In the veterinary environment it is important to not only take care of the patient's physical recovery but also their mental wellbeing. This article looks at previously published research and highlights why it is important to consider mental wellbeing in patients. The article also identifies one method that can be used to enhance the mental wellbeing of inpa-tients through mental stimulation.
The mental wellbeing of inpatients and their welfare
It has been stated that the mental wellbeing of patients can effect their quality of life and ultimately their welfare within practice (Yeates, 2012). Yates stresses how important it is to strive for the optimum levels of mental wellbeing to enhance inpatients' welfare.
It has been suggested that a quality of life (QoL) assessment should be undertaken in veterinary practices, as it is in human hospitals, to assess patient welfare (Yeates and Main, 2009). This involves both a physical assessment and a mental assessment. Although the paper does not give a good outline on how to assess a patient's wellbeing it offers an interesting viewpoint of how a patient's wellbeing should be viewed and assessed, indicating the importance of taking into account the mental state of the patient to assess welfare, rather than just assessing the physical wellbeing.
Compromises related to medical examination or treatment have been identified within practice; these compromises are linked to the Animal Welfare Act of 2006. It has been identified that the occurrence of stereotypic or unnatural behaviours, such as those that indicate a stress response (Box 1), signal a compromise in welfare (Yeates, 2012). A patient's mental wellbeing can affect their overall welfare, and this can be assessed by using the behavioural parameters outlined by Beerda et al's studies (Beerda et al 1997, 1998, 1999, 2000) (Box 1).
In order to achieve a complete welfare assessment an animal should be evaluated in terma of its interactions with its environment (Odendaal, 1998). For example, a patient that is circling within its kennel may be lacking stimulation and require either enrichment via a feeding tool such as a treat ball or mental stimulation via basic obedience training such as ‘sit’, ‘down’ or ‘leave’. Indeed, it has previously been identified that enrichment and the opportunity for patients to problem solve may combat boredom and enhance mental wellbeing (Odendaal, 1998). This supports the idea that mental stimulation for patients can have a positive effect on the overall welfare of patients.
Numerous studies have highlighted how important it is to understand how compromised mental wellbeing can be detrimental to patient welfare (Odendaal, 1998; Yeates and Main, 2008; Yeates, 2012). It may also be pertinent to look at how behaviours are interpreted in practice. Christiansen and Forkman (2007) stated that a behavioural aspect is important for gaining a complete welfare assessment. In addition, a sound understanding of behavioural interpretation is important to implement correct welfare assessment (Christiansen and Forkman, 2007).
Identifying stress
To be able to respond to the problems of stress responses in inpatients, stress must first be identifiable, and the behaviours that communicate the animal's physiological state identified. Previous research has provided a link between certain outward behaviours that correlate with the physiological signs that indicate the dog is in a stressed state (Beerda et al, 1997; 1998; 1999; 2000) (Box 1).
Studies have looked at elevated cortisol levels or an increase in heart rate as an indicator of the physiological state of stress. Beerda et al carried out a series of studies looking at stress levels. These studies identified the behaviours that occur in association with these physiological reactions (Beerda et al, 1997; 1998; 1999).
The first of these studies highlighted that a dog, accidentally exposed to extreme noise levels during an experiment into stress response which utilized a number of subjects, showed an increase in heart rate and an increase in cortisol compared with base level readings prior to the experiment. This correlated with the onset or increase of certain behaviours such as snout licking, paw licking, trembling of the body and a lowered body posture (Beerda et al, 1997).
This was then furthered in 1998 when Beerda et al exposed 10 dogs to certain stimuli perceived as potentially stressful. This included loud noises and novel stimuli. Based on the physiological responses of the dogs to the stimuli those that elicited a stress response correlated with certain behavioural responses. These included trembling of the body, snout licking and yawning (Beerda et al, 1998).
In 1999 Beerda et al suggested that behaviours such as auto-grooming, paw lifting and vocalizations were indicative of chronic stress. The subjects that exhibited these behaviours were exposed to both spatial and social restrictions (Beerda et al, 1999). This study not only highlighted the behaviours that are related to a perceived stressful situation, but also indicated that a kennelled environment, with little opportunity for interaction with conspecifics, can elicit a stress response and the onset of related behaviours.
To add validity to this claim Beerda et al then stated that dogs kept in a kennel environment with little enrichment or interaction opportunities exhibited stress-related behaviours such as paw lifting, body trembling, yawning and oral behaviours (Beerda et al, 2000).
This series of studies identified behaviours that correlated to an increase in physiological stress. These included paw lifting, trembling of the body, yawning, vocalizations, auto-grooming and snout licking. These studies also indicated how a kennel environment can elicit these responses, as could, it could be inferred, the veterinary hospital environment.
The veterinary environment and patients
The veterinary environment has been shown to elicit a physiological stress response in dogs — increase in heart rate and elevated cortisol levels. Studies have looked at both pre and post-operative exposure to the veterinary environment, and these are discussed below.
It has been suggested that not only hospitalization but also examination and exposure to a veterinary clinic can result in physiological stress responses as shown by cortisol:creatinine ratios (von Vonderen et al, 1998). The initial interactions between the veterinary environment and patient can, therefore, cause stress to an animal.
One study also showed that a dog exposed to veterinary practice conditions presented fear-based behaviours (lowered tail position, tail tucked between legs, crouched body posture, body trembling) (Doring et al, 2009). This study focused on interactions between canine patients and the veterinary surgeon. When exposed to the primary examination almost two thirds of the dogs studied showed fear-related behaviours (Doring et al, 2009). The study suggested that initial interactions can be stressors for that patient, adding validity to the conclusions drawn from von Vonderen et al's 1998 study.
To further illustrate the physiological and behavioural effects of the veterinary environment Vaisanen et al looked at 41 bitches caged within a veterinary hospital. This study showed both an increased heart rate compared with readings taken before admittance to the practise, and behaviours that have been shown to be indicative of stress such as snout licking and vocalization (Vaisanen et al, 2005).
This was also seen in a second study which indicated that a procedure as routine as neutering can result in a stress response from an individual post op-eratively (Devitt et al, 2005).
The idea that stress can be seen both pre and post operatively was suggested in a 2009 study, which showed that cortisol levels, both pre and post opera-tively, increased compared with readings taken before admittance to the practise when dogs were housed within the veterinary kennel environment. This study also stated that the behavioural responses from these dogs indicated that the stress caused by the environment and procedures relates to challenged dog welfare (Siracusa et al, 2009).
These studies illustrate how various aspects of the veterinary procedure can elicit a stress response in patients. This can begin from the initial exposure to the veterinary environment through examination and be present during post operative housing in kennels. This stressed state can have detrimental effects on patients aside from indicating a reduced standard of welfare.
How does stress affect a patient's recovery?
Studies have identified the detrimental effect a state of emotional or mental stress can have on a recovering patient (Ben-Eliyahu et al, 1991; Kiecolt-Glaser et al, 1995; Marucha et al, 1998; Detillion et al, 2004; Gouin and Kiecolt-Glaser, 2011). These studies, discussed below, looked at a number of species and show a similarity in results.
One study showed that women who cared for mentally disabled relatives exhibited prolonged wound healing times compared with a control group. The study concluded that the women who acted as car-egivers were under more psychological stress than the control group, which impeded the wound healing process (Kiecolt-Glaser et al, 1995). Kiecolt-Glaser has furthered this work and demonstrated the link between stress and impaired wound healing. In a 2011 paper they stated that physiologic stress can directly influence the wound healing process (Gouin and Kiecolt-Glaser, 2011).
A study of mucosal wound healing in humans found that if the wound was left to heal during a stress eliciting period (a period of major examinations for students in the case of this study) the wound took an average of 3 days longer to heal than if the wound was left to heal during a break from university (Marucha et al, 1998).
To further validate this hypothesis it has also been stated that in humans psychological stress reduces wound healing by impairing the inflammatory response and matrix degradation process. This study concluded that if methods were devised to reduce patient psychological stress levels this would improve wound repair post surgery (Broadbent et al, 2003).
Taking this theory into the animal kingdom the same results have been seen in non-human animals. For example Siberian hamsters that were subjected to a cutaneous wound showed delayed healing times when exposed to stress. When the hamsters corti-sol levels were raised wound healing was impaired (Detillion et al, 2004).
Rats that were subjected to acute stress showed a decrease in cytotoxicity against a tumour along with an increase in surface lung metastases. These results supported the hypothesis that stress negatively affects the immune system (Ben-Eliyahu et al, 1991).
Although these studies are based on humans and rodents it is the general consensus in literature that stress impedes on wound healing in general. This is not the only negative effect of physiological stress. It has also been documented that stress can result in immunosuppression and increase the likelihood of infection.
One study indicated that in mice stress impaired the bacterial clearing that occurs during wound healing which increased the incidence of opportunistic infection (Rojas et al, 2002). Further studies have indicated that a state of stress can enhance immuno-suppression and in turn increase the chance of infection in the wound.
A study on African wild dogs also highlighted the detrimental effects of prolonged stress on the immune system (Creel et al, 1997). This paper stated that short instances of stress, such as that from a one of restraint to administer a vaccine, is not harmful to the animal, however a prolonged period of stress, such as that sustained over a number of hours, can result in immunosuppression. This is pertinent as in veterinary practice, specifically in intrusive surgery or intense medical cases, these instances of stress may be frequent which has the potential to cause the detrimental effects documented.
These studies show that stress can affect both wound healing time and immunosuppression in humans, rodents and wild dogs. This provides a model of the potential negative effect of stress on patients' recovery. It is therefore important to understand how patient stress levels can be reduced to enhance their recovery.
Mental stimulation as a tool for stress relief
In this article the term ‘mental stimulation’ is used to describe any activity that gives the patient the opportunity to use their mental capabilities to problem solve. This type of enrichment has been seen to be successful in stress inducing captive environments. The studies are highlighted below.
Meehan and Mench suggested that integrating appropriate challenge into the lives of captive animals can have a positive effect on behavioural and physiological indicators of stress, resulting in improved standards of welfare (Meehan and Mench, 2007). In this study the use of feeding enrichment, such as treat balls, food puzzles and hiding of food in objects is identified as appropriate challenge when the enrichment is changed regularly. This ensures the enrichment stays cognitive and does not become merely a physical barrier to food. If this theory is transferred into the context of veterinary patients it is possible to identify ways to reduce patient stress.
Studies in similar environments to veterinary clinics such as rescue kennels or laboratory environments have shown that opportunities for mental stimulation can reduce the exhibition of stress-related behaviours. They have also shown reduced physiological stress reactions. These studies are discussed below.
Enrichment has been shown to have positive effects on kennelled dogs; research indicates an animal's mental state is essential to good health and well being (Coppinger and Zuccotti, 1999). Coppinger and Zuccotti concluded that offering dogs food puzzles in the kennel environment provides the dogs with the opportunity for mental stimulation while gaining food from the puzzle.
Another study showed that the provision of a feeding enrichment, in this case a rubber cone toy that has to be manipulated in order for the food to be obtained, stimulates appetitive and variable behaviour patterns which it suggests reduced stress levels, as recognized stress behaviours were less prevalent (Schipper et al, 2008).
In addition, a study has indicated that dogs exposed to contact with humans showed reduced cortisol levels compared with dogs that did not have human contact (Coppola et al, 2006). The contact session in this study included obedience commands and the opportunity for mental stimulation for the dog.
It is apparent, therefore, that by offering dogs the opportunity for mental stimulation through environment enrichment tools the behavioural and physiological indicators of stress can be reduced.
What does this mean for veterinary patients?
Research has indicated that the veterinary environment can cause a stress response in dogs similar to that of dogs exposed to a rescue or laboratory environment. Within these environments it has been suggested that mental stimulation could reduce these stress levels. Studies have shown how the opportunity for dogs to experience mental stimulation in these environments has reduced both behavioural indicators of stress and the physiological signs of stress (Coppinger and Zuccotti, 1999; Coppola et al, 2006; Meehan and Mench, 2007; Schipper et al, 2008).
Taking these data it is possible to identify ways in which mental stimulation may be an effective tool in reducing stress within veterinary inpatients. By offer-ing the dog a feeding puzzle, such as The Company of Animals food puzzles or a Bamboozle tube toy, we may be able to reduce the dogs' stress levels and in turn improve their welfare and healing.
For dogs that cannot or will not eat while in practice the use of basic obedience commands could offer the stimulation needed to reduce the stress experienced by patients. This offers not only an improvement to inpatient welfare but also reinforcement of basic obedience training. These recommendations all include an aspect of human interaction which may be of equal importance in reducing the stress experienced by canine patients. This has been seen in studies which have highlighted human interaction as an enrichment method (Hennessey et al, 1998; 2002). These studies used ‘petting’ methods which included stroking and massaging the subjects along with speaking to them softly. There is potential to further this by utilizing grooming to enhance the human interaction and petting session as the motions of petting and sttroking are similar to that of grooming, however the author could not locate any studies to validate this claim.
In turn the reduction in stress reduces the negative effects stress has on veterinary patients and provides an opportunity for more positive associations to be made with the veterinary environment to improve reactions to subsequent visits.
Conclusion
This paper highlights how the veterinary environment can cause patients to experience a state of stress which can be identified through the presentation of certain stress-related behaviours. This state of stress can have negative effects on the dog's welfare and rate of recovery post op.
By utilizing the mental stimulation and enrichment techniques discussed here this stress response can be reduced, improving the welfare of canine patients. This then has wider applications such as improving the safety of staff and making any subsequent visits to the practice less stressful for the animal through positive associations with the practice environment.