The impact environmental variance in waiting rooms has on the expression of fear in canine patients

Fear-related behaviours are commonly observed by veterinary surgeons and registered veterinary nurses in practice, and present a prominent welfare and safety issue when dealing with canine patients (Dawson et al, 2016). Poor experiences may lead to negative associative learning which may influence behavioural expressions used in the future (Rooney et al, 2016; Hargrave, 2017). Increased levels of stress and fear in patients may lead to an increase in defensive or fear-aggressive behaviour, potentially limiting clinical treatment options and inherently impacting patient welfare and health (Edwards et al, 2019a).

Döring et al (2009) concluded that 78.5% of dogs studied (n=135) demonstrated fear-related behaviour, with 13.3% of dogs requiring ‘dragging or carrying’ into practice. Stanford (1981) and Edwards et al (2019b) found that 70% (n=462) and 55% (n=26 555) of patients expressed fearful behaviours in practice. Although periods of exposure to medical settings are generally short, this perspective fails to consider the impact negative experiences have on the animal after the event, and before similar events in the future. Not only may this impede positive mental states and wellbeing, it may increase specific learned behaviours and affect the experiences dogs have during unforeseen periods of hospitalisation (Riemer et al, 2021).

Dinwoodie et al (2019) reviewed the instances of behavioural issues leading to aggression in dogs, highlighting that in 65% of dogs surveyed that had bitten a person, this was due to fear. The severity of these instances during veterinary visits varied, with 37% of bites not puncturing the skin, while 32% did. Therefore, reducing fear in patients could limit injury to all parties, reducing short- and long-term staff injury, sick pay and subsequent locum cover. It may also enhance job satisfaction in the industry, which currently struggles to retain staff (Riemer et al, 2021; Menor-Campos et al, 2022). Due consideration should also be given to the impact behavioural expression has on owner experiences. Volk et al (2011) demonstrated that poor owner experience increases reluctance to seek medical assistance, not only limiting opportunities to identify and treat primary illness, but also hindering the development of client–practice relationships and retention (Hauser et al, 2020).

Potential catalysts for a fear response within practice may include noise, smell, unfamiliar surroundings and other animals (Edwards et al, 2019b). Typically designed to enable hygiene control and client satisfaction, the layout of seating in the waiting area is commonly sterile. The presence of others in the waiting area may also be a source of anxiety irrespective of social preferences; those who wish to socialise are inhibited, building frustration, while those classified as ‘anti-social’ may not be able to retreat or react appropriately, increasing stress and aggressive behavioural escalation (Rooney et al, 2016). Mariti et al (2015) and Engler and Bain (2017) identified high levels of fear behaviours during the period of time dogs were in the waiting room; however, did not consider the variable aspects of the environment that may have contributed to this. Limited evidence exists in relation to the improvement of canine experiences via environmental manipulation in practice, despite the ‘Cat-friendly Clinics’ scheme becoming mainstream (Moody et al, 2018). Therefore, further exploration of the impact that changes in the waiting room may have is needed (Sánchez-Vizcaíno et al, 2017). Further research is also needed to establish the importance of environmental variation.

Aims and objectives

This study aimed to identify and evaluate the influence of environmental factors in the waiting room that may affect the expression of fear-related behaviours in canine patients visiting a veterinary practice.

The research objectives included:

• Establish the differences in key environmental variables between waiting rooms at different UK veterinary practices
• Investigate the difference between dog behaviour before and after routine consultations
• Determine whether there is an association between practice waiting room environmental variables and the behaviour of dogs before and after a consultation.

Materials and methods

A quantitative, cross-sectional design was implemented with pre–post patient observations and environmental variation data obtained. A deductive approach was undertaken within a real-world setting using an observational approach across multiple practices.

Sample population

A study sample population of 54 dogs in total from five difference practices was obtained for behavioural and environmental data collection via convenience sampling. Owner consent was obtained at the time of the appointment allowing for an opportunistic approach to participant acquisition. To limit bias in non-probability sampling, owner contribution to data collection was limited to demographic data only. Practices were small animal, first opinion practices based in the UK and included examples from corporately-owned, group and independently-owned businesses (Edwards et al, 2019b). To aid demographic patient diversity, no exclusions on breed were stipulated, and patients aged 1–10 years were included providing they were clinically sound and not on medication which may have impacted on their behavioural expressions. All patients were visiting the practice for routine health reviews and deemed suitable for inclusion by veterinary practitioners (Väisänen et al, 2005).

Data collection

Environmental variables including flooring, seating arrangements, visual, audio and olfactory stimulants and other products were measured and noted to consider aspects that may influence the patient experience in the waiting area (Riemer et al, 2021).

A 19 element, three-point ethogram, adapted from Tod et al (2005) and Hauser et al (2020), was used to categorise patient's behaviour. Data were obtained by interval recording of behaviours in a whole-interval sampling method while patients were entering and exiting the consultation room (Melco et al, 2020). All behaviours observed in this timeframe were noted and rated 0–3 (0= not visible, 1= inconsistently visible, 2= consistently visible, 3= excessively visible). Behavioural measures were collated by qualified and registered veterinary surgeons or veterinary nurses who had undertaken a standardisation process to ensure equity in the information collected and to minimise variation in the interpretation of behavioural outputs. Observers measured behavioural expressions while sat in one corner of the waiting room to minimise the impact their presence may have had on the patient. Further key information about the patients' past experiences, interactions, details and demographics were also noted for consideration alongside the environmental factors present. As patients were in attendance for legitimate health checking, where possible a standardised approach was established to promote comparative experiences between practitioners.

Data analysis

A Shapiro–Wilk test of normalities was used to identify data distribution due to the modest sample population (n=54) (Nair and Diwan, 2020). Descriptive statistics examined participant demographics, environmental variants and external influencing factors such as excessive environmental noise during data collection. A Wilcoxen signed rank test was used to examine differences in pre–post behaviour data (Field, 2013). While examining parametric data sets for difference, a Paired t-test was used, all data reviewed for correlation were non-parametric; therefore, a Spearman's rank correlation was undertaken to examine the relationship of environmental variables and behavioural score.

Ethical considerations

Ethical approval was gained from Hartpury University Ethics Committee (ETHICS2021-55). Data were anonymised and stored securely in accordance with the Data Protection Act (2018). Site permission and owner consent was obtained, and all parties were over 18-years-old and able to provide voluntary informed consent. No control group was implemented as per the ARRIVE guidance (Percie du Sert et al, 2020). Due consideration was given to the 3Rs (refine, replace, reduce) in this research design, as further proof of methodology is required prior to undertaking an epidemiological research sample within this field (Sneddon et al, 2017).

Results

To identify the common environmental factors in practice waiting areas, 21 practices were visited to establish key elements to consider. Factors used for data analysis were then cross compared with commonly perceived aspects that are deemed to be positive or negative, as per Lloyd (2017) and Riemer et al (2021) for example. Each factor measured, such as distances between patient seating, flooring type, audio, visual stimulation, use of dog appeasing pheromone (DAP) and the presence of a separate species waiting area, was then assigned a –1 or +1 as seen in Table 1.

Patient demographics

Patient (n=54) demographic mean and standard deviation included age (5.38 years ± 2.94), weight (20.90 kg ± 12.38), and body conditioning score (BCS) (5.83 ± 1.45). Of these, 28 dogs were obese (>6/9, n=51.85%). While 25.9% of the patients were classed as gundogs and a further 25.9% cross breeds, comparative analysis of breed was not possible within this sample set due to broad demographic diversity. Participants were split between entire male (14.8%; n=8), neutered male (38.9%; n=21), entire female (20.4%; n=11) and neutered female (25.9%; n=14). A Spearman's rank correlation test was undertaken to explore the relationship between variables such as age, BCS and weight, demonstrating no significant findings to suggest an influence.

Behavioural analysis

Across all participants, the behaviour score pre- (M=10.40 ± 5.71) and post-consultation (M=8.12 ± 4.10) were deemed non-parametric via Shapiro–Wilk (P≥0.05); therefore, a Wilcoxen signed rank test of difference was used. A statistically significant difference revealed that fear-related behaviour decreased between pre- (Md= 10.50) and post-consultation (Md= 9.00) behavioural measures (Z= -3.821, P<0.001, r=0.52). Table 2 demonstrates the ethogram observations and severity rankings.

Each element of the ethogram was analysed via a Wilcoxen signed rank test for significant difference in observations of fear-related behaviours pre- and post-consultation as seen in Table 3.

A comparative review of the pre-consultation behavioural score and the practice environmental scores was undertaken. Data were deemed non-parametric via Shapiro–Wilk (P≥0.05), therefore a Spearman's rank correlation was used. A weak negative statistically significant correlation was identified between environment scoring and pre-consultation behaviour r_s (52) = -0.27, P=0.050, n=54. Individual practice data were also analysed to assess the significant changes in BS pre- and post-consultation as set out in Table 4.

Due to the environmental variant and sample population, limited statistical analysis was deemed suitable, with the exception of flooring. A Spearman's rank correlation was used to examine the relation between flooring and behavioural score, identifying a statistically significant weak positive correlation r_s(52)=0.28, P=0.035, n=54. This suggested smooth flooring increases the expression of fear in canine patients.

Practice analysis

Reviewing the data for practices individually demonstrated variation in patient behavioural score which when compared to the environmental score further evidences the relationship between the environment and expression of fear-related behaviour. Data across these practices found 63% of patients (n=34) have a reduction in fear-related behaviour post-consultation, while a further 11% stay the same (n=6). The pre- and post-behaviour score and age for patients from practices 1–5 are seen in Figures 1–5.

Discussion

This study aimed to collate and evaluate the environmental factors present within veterinary practice waiting rooms in the UK and establish if design influenced the expression of fear-related behaviour in canine patients. By reviewing a pilot study population (n=54), proof of concept was established, identifying key design aspects which may alter the experience of patients within the practice.

Environmental factors

Practice 1 and 5 not only demonstrated notably higher levels of noise, activity and stimulating factors in the waiting area, they also both used smooth flooring, and received an environmental score of -7 and -1. Only practice 4 also had smooth flooring, but, with a remarkably small sample from that practice, analysis was not deemed suitable. In contrast, practice 3 had the most positive environmental score of +5, with their patients demonstrating the lowest levels of fear. This suggests that variations of factors in the environment, based on preconceptions from Edwards et al (2019a) and Riemer et al (2021), have the propensity to alter the feelings and expression of fear in canine patients (Wilsson, 2016; Arhant et al, 2019). The environmental factors from practice 3 that were deemed of note included an increased distance between the waiting area and the consultation room, reduced patient–patient interaction, increased distance from the waiting area to reception, reduced noise and the addition of non-slip flooring coupled with matted areas.

While only practice 5 used DAP, they also had the highest mean behavioural score of all practices sampled, supporting the findings of Wong and Govendir (2021), who questioned the impact this intervention had. However, consideration for the reduced concentration of pheromones in open spaces is reported as a factor that may effect efficacy (Taylor et al, 2020).

Visual and audio stimulation

Secondary to hygiene considerations, the predominate focal considerations when designing the layout of a practice waiting area are to visually appease the sensibility of owners. Practice 1 and 5 used a TV to advertise products, clinics and services on moving slideshows. The inclusion of visual stimulation to owners may enable a change in their perception of waiting time, known as wait warping, which may also be why practice 1 and 5 included them within their busy waiting rooms (Barrand, 2011). The information shown enhances client education as well as product advertising; however, little evidence suggests the impact this has on canine experience of the practice. Many practices use slideshow imagery including dogs and cats, both of which could increase an alert or frustrated response.

Further research into the impact noise has is also needed to identify optimal methods of managing the practice environment. The use of radios is commonly deployed as a method of client entertainment, blocking out phone calls, noise in consultation and kennel area. Although, like TV stimulation, these may be factors commonly experienced in a home setting. Menuge et al (2021) suggested that while sights and sounds may not have an impact in familiar setting, when combinations of stress stimuli are present in a new setting this reduced dogs ability to cope and lead to further habitation requirements (King et al, 2022).

Conversely, prior research also demonstrated the positive impacts audio stimulation may have across many species and therefore investigation into the sounds that could be used to specifically target patient groups could be considered in the future (Hampton et al, 2020; Kriengwatana et al, 2022).

Flooring

Practices in this study which used smooth flooring were also associated with the higher levels of fear-related behaviour. To consider a sustainable and practical solution, given the hygiene concern within veterinary practices, the inclusion of washable matting in the seating area could enhance patient comfort and stability, as well as limit stress and risk of injury (Stellato et al, 2019).

Seating

In this study, some species-specific waiting areas were separated by <1 m while other with extensive waiting room space managed in excess of >6 m. Future consideration should be given as to a threshold these waiting areas should have to ensure adequate distance is provided (Lloyd, 2017). The spacing between seating in the canine area predominantly was <0.5 m, with some practices using a bench design. Future review of the impact variable distances may have on patient comfort would help to identify optimal design and layout.

Patient behaviour and demographic

The significant reduction in the expression of fear-related behaviour is likely multifaceted and may be subject to individuals' prior experiences, a factor that was not within the scope of this research. However, it is evident from the results of this pilot study that the environmental aspects of the practice, potentially coupled with the expectations formed via previous visits, may elicit a heightened fear response, as opposed to the experiences dogs have in the consultation itself; which is in line with the findings of Csoltova et al (2017).

No significant findings were identified between patient demographics and behavioural score. However, the impact of lived experiences and breed behaviour variance is often discussed within the literature (Hernander, 2009). Serpell and Duffy (2014) concluded breed-associated temperament, including fear, can be associated with specific genomes and therefore a broader investigation into the impact of breed and individual personalities is needed.

Limitations and future research

Although comparable to others in the field, a stronger statistical reliability would benefit the conclusiveness of the results if a larger sample population across more practices was obtainable (Hauser et al, 2020). It also would have been interesting to have extended the observation time period and triangulated the data via video recording of the patient's experiences more holistically. However, within the current study this method would have further limited practice participation and not would not have been possible in the timeframe of the project. Further measures from the waiting room such as decibels, frequency and sound variance could enable further conclusive evidence regarding the impact of noise (Landsberg et al, 2015).

There is scope for further research to also examine the impact of individual feelings around noise, other animal interactions and the influence of strangers. To establish this a similar research design could be undertaken to ensure authentic data from patients from varying backgrounds are gained. Further analysis of the time patients spent in each environment could have provided more understanding of the impact this may have on the patient experience.

Perego et al (2014) concluded that patients waiting outside the practice evidenced lower serum cortisol concentration and stress indicators in those undergoing haemotology. Future research could also consider obtaining more specific clinical data from patients in relation to stress perimeters. The use of convenience sampling in this pilot study has shown a reliable way of sampling a broad demographic of patients, indicative of the average patient type seen across practices. This non-invasive method of collecting real-world data has shown viability of the method for future projects.

Future research should aim to assess the impact of environmental manipulation longitudinally to establish more comparative analysis of individual's experiences. This would enable a more targeted approach to participant acquisition from specific demographic groups and experiences (Serpell and Duffy, 2014).

Conclusions

Environmental variables and behavioural data were analysed, showing a significant decrease of fear-related behaviour once the consultation had concluded, compared to pre-consultation observations. Evidence from this research proved reliability in the concept of data collection and analysis and provides scope for future longitudinal research to be undertaken. Further research from a broader sample of practices is needed to assess the impact that increased environmental diversity may have on behaviour. This would also give scope to strengthen the validity and reliability of the evidence and assess the efficacy of potential interventions. Practices should consider the use of non-slip flooring throughout the waiting area, as well as methods to reduce the noise and activity in the waiting area. Further analysis of the importance of space between seating and species-specific areas is needed to understand how to optimise this. By focusing on the malleable aspects of practice design, moving forward the industry may be able to suggest, with suitable reliability, a method to enhance the quality of patient experiences. This would enhance welfare and promote access to vital medical care. Enhancing relaxation in patients may also optimise diagnostic accuracy, enhance treatment options, protect the safety of both clinicians and owners, and increase client satisfaction and retention.

KEY POINTS

• Dogs consistently exhibit fear-related behaviour while visiting veterinary practices.
• The environmental aspects of the practice impact the degree of fear-related behaviour expressed.
• Slippery flooring and practice lay-out have the propensity to influence fear-related behaviour.
• No relationship was established to suggest canine demographics impact the expression of fear.