For veterinary nursing teachers, one of the hardest things to instil in students is an appreciation of the responsibility they have when giving advice to clients (personal experience). This is also a difficult thing to assess. The role of the veterinary nurse to, alongside the veterinarian, assist the client through the diagnosis and subsequent treatment of conditions in their patients, is of significant importance as they are often the ones ‘on the front line’ when it comes to client questions and concerns relating to chronic conditions. The ability to communicate the right advice to the right client at the right time can be challenging. The Chronic Illness Management Plan (Figure 1) was developed to assess the accuracy and quality of advice in training veterinary nurses after careful consideration of many things: the nursing processes and duties of veterinary nurses within a veterinary clinic, a desire to formalise and document the advice given about chronic illness in veterinary practice, which the author had increasingly seen a need for, and the need to meet the criteria of a unit of competency within the Certificate IV Veterinary Nursing qualification. The unit ACMVET409A Provide specific animal care advice is one of the larger units of the Certificate IV Veterinary Nursing qualification (further information about this unit of competency can be found at: http://training.gov.au/Training/Details/ACMVET409A#). This unit assesses the skills and knowledge of training veterinary nurses to give specific animal care advice to owners about a wide range of health issues. The rationale of the Chronic Illness Management Plan or CHIMP is explained in Table 1.
| Ability Model | CHIMP | |
|---|---|---|
| Diet | Food | Illness can have a significant impact on the nutrition requirements of an animal. Sometimes food will form part of the treatment and sometimes it will simply be good nutrition required. |
| Water intake | Water | Many diseases affect the drinking behaviours of animals. Treatments may also affect water intake, e.g. furosemide, corticosteroids. |
| Urination | Toileting | Many diseases affect the defecation and urination behaviours of animals. Treatments may affect this also. |
| Defecation | ||
| Respiration | Breathing | It is not just cardiac and respiratory disease which can affect respiration, pain, injury and disease of other organs and organ systems can affect respiration. |
| Temperature | It is not always possible for the client to easily assess an animal's temperature at home and often it is not necessary. However, it is important from a husbandry perspective to make adjustments to the animal's housing to allow for the requirements of additional warmth or cool the animal as influenced by the disease or treatments. | |
| Grooming and Cleaning | Grooming | The ability of the animal to groom itself and keep clean may be impacted by the disease. It is important for the welfare of the animal to advise the client about this and suggest strategies to groom the animal and keep them clean. |
| Mobility | Getting around | Arthritis is not the only disease which will affect the mobility of animals. Bedding type and location, exercise areas, exercise types and frequency of exercise may all need to be looked at to meet the needs of the animal |
| Sleep and rest | Sleep and rest patterns can be disturbed by either the disease or the treatment. The client will need advice on how to address these requirements and also how to manage these changes should they affect the client themselves. | |
| Express normal behaviour | Behaviour | Changes in behaviour are generally what indicates that an animal is unwell. Clients need advice as to the signs to watch out for which indicate an animal is not responding to treatment as it should or is in fact getting worse. |
Researching the literature
The role of the veterinary nurse within the veterinary practice is clearly explained by Orpet and Welsh (2011) who discuss both the role of the veterinary nurse, and the associated responsibility veterinary nurses have in carrying out their duties. The veterinary nursing process as defined by The Ability Model of nursing care (Orpet and Welsh, 2011) has in a sense, both formalised and appreciated the importance of the daily duties veterinary nurses carry out. Veterinary nurses, primarily through nursing appointments or during reception duties, assume an important role in addressing patient welfare (Yeates, 2014), offering advice to pet owners on the management of their pets with chronic illnesses as inpatients, outpatients and in the home. Veterinary nurses can be the link between the veterinarians and the owners, often disseminating the complicated medical information associated with a pet's diagnosis and treatment as more easily digested advice for the client.
Communicating effectively with pet owners about the complexity of their pet's illness can be a difficult part of the successful treatment of chronic conditions. Compliance with the recommended treatment and management of disease can be influenced by effective communication (Abood, 2007). In addition, just as doctors can improve the health-related behaviours of a patient through effective communication, if steps are taken to improve the communication between veterinary team members and their clients benefits can be seen in veterinary medicine. Assisting the client to understand both the condition itself, the treatment and the management of this treatment with the pet in the home through effective communication is imperative to client compliance and this responsibility can fall to the veterinary nurse. Renberg (2012) writes that communication, detail and honesty are three of the most important approaches to promote client compliance after orthopaedic surgery. Ballantyne (2014) describes how the definition of holistic care developed for the world of human medicine may be extrapolated to veterinary nursing, a definition that would constitute specific, patient-centred care. The CHIMP could have uses beyond that of an effective assessment tool (as discussed previously), and could provide a way of creating effective communication enabling a holistic approach to the management of the chronically ill pet by the client. It could serve both as a tool to guide pet owners through the treatment and also a prompt for pet owners to discuss all aspects of the pet's health which could provide essential information to the veterinary team.
Renberg (2012) writes that communication pre- and postoperatively is important. He goes on to say that not providing the client with explicit details of how to care for their pet postoperatively can inhibit both the ability and the inclination of the client to be compliant with treatment and care instructions. The final factor Renberg (2012) considers essential is honesty. He writes that he looks to give advice to clients that they are able to comply with by considering what is realistically achievable for the client. The author's experience as a veterinary nurse has led her to come to similar conclusions, and this need for there to be effective communication extends to that of medical patients. When dealing with patients and clients in any situation, but particularly when managing chronic illness, any advice imparted needs to be given freely and clearly throughout the diagnostic and treatment process. It needs to be specific to the client and their pet and take into account the abilities of not only the patient but also that of the carer or owner. Creating a clear record of this advice for the client is also important.
The continual follow up and best-practice monitoring of chronic illness can be a challenge for many reasons. Clear, effective communication is important to ensure that clients dose animals correctly with the correct medications, provide proper home care for their pet and attend appropriate follow-up appointments (Shaw et al, 2004). Cost, time, and lack of understanding can all contribute to less than ideal management of the chronic illness. Ackerman (2011) emphasises the importance of explanation and planning to ensure that the information imparted to clients is understood and then acted on accordingly. This information, Ackerman (2011) goes on to say, can be presented in a number of ways, orally, through educational DVDs, and via a written document. Both Ackerman (2011) and Renberg (2012) write that the agreement of all parties involved in the treatment and management of a pet's health issue is important. The CHIMP has the potential to provide an effective written strategy of imparting appropriate and practical information and advice for the client.
Development of the CHIMP
Orpet and Jeffery's Ability Model of nursing care (Orpet and Welsh, 2011) has shown veterinary nurses that a high standard of care for inpatients is achievable by following a process of understanding patient needs and abilities. There is some potential to extend this methodology and apply it to the advice given to the pet owner which could assist them with managing their unwell pet. Orpet (2011) writes, in reference to nursing care within a veterinary hospital, that using a structured framework of nursing care can ensure that no aspect of a patient's needs is neglected. The same commonly accepted process of assess, plan, implement and evaluate nursing care for inpatients (Orpet and Welsh, 2011) would also be useful to effectively manage the outpatient. Pet owners are not able to do this alone and the use of a structured format such as that of the CHIMP may assist the client in managing their chronically ill pet in the home. As stated earlier, it may also be useful to prompt the client in providing the veterinary team with pertinent information to customise the treatment and management of the pet's illness.
The CHIMP was designed to use the same parameters as that of the Ability Model (Table 1) in order to capture evidence that veterinary nurses were able to demonstrate their knowledge of the nature, treatment and management of common chronic illnesses and apply this to a specific pet. The CHIMP as an assessment is effective. The CHIMP could become a useful tool to be used in practice to provide advice in the form of appropriate and easily digested information. The extent of the advice that clients require extends beyond the pet's needs and can enter the territory of client needs. Clients, in order to be compliant and as discussed earlier, need explicit advice which assists them to understand the importance of the treatment decided on. They also need to have the tools and knowledge to allow them to trouble shoot problems with medications, eating, etc., as they arise and if the clinic is not open to support them. They need to know what to tell another veterinarian should they need to seek attention from a veterinarian other their regular veterinary surgeon, and they need to know how the disease is expected to progress and how this could affect their pet. As Coe (2012) found in his study, clients who are given a clear recommendation with specificity to the individual client's capabilities and pet's needs, are more likely to be compliant and therefore treatment outcomes more successful.
The cost of veterinary diagnostics, treatments and monitoring can be a difficult conversation to have with a client. It is hard for them to plan for the expenses incurred in the treatment process if clients are not given some idea of what to expect. While this is often covered by the veterinarian during the discussion of consent to treatment, the CHIMP could also capture this information and integrate it with the importance of proper holistic management of the pet's illness. By laying out a schedule of expected revisits with associated costs and time investment required the CHIMP can allow the client to plan and budget effectively for the ongoing treatment and management of their pet's illness.
Conclusion
It is not intended that the CHIMP be the only strategy which is used to communicate with the client regarding the treatment and management of chronic illness in a pet. It was designed to be a useful tool to assess the ability of veterinary nurses to provide specific animal care advice and has the potential to be a useful strategy to provide advice and guidance for pet owners. Over time the CHIMP would need to evolve in order to be relevant for the pet as the disease progresses and as the requirements of the pet change. It is intended to be comprehensive in assessing the ability of veterinary nurses to give advice and has the potential to allow clients to feel confident in taking their pet home where the reassurance of constant veterinary attention is removed. The value of using this as a tool is only as much as the way in which it is written. An example of a completed the CHIMP can be seen in Figure 2. Keeping up to date with the range of treatment options, supportive therapies and, importantly, nutritional options is vital to ensuring that the advice given to clients, in any format, is the most accurate and the most relevant for each individual case. It would be a step in the right direction for the CHIMP, whether in its current format or with amendments, to be used as a tool to be developed to encourage clients to adhere to treatment plans with the ultimate goal of having successful outcomes for their pets.
