Concern regarding the provision of out-of-hours care in veterinary practices (VPs) has high-lighted the mismatch of the public's perception of 24-hour emergency care availability against what is actually achievable in practice (Tremlett, 2007). As litigation increases in VP the Veterinary Defence Society (2015) stated the importance for veterinary professionals to act within the guidelines of regulatory bodies. The Guide to Professional Code of Conduct for veterinary surgeons (VSs) and registered veterinary nurses (RVNs) (RCVS, 2019a,b) offers guidelines surrounding inpatient care and clearly states that the VS and RVN are responsible for providing appropriate and adequate inpatient care by persons with the relevant knowledge and expertise. RVNs and animal care assistants (ACAs) play an important role in the provision of overnight patient care in hospital facilities but there are many ethical, moral, and legal dilemmas involved when implementing such provisions that affect the patients, staff, and clients.
The patient
Shea (2014) discussed how cats and dogs have become part of the family in recent years and although still classed as a person's property, pets are increasingly gaining their own rights in law, for example protection under The Animal Welfare Act (2006). There is a legal and moral duty for night staff to provide patients with suitable holistic care to ensure their welfare and prevent unnecessary suffering (Animal Welfare Act, 2006). The RCVS (2019a) states that RVNs must work with their colleagues and VP in order to provide care to animals and must ensure that tasks are delegated only to suitably qualified and competent staff. Oxtoby et al (2015) suggested that organisations have a lack of awareness and priority of patient safety alongside financial pressures, which contributed to a large portion of treatment errors. Some practices use unqualified staff to cover night shifts in veterinary practice, which is mirrored in human hospitals and nursing homes due to costs and resourcing (Keeney et al, 2005). Problems have arisen around unqualified health care assistants (HCA) carrying out nursing work at the risk of the patient's safety (Keeney et al, 2005), especially when being put in charge of entire wards (Borland, 2012). The RCVS (2015a) believed that unqualified and untrained staff acting as RVNs are potentially detrimental to animal health and welfare. Under the Veterinary Surgeons Act (1966) it is illegal for unqualified staff to perform schedule 3 procedures such as administering injections or fluid therapy, however Branscombe (2012) explained that action may not be taken by the RCVS if minor medical treatments are delegated to lay staff which do not put animals at risk and could be carried out by the owner. The Commission for Social Care Inspection (2006) found that inappropriate handling of medicine by unqualified staff was a problem in care homes leading to poor storage of medications and incorrect treatment being given to patients.
Conversely many studies in the human field have found an increase in patient satisfaction on the introduction of HCA (Ramprogus and O'Brien, 2002), while Keeney et al (2005) found that patients were happy to be cared for by a HCA that had been correctly trained. Pearson et al (2006) concluded an increased proportion of unqualified staff had no detrimental effect to patients' care, attributed to many tasks requiring enthusiastic, practical skilled personnel rather than academically trained staff. Animals are not able to comment on how well they have been treated so the performance of qualified versus unqualified care would be based on clinical outcomes and client perception. Unlike patient safety in human health care there is limited research regarding patient safety in veterinary practice, with the requirement for clinical governance only just filtering into the RCVS Practice Standards Scheme (Oxtoby et al, 2015). Further research is required to identify how different levels of nursing care influence patient outcomes in order for VPs to improve patient care.
The RCVS has a duty to maintain public confidence in those providing veterinary care, but the moral dilemma is passed to the VSs and RVNs when they ask unqualified ACAs to perform tasks they are not qualified to do when they are the only staff available. Consequentialism plays a role in deciding whether out-of-hours medical treatment should be delegated to unqualified staff, as although they would be providing 24-hour care to improve the patients' health, in the event of an investigation should an animal suffer from inappropriate treatment, such as incorrect dosing or administration of medication, the VS would be, and the RVN may be, held accountable for the actions of the ACA, and disciplinary action from the RCVS may ensue, which could include removal from the register (RCVS, 2019a,b). The ACA could be prosecuted for breaking the law under the Veterinary Surgeons Act (1966), by performing medical treatment to animals, and could be fined or imprisoned depending of the severity of the action. The RVN or VS may decide to go back to the practice to give the medication themselves in order to follow the rules and provide correct patient care regardless of the fact that they were not on duty at that time, which would be a deontological action with disregard for consequences such as their own fatigue (BBC, 2015). Only if a RVN covered the night shift would medications be able to be given without the presence of a VS, providing it had been prescribed (RCVS, 2019). It is important that patient care and staff careers are not placed in jeopardy when using ACAs, and alternative arrangements should be made for patients whose care requirements are higher than the abilities of the staff nursing them. For this reason many practices choose to use dedicated out-of-hours emergency services to provide their clients with 24-hour veterinary care (Tremlett, 2007). This may be detrimental to the business as clients do not want to be registered with practices using this format due to increased traveling time, higher fees, and a lack of familiarity with the out-of-hours practice. Transporting sick patients may also be detrimental to their health.
The staff
The VN is exposed to many occupational health risks during their daily duties such as exposure to some un-cooperative, aggressive or unpredictable animals (Soest and Fritschi, 2004). Nonmaleficence must be considered by employers to ensure no harm is done to their employees as a consequence of practice protocols (De Angelis, 2009). The RCVS declaration underpins that VNs will ensure the health and wellbeing of animals in their care, but as stated by Brennan (2010), employers have a duty of care to ensure their employees are safe enough to fulfil these duties in accordance with The Health and Safety Act (1974).
Lone working
There is no stipulation for personnel to be on site 24 hours daily unless a practice holds hospital status under the RCVS (2015b) Practice Standards Scheme, but many practices feel a duty of care to patients and employ an onsite lone worker, as defined by the Health and Safety Executive (2009) as someone working by themselves without close or direct supervision. Although there is no law against working alone, there is a requirement for the employers to carry out a risk assessment within the regulation of the Health and Safety Act (1974) so that exposure to the risk can be balanced against the requirement of the task. Using Kohlberg's theory Nehru (2010) stated a good employer is motivated to avoid guilt and shame by providing a duty of care to their employees, following rules and regulations to achieve this. Brennan (2010) assessed safe lone working in healthcare workers and found that only 16% of district nurse organisations actually conducted a lone worker risk assessment even though failing to do so may leave employers open to large fines, compensation, or even corporate manslaughter should a fatality occur. A risk assessment should be completed by the employer to identify what should and should not be carried out by lone workers, taking into account some tasks may be too difficult or dangerous to be undertaken alone (Shilcock and Sutcliffe, 2008). By instigating a risk assessment procedure the employer is performing an act of beneficence to the employees by showing they care about their safety and are compassionate to their needs in order to keep them safe (De Angelis, 2009). The Chartered Institute of Personnel Development (2006) has outlined the requirement for an employer to take into account the capabilities of the employee and provide adequate training to the task in hand, which was not the case when a veterinary nurse received compensation when bitten by an aggressive dog that she had not been trained to deal with on her own (Truth Legal, 2015). A study by Soest and Fritschi (2004) found that of 147 RVNs in practice 98% had experienced a dog or cat bite or scratch, making injury in practice a common occupational hazard. These injuries were not regarded as life-threatening, but as a lone worker it is imperative that the staff members are fully trained to deal with the species they are caring for, have skills to assess when a patient is acting aggressively, and have the ability to call for backup should it be required (Worksafe, 1996) (Figure 1).
Shift pattern
Under the increasing pressure to provide adequate and expected services of care for hospitalised patients there is an increasing need for more dedicated night RVNs and VSs (Dawson, 2011). The Society of Practicing Veterinary Surgeons (2015) reported that 62% of RVNs worked nights. It is important to identify the effects of working patterns on staff in VPs so that justice can be used to treat the patients and staff in a fair and equal manner, acting in a nonmaleficent way allowing no harm to come to employees, while giving a high standard of patient care 24 hours a day.
Research in the human field has shown that although the Royal College of Nursing recommended all nurses share night duty to prevent professional and social isolation (Kemp, 1991), Coffey et al (1988) found that fixed shift patterns including night shifts were less stressful and produced higher performance rates than nurses who rotated through three or more shift patterns. Finding a suitable rota that works for staff health and wellbeing and patient care is a difficult balance.
Night work is advantageous to some, facilitating a family–work balance, while obtaining financial reward (West, 2012); however shift work has been found to be detrimental to health with an increased risk of coronary heart disease, peptic ulcers, diabetes and breast cancer (Ahmed-Little, 2007). Matheson et al (2014) explained that night workers are at risk of shiftwork disorder, a disruption of the circadian sleep–wake cycle, leading to insomnia, fatigue and exhaustion. Employers using a utilitarianism approach, assessing the advantages and disadvantages of different rota patterns in regard to adequate patient care, staff health requirements and economic balance, are more likely to be seen as good employers and create loyalty from their staff (Nehru, 2010).
Refinement is required to reduce the impact of shift work on employees by using research that has identified how shift work can be improved by reducing shifts to a maximum of 12 hours, allowing staff to have an input in rota construction, providing suitable rest areas for structured naps during the night, advising regular exercise and providing adequate off duty between shifts (Ahmed-Little, 2007). The Working Time Regulations 1998 entitles staff to an 11 hour break between shifts, and it is a VP's moral duty to make sure staff have fair working hours to reduce fatigue and stress, as these have been related to causing errors in patient care (Oxtoby, 2015).
The client
Tremlett (2007) pointed out that clients' expectations of clinical standards towards their pets are increasing, and as veterinary professionals continue to enhance their clinical skills and care, a price must be paid for these advanced services. According to the RCVS (2019a,b) clients are entitled to have their animal cared for, monitored, and treated by experienced personnel, which could refer to qualified or unqualified staff as long as they have been trained adequately and are not carrying out tasks they are not qualified to do. Clients should be aware of the level of supervision their animal will be given in hospital, and gaining informed consent is stipulated in the RCVS Code of Conduct (2016). Deontological ethics recognise consumer rights to freedom of information, and it is important that the VS and RVN have autonomy and do not deceive clients (Gillon, 1994). If a problem arises with an animal during the night and a client raises a complaint, disciplinary action and civil litigation could be brought against the VS or RVN if the client believed their pet to be under the constant care of a veterinary professional when one was not present on the premises (RCVS, 2019a,b). Details of how the practice is staffed during the patient's stay should be included on the consent form, and a signature from the client should be obtained to confirm their understanding.
A report by the Department of Health found the cost of emergency care in the National Health Service increases by an unsustainable 83 million per year due to enhancement of medical science (NHS England 2013). There is concern that as quality and provision of care for hospitalised pets increases the fees to the clients must be raised to cover the extra costs of treatment (Manning, 2005). Already emergency 24-hour VPs are charging higher consultation and hospitalisation fees, justified by their consistent, high quality care using fully qualified staff 24 hours a day (Vets Now, 2016). Cost may escalate beyond what an average client can afford and consequently they may choose not to seek veterinary treatment at all as they cannot afford it, potentially leading to animal welfare issues. This concept often leads to a loss of trust between client and VP as the client believes that profits are placed over patient needs. This is a very delicate situation for many VPs as their moral duty as VSs is to treat animals, but the practice requires adequate payment for that service in order to continue providing services to others (Manning, 2005). A similar situation has arisen in general medical practice where out-of-hours care must be provided in an economical way that is acceptable to the public (Maxwell and Toby, 1993). A beneficence outlook may help to analyse the cost and benefit for both client and VP in order to balance both parties' expectations regarding cost, service level and customer expectation (De Angelis, 2009). The use of technology such as CCTV, wireless monitoring devices and virtual consults may also be implemented to improve patient, staff and clients' expectations.
Conclusion
As clients' expectations increase and animals gain more recognition pressure is placed on VPs to offer a higher level of service. The moral dilemma on how to provide this alongside the regard for employee health and safety while running a profitable business is extremely difficult. It is important for management to have up to date risk assessments, adequate staff training records and suitable protocols for shift work following government guidelines. While unqualified staff can be a good option for overnight care it is important that training is given to ensure everyone is aware of what they can and can not do or delegate. However the VP decides to staff its 24-hour nursing care, it is important to have transparency with the client, having protocols in place that can be explained thoroughly to give confidence in the practice.
KEY POINTS
- Balancing patient care, client satisfaction and employee welfare with the economics of the business causes many ethical dilemmas.
- Using unqualified staff to cover overnight patient nursing care can be a cost effective method of staffing a veterinary practice but care must be taken to provide qualified support to prevent incorrect delegation of veterinary procedures.
- Clients should be fully aware of who is looking after animals.
- Night work can be detrimental to employees' health but is a necessary requirement in veterinary practice. Well designed rotas are important to protect employees' welfare.
- Patient care should be maintained to a high standard however the practice chooses to staff it.