handling attempts. Unsure handling can lead to patient and staff injury, due to inappropriate or inadequate handling. Poor handling interactions can damage handler confidence, which then can negatively affect future interactions.’

The overall median competence and confidence scores when handling amenable and aggressive patients were both very high (amenable: both 10.0 (IQR 1.0); aggressive: both 9.0 (IQR 2.0)), and there was no statistical difference between the median scores of both attributes within the same handling scenario. However, the median scores of both competence and confidence were statistically significantly lower when comparing handling amenable patients to aggressive patients (both P<0.001) (Figure 4). Competence and confidence scores were strongly positively correlated in both handling scenarios (amenable: r=0.854, P<0.001; aggressive: r=0.94, P<0.001).

Participant variables which influence competence and confidence when handling feline patients

Table 1 reports the full results of all participant variables investigated.

Amenable patients

Age was a statistically significant variable for both attributes (P=0.049 and P=0.009), with significant differences found between age groups 25–34 years and 45–54 years (P=0.04). Length of qualification was also statistically significant for confidence (P=0.02), with significant differences found between 1–3 and 16–25 years (P=0.022). Self-identification as being their practices ‘cat nurse’ and whether the participant enjoyed working with cats was statistically significant for both competence and confidence (P<0.001 for all), where currently or previously living with a cat was only significant for confidence (P=0.043).

Aggressive patients

Age was a statistically significant variable for both attributes (P=0.007 and P=0.002), with significant differences for competence between age groups 18–24 years and 55+ years (P=0.015), and for confidence between age groups 18–24 years and 45–54 years (P=0.034), 18–24 years and 55+ years (P=0.003), and 25–34 years and 55+ years (P=0.035). Length of qualification was also statistically significant for both attributes (P=0.022 and 0.006 respectively), and type of qualification was significant for confidence (P=0.017), although post hoc testing could not detect differences between specific groups. Self-identification as being their practice's ‘cat nurse’, and currently or previously living with a cat were statistically significant for both attributes (P<0.001 for all), as was whether the participant enjoyed working with cats (P=0.002 and P<0.001, respectively).

External factors that influence competence and confidence

Additional training in feline handling and restraint had been undertaken by 122 (80.8%) participants (Figure 5), with the most common activities attending CPD lectures and informal in-house training (both n=43, 35.2%). No participant had undertaken any practical CPD. Just over half believed extra training had improved their competence (n=99, 66.0%) and their confidence (n=91, 60.5%) in feline handling. Factors stated to most impact on confidence included experience with patients (n=139, 27.9%), colleague influence (n=90, 18.0%) and use of handling/restraint aids (n=84, 16.8%) (Figure 6). A combination of training and practical experience in handling was described as essential (n=51), and influence from experienced colleagues and practice culture was important (n=47) but was described to have both a positive and negative effect.

‘Negative culture in some practice person[n]el made me more aware of how NOT [Sic] to do it. Demonstration by experienced colleagues is always a positive asset.’

Learning new restraint techniques and use of handling aids were stated to help registered veterinary nurses adopt a more ‘hands-off’ and ‘cat-friendly’ approach (n=17). Types of handling aids that were described included cat bags, muzzles, towels, music and pheromone sprays. A small number (n=5) specifically mentioned working in an ISFM accredited practice, suggesting that low-stress handling practices were embedded in only a small number of clinics.

Discussion

This study has provided new insight into registered veterinary nurse perceptions of working with cats. Most of the participants in this study held positive perceptions towards felines, enjoying working with this species and perceiving themselves to be their practice's ‘cat nurse’. This suggests there are positive advocates for this species in many veterinary practices. Beyond a love of cats, influential factors appeared to include self-confidence, positive experiences working with cats, cat ownership and an interest in the species. Concurring with previous studies, living with or owning a cat, was described as invaluable for increasing understanding of the species and its normal behaviour, and in gaining handling experience (Da Graca Pereira et al, 2014; Hill, 2023). From the free-text responses, the knowledge and skills developed at home appeared to help registered veterinary nurses become more patient-centred and consider how to adapt their nursing approach to better meet individual feline patient needs (Nibblett et al, 2015). Cat ownership or living with a cat, along with an enjoyment of working with cats and self-identification as a ‘cat nurse’ were seen to result in statistically significantly higher attribute scores when handling both amenable and aggressive cats, and may be factors which support the actual, or perceived, development of competence and confidence. However, it is important to highlight that no conclusions could be made about the rate or degree of development of these attributes, or if one attribute develops first and influences the development of the other attribute. Both attribute scores were strongly positively correlated and no statistically significant differences between median attribute scores within the three scenarios were noted. This suggests that either both attributes develop at a similar rate or similar perceptions of both attributes are held. It is possible that participants did not understand the differences between competence or confidence, though definitions were provided.

Median competence and confidence scores overall across the scenarios were very high, with the lowest median scores unsurprisingly seen in those who stated that they did not enjoy working with cats. Both competence and confidence scores were statistically significantly higher for handling amenable cats when compared to difficult cats, reflecting the inherent challenge that these latter patients pose for registered veterinary nurses. Further studies should aim to investigate causal factors to these perceptions, although lack of confidence in veterinary students handling unpredictable cats was similarly noted by Reeve and Hibbert (2022), with enjoyment interacting with cats, frequency of practicing the skill, and self-perceptions of skills in behaviour identified as statistically significant factors (Reeve and Hibbert, 2022). For the small number in this study who did not enjoy working with cats, many noted that this had been influenced by previous bad experiences, fear of the species, a lack of confidence and a lack of cat ownership.

Injury from biting and scratching injuries are relatively common, especially in early career, with a reported incidence rate for veterinary nurses of 48% (van Soest and Fritchi, 2004). Our findings suggest these incidences may result in longer-term impact on registered veterinary nurses' perceptions of working with felines: a factor which should be explored and addressed to ensure all staff can work proficiently and safely with this species. Participants in this study believed that confidence in feline handling can affect patient care: if registered veterinary nurses fear cats, they may avoid working closely with these patients, especially when they are displaying more challenging behaviours. This may have a negative impact on the level of care provided, and concern was expressed of missed treatments, minimal observation and checks, and a reduced level of interaction; all of which may ultimately cause the patient harm.

‘I don't feel patients receive your best care if you aren't comfortable handling them, such as grooming them if they are a long-stay patient or checking their IV is ok and rebandaging it.’

The personal qualities described as being required of a ‘feline friendly’ nurse included being calm and patient, confident, respectful, brave, caring, compassionate and interested in the species. Excellent knowledge of behaviour and body language, of the restraint tools and techniques that can be used, and of how to create a calm and stress-free environment were also described as important. The requirement to be effective with one's nursing practice was described by many as being essential and was stated to require experience and practice, a need to work slowly, gently and quietly, being organised, giving patients time, the ability to direct others who are less confident, and knowing when to stop and give the patient a rest or recommend deferring treatment to another time.

‘Patience, understanding, kindness, confidence and bravery. Also the ability to speak out when something isn't working and the ability to recognize better methods to succeed.’

Student training was not perceived to have provided high levels of competence or confidence in feline handling, with these scores much lower than the scores when rating current perceptions in handling cats. Training was stated to provide a ‘basic tool kit’ for patient handling and some participants felt the level of didactic knowledge they gained in formal education settings could have been expanded to include greater focus on behaviour and low-stress handling techniques; a finding that undoubtedly reflects the era in which some of the participants trained.

Although education would ideally prepare students for the varied interactions and temperaments that can be experienced with the feline patient, significant barriers exist for institutions in using live cats for practical teaching of handling and restraint (Duijvestijn et al, 2022). Such animals are typically selected based on temperament and tolerance of repeated handling and interaction, so they do not pose a safety risk to students (Dunne et al, 2015). There is also increasing pressure for the rational use of live animals for teaching and a growing preference for simulation (Dunne et al, 2015; American Association of Veterinary Medical Colleges, 2022). Teaching animals do not realistically reflect the scared or aggressive patients that registered veterinary nurses meet in the clinic and this learning should be supported in other ways.

Participants described the benefits of time spent in the clinical environment in gaining skills in feline handling and it is clear the practicum is an essential component of veterinary nurse training, with similar positive outcomes of clinical placement on veterinary student Day One abilities reported by Schull et al (2011). Alongside gaining experience from multiple interactions and repetition, peer influence and more knowledgeable and experienced colleagues were described to boost confidence and encourage diverse handling techniques, although it should be noted that this influence was not always positive. This is a part of the ‘hidden curriculum’ which warrants further exploration to ensure student veterinary nurses are getting the most out of this aspect of their training (Mossop and Cobb, 2013). It is not unexpected that both competence and confidence would score lower at this early-career time point given that these types of practical skills are known to develop over time and with experience as veterinary nurses move from novice to expert (Dunne et al, 2020; Reeve and Hibbert, 2022). However, it is important to highlight that these data could have been strongly influenced by recall bias and may be reflective of the standards in education and accepted practice that were present at the time the individuals' qualified (Sedgwick, 2012). As such, these findings may not reflect more modern teaching practices or curricula and should be interpreted with caution.

Participant factors of statistical significance included age and length of qualification, and there was a general trend overall of increasing attribute scores as years increased. The independence of these variables is disputable; however, as in most instances the older participants were the longest qualified. Future studies using multivariate models are required to determine the relationship between these variables. All but 27 participants were qualified longer than 2 years, which meant most exceeded the time described by Dunne et al (2020) as being required by veterinary nurses to develop competence in the workplace and may explain why, overall, the scores were high. However, the findings in this study suggest that confidence, and to a lesser extent competence, when dealing with more temperamentally challenging patients may take longer to develop across an individual's career and may be attributes that improve with increasing age. These findings echo those of Hill (2023) who reported longer qualified veterinary nurses were more confident assessing feline behaviour and adapting handling techniques to patient requirements; and of Fielberg et al (2020) who found that veterinary practitioners with less experience found it more challenging to interpret fear responses and signs of aggression. Further training and CPD may be key factors in developing these attributes over time and it is crucial that all members of the veterinary team are proactive in developing their skills (Clark, 2020), as many of the participants of this study had already done.

Other significant variables in handling cats included enjoyment of working with this species and a self-perception of being their practice's ‘cat nurse’, revealing that supporting veterinary nurses to hold these views may be important. In agreement with the findings by Hill (2023), type of qualification was also found to be statistically significant but only for confidence in handling aggressive cats, where scores were lower for those with a BSc degree compared to those holding other qualification types. Despite the requirement for the same number of hours to be spent in practice across the different training pathways (RCVS, 2023b), those with a degree appear to feel somewhat less prepared for managing more challenging patients and this is an aspect of the curriculum that higher education institutions should consider.

Limitations

This study does not reveal whether a mismatch exists between perception and actual levels of competence and confidence, as this could only be tested in a true clinical setting and should be a focus for future research (Duijvestjn et al, 2022). The small sample size reduced the power of this study, however many of the findings are supported by existing literature (Dunne et al, 2020; Fielberg et al, 2020; Hill, 2023). Social bias may be present as participants may not have wanted to be completely truthful in their responses for embarrassment or fear of judgement at scoring themselves low in either attribute (Grimm, 2010). Sampling bias is also highly probable, with those interested in cats more likely to participate in such a study (Sedgwick, 2012). As such, the high median attribute scores reported here should be interpreted with caution as they may not be representative of the wider registered veterinary nurse population. Nonetheless, the demographic data appeared to be a true representation of the UK registered veterinary nurse population, with similar age and qualification route distribution to the most recent RCVS survey of the profession, although degree-level nurses appeared to be slightly overrepresented in this study (RCVS, 2019).

Conclusions

This study has provided insight into registered veterinary nurse perceptions of competence and confidence of feline handling and what contributes to an individual identifying as a feline friendly nurse. Registered veterinary nurses need to be both competent and confident handling felines across a diverse range of scenarios, and it appears that both attributes develop concurrently over time in these professionals. Although practical training is an essential component for supporting student veterinary nurses to develop these attributes, cat handling is difficult to achieve in formal education settings. Feline-specific work experience may not be an essential entry requirement for training programmes; however, educators should remember that this experience may provide important basic skills from which student veterinary nurses can develop. If no such building blocks exist, then time should be spent to ensure trainees gain both didactic knowledge and practical skills, with the development of the latter strongly supported during clinical placement. The perception of a lack of education in handling, behaviour and feline friendly practice by these registered veterinary nurses support the value of clinical practice for developing these skills. Undoubtedly, however, formal education practices have evolved over time since many of the participants qualified. Nonetheless, educators should be mindful of ensuring curricula are current and reflect modern practices such as low-stress handling techniques.

Developing a cat-friendly culture in practice and setting high standards of patient care are imperative for the welfare of this species, and practices appear to be using low-stress approaches for feline patients. Where individual registered veterinary nurses lack competence or confidence, especially when arising from previous negative experiences, time should be spent supporting individuals to overcome their personal barriers to develop these attributes. Positive role models are beneficial, although peer learning can sometimes be negative and perpetuate out-dated feline handling practices. The benefits of cat ownership should also not be overlooked as it appears to bring many benefits to registered veterinary nurses and may be a route considered by those who feel they want to augment their understanding of feline behaviour and develop handling skills. Evidence-based practice protocols and ‘feline friendly’ accreditation may also help support a whole-practice approach and CPD should be encouraged for all members of the veterinary team to incorporate a multi-modal approach to ensuring good patient welfare.

KEY POINTS

• Competence and confidence in feline handling is strongly positively correlated and although self-rated perceptions of these attributes is generally high in veterinary nurses, they are reduced when handling difficult or aggressive cats.
• Veterinary nurses who enjoy working with cats, who have previously owned or lived with a cat, are older, and have been qualified longer score significantly higher for competence and confidence in feline handling.
• Negative experiences, such as sustaining injuries, when working with cats is an impactful factor for veterinary nurses and may have longer term effects on the individual, their confidence, and the care they provide this species.
• Developing a feline friendly practice culture is important, and some qualities described of a feline friendly nurse include being calm, patient and caring, having a good knowledge of feline behaviour and body language, and being patient-centred and delivering individualised care.
• Practical experience is critical for developing competence in feline handling, though the quality of workplace learning can be variable and should be supported with teaching that delivers a strong foundational knowledge of feline behaviour and low-stress handling techniques.