Stress-free vet visits: considering the effects of the COVID-19 pandemic

Preparation is key when making arrangements for all animals to visit the practice, but especially so for those who are anxious or fearful. Failure to plan may result in increased fear, anxiety and stress during veterinary practice visits. Reducing stress is challenging enough under normal circumstances, but with the COVID-19 pandemic restrictions and the additional pressures these created, it is important not to lose sight of the possible impacts on animals' emotional states. There is much evidence that stress is caused by vet visits (Taylor, 2016) and this may result in clients with fearful, anxious or stressed pets failing to attend clinics (PDSA, 2019). Arhant et al (2019) examined the effects of the physical environment, the techniques and approaches used by staff, and the procedures carried out. This study also identified a number of barriers to implementation of the recommendations for daily routine changes which could reduce stress, including time pressures and the building construction.

A well-prepared practice will have a process in place to identify animals likely to be particularly fearful, anxious or stressed, although considering ways to reduce stress is important for all patients, whether they are visiting for routine preventative treatments, being treated for illness or undergoing a procedure requiring hospitalisation.

Staff training is essential for the implementation of effective stress reducing procedures, as these improve understanding of the individual animal's needs. Reception, veterinary and support staff all need to be able to identify an animal's emotional state; create a low-stress environment; and appropriately use techniques for handling, restraint and examination. Information gathered about a patient, with regard to fear, stress and anxiety, needs to be effectively communicated to staff across the practice, to ensure that the clinic visit can be as smooth and effective as possible.

Practice systems and procedures

The process starts at reception when the patient is booked in. Information about the animal's previous behavioural history at the practice should be logged, alongside a relevant medical history. The client should be involved in planning and preparation for the visit, for example by helping the pet to be calm and relaxed while travelling to the practice to keep anxiety levels lowered, or by putting a muzzle on at home, which is much less stressful.

A behaviour traffic light system (Table 1) can be the start of an effective process, allowing a record of behaviour issues to be kept.

A number of studies have looked at stress reduction within the vet practice. In a study by Feilberg et al (2021), seven areas were identified whereby survey respondents (veterinary surgeons or nurses) scored responses questions on a Likert-type scale. These areas concerned the clinic environment; waiting room; hospital wards; record-keeping; availability of client education information; staff approaches and practice ethos. The 74 survey questions address low-stress handling techniques, and were developed from practice certification schemes:

• International Society of Feline Medicines' (2022) ‘cat friendly clinic’ list
• PDSA's (2022) ‘preventing stress in cats’ guidelines
• Rabbit Welfare Assocation and Fund list of rabbit friendly vets (2022)
• Fear Free practice certification (2020)
• BVBA dog friendly practice scheme (2020).

Of the 1012 practices to which the survey was sent, 91 responded – a rate of 9%, which may be indicative of a low priority given to reducing stress in practice.

In order to maintain welfare standards during the visit (the purpose of which is to improve the animal's welfare by developing and maintaining physical health and wellbeing), the impact on the animal's mental health and emotional state must also be considered. Animal behaviour is motivated by emotional states. Many factors will influence this state (Figure 1, Table 2).

The physical environment within the practice can promote a sense of wellbeing by removing as many of the potentially frightening aspects of the situation as possible. Simple strategies in waiting areas including separation of animals (73.3% did this in wards); physical barriers to prevent eye contact between animals (seen in only 28.8% of practices); use of pheromones (seen in 78% of practices), and covers on pet carriers (61.1% of practices). These percentages show how varied these strategies are in terms of implementation (Feilberg et al, 2021).

Techniques and approaches used by veterinary staff

Animals coming into small animal veterinary practices may show a variety of behaviours based on their emotional state. It is important to ask whether they are showing happiness, excitement, interest, anxiety, stress, fear or aggression? A key aspect of staff training is the development of an understanding of species-specific non-verbal signalling and communication attempts made by animals in order to express their emotional state. Staff can use this knowledge to minimise stress and anxiety in their patients. In Feilberg et al's study (2021), although 98.9% of staff self-reported being able to identify fear, anxiety and stress, only 63.7% reported the pre-visit use of anti-anxiety medications, sedatives or pheromones (where indicated). Only 41.8% had a staff member identified as a stress-reduction advocate and only 38.6% had a staff handbook outlining the practice's stress reduction definitions and goals.

Bearing in mind the methodology of the Feilberg et al (2021) study, it is highly likely that this represents significant under-reporting (as identified by the researchers themselves). Further studies involving observable or measurable data are needed, as supported by Dawson et al (2018), in order to ‘develop and evaluate a tool for the assessment of behavioural welfare related to veterinary care.’ Data from Dawson et al (2018) indicated a low (9%) participation rate. The ability to identify the need to use appropriate approaches to minimise patient fear was self-reported as 77%, but in observations in practice this was seen as being accurately identified in only 50% of cases, for example, 50% of practices were reportedly routinely scruffing cats, a very stressful and outdated technique, not considered acceptable in cat-friendly clinics (International Society of Feline Medicines, 2022).

Helping staff to identify and deal appropriately with stressed animals is essential in moving forward with improved practice and therefore welfare. Tables 3 and 4 show mainly straightforward signs that can be given as visual and written information, for ease of access and to maintain awareness. However, in Feilberg et al's (2021) study, only 42.2.% of practices had literature on display to help staff recognise stress and/or escalating aggression.

The many different dog breeds and crosses may make it difficult to identify a dog's emotional state - behaviour is often the best clue (Duffy et al, 2008). Some behaviours are obvious – growling, snapping, barking; others such as tail wagging, (as illustrated above) can be much more subtle, and so easy to misinterpret. (Appendix 2).

The way in which veterinary staff approach and examine an animal can be crucial to reducing (or causing an escalation of) an animal's sense of potential threat, and therefore stress and anxiety. Allowing the animal to approach, instead of trapping it; or approaching from the side rather than the front can both be used to good effect, allowing veterinary procedures to take place with fewer problems (Taylor, 2016). Making decisions about when to proceed, when to wait, and when sedation may be appropriate, are all part of the consultation and examination process for veterinary surgeons, often in situations which can be very pressured.

Good practice dealing with clients

Engaging clients in a dialogue to offer support and behavioural first aid advice would be appropriate when the animal is clearly anxious or fearful, or in a young animal where problems are just beginning (Van Fleet, 2013). Veterinary staff are often the first point of contact for many owners whose pets demonstrate problem behaviours. Taking a few minutes to point the owner in the right direction can have a hugely positive impact on the welfare of the pet and their owners. If staff are untrained, inaccurate information may be given, for example offering outdated ideas which are not evidence-based, such as the idea of dogs trying to ‘dominate’ humans, or ‘pack leader’ theory (Drews, 1993; Van Kerkhove, 2004). These disproven theories promote punishment-based training, which is likely to lead to damage to the owner–pet relationship, increasing confusion and fear in the animal and increasing the likelihood of aggression being shown. Alternatively, there may be no information available for clients. Feilberg et al (2021) reported that client literature on stress reduction was only available at the vet practice in 41.1% of practices; stress reduction on the journey to the vet practice in 35.3% of practices, and the types of behaviour problems commonly seen in 36.3% of practices. Basic behavioural information can be made readily available through information sheets, from appropriate sources such as the Animal Behaviour Training Council (ABTC), The Association of Pet Behaviour Counsellors (APBC), the RSPCA (2022) and the PDSA (2021). This is an achievable goal in most practices.

Behaviour referrals, where appropriate, should be made to a suitably qualified person for behaviour support, such as a veterinary behaviourist or a clinical animal behaviourist (practitioners listed at www.abtc.org.uk). The PDSA Paw Report (2021) shows that only 5% of clients whose pet had an identified behaviour problem were referred by their vet to a clinical animal behaviourist for advice, indicating low levels of this practice in the UK.

The effects of the pandemic on the stress levels and behaviour of animals

From the reflections of the veterinary staff during the pandemic, it was generally felt that the client's absence from the practice building (and therefore for much of the examination process) increased the time needed for consultations. The actions of speaking to the client by telephone (history taking), examining the animal, then further discussions regarding the formulation of a testing and treatment plan, involved three stages, rather than these events happening simultaneously. Vets reported having a better opportunity to focus entirely on the animal and to therefore give their full undivided attention during the examination process, which was often reported as being more efficient and completed more quickly. The consultation and examination itself could be more efficient, but the processes around it were slower.

Increased numbers of inexperienced clients demonstrating little understanding of their pet's behaviours and needs have been reportedly seen in practice over the pandemic, as clients seeking registration also increased. ‘Lockdown puppy’ owners were sometimes described as extremely difficult to engage with and very demanding in many cases, having little understanding of the functioning of the vet practice, despite staff doing their utmost to provide the best possible quality of care to their pet. Under-socialised dogs (those for whom normal experiences of going out and meeting people and other dogs were limited or prevented during COVID-19 lockdowns) were identified as one of the biggest challenges, with too many people having impulse-bought puppies during the lockdowns. In this small sample of case studies, behaviour issues (including stress during the vet visit, as well as in many other situations) were reportedly more common during the pandemic.

In some cases, dogs and cats were reported as less problematic for vets during examination in terms of their behaviour, and were described as more compliant. However, it is unclear whether this is a result of reduced stress because the client (with their own anxieties) was not present, or because the animals were more inhibited or shut down (more anxious because of the loss of a familiar person, who might otherwise provide support and reassurance). Pereira et al (2021) suggested that dogs may respond to their owner's trait anxiety directly by showing increased stress and anxiety-related behaviours. An association was also reported by Pereira et al (2021) between fear and anxiety in dogs and the protective behaviours of owners. Further research is needed to identify to what extent owner presence, or absence, impacts on stress at the vet practice, and the possible impact of veterinary staff stress on animal behaviour.

In a compilation of veterinary staff reflections from telephone and face-to-face discussions, one vet estimated that 9 out of 10 animals were better behaved, calmer and more relaxed, without the presence of the client. Another reported that some dogs were panicking when taken from the client in the car park, but were much calmer once inside the building. Without the distraction of the client, the vet could focus better, act more quickly, and some animals that had previously been a behaviour concern were reportedly easier to handle. However, some vets and nurses felt that there was an increase in reactivity seen from dogs and cats owing to greater stress levels. Others reported less incidents of aggression, so overall there was a mix of responses.

Examination outdoors was seen as beneficial for many animals, without the waiting room experience. Figure 2 shows an example using the car, and treats during the initial examination.

Use of car parks and gardens was commonly seen, the latter also being used as a safe space for euthanasia, if safely enclosed.

The types of behaviours reported as increased within the practice setting by some vets were kennel guarding and aggression, with an increased use of muzzles for safety being reported. Poor use of ill-fitting harnesses was also cited as a potential problem area, both from a safety point of view, for example by allowing the animal to escape, and from a behaviour perspective, where inexperienced owners lacked control of their dog through inappropriate, or badly fitted, equipment.

The stress on vets, nurses and reception staff increased with the larger workload. Nurses having to hold or restrain the animal at every consultation (without clients) was seen as an additional burden, although staff were typically more relaxed within the building without clients, which could potentially have an impact on patient stress levels. Again, this is another area for further research (Horwitz, 2018).

Some elderly and more clinically vulnerable clients who were self-isolating were thought to have not sought advice through the pandemic for preventative procedures such as vaccinations. This may have had a negative impact on welfare, with behaviour consequences in some cases. There is potentially a large backlog of work building up, such as dental treatment or treatment for arthritic pain, with corresponding behaviour-related problems such as anxiety.

Some practices (including emergency out of hours practices) have introduced remote consultations either by phone, social media platforms or in the building itself with links between the waiting area (client) and the treatment area (vet). Video consults have also been used for postoperative checks and for some puppy and kitten consultations. From the pet's perspective, no visit will always be less stressful than a visit (Taylor, 2016; Feilberg et al, 2021). Other practices have allowed clients back into the clinic at an early stage, as this was perceived to be what clients wanted, as confirmed by take-up when appointments were available.

Generally, client tolerance seemed to be reduced, as the general levels of human anxiety increased. Wearing of face coverings and subsequent loss of non-verbal signals to and from clients, such as facial expression, was reported as problematic (particularly for some, especially those with hearing impairment). Given that we are a verbal species and that we as humans have been significantly affected by this, it is important to consider how much more impact has this had on our non-verbal pets, who are so much more reliant on facial expressions and body language for communication?

Potential changes to protocols and procedures following the pandemic

In general practice, consultation times of 15–30 minutes were reported (in some cases a 50% increase) and in referral practice, consultations had increased from 45 to 60 minutes. This may have had an effect on animals' stress levels, as consultation times were prolonged even though examination may have been quicker.

Having less contact with other animals in the enclosed space of the waiting room was seen in all cases to be positive in terms of stress reduction. The animals are reportedly more relaxed having waited outside, walking around with their owners, rather than sitting in the waiting room with a number of other animals and people. This may not continue, as, despite the benefits for patients, clients would prefer to wait in the building. Several vets, however, indicated a desire not to return to having a number of animals in the waiting room at the same time.

Some practices have introduced a one-way movement system through the building, with colour-coded routes and separated waiting areas which they intend to retain (Figure 3).

On balance, vets felt it more beneficial to have the client present at consultation, but some practices plan to continue to limit one owner with one pet as a good model.

Conclusions

The combined effects of the pandemic are creating a perfect storm within the veterinary world. There is greatly increased demand for services, as pet numbers have increased, combined with a drop in the numbers of qualified vets and nurses available. Providing a comprehensive service to owners, especially those with a limited understanding of their pet's needs and what can be offered, is becoming increasingly difficult. The effects of having many under-socialised animals, animals who have not received treatment at an early stage, a backlog of patients waiting for routine procedures, and the increased behavioural consequences of all this, are yet to be fully understood. The same is true for the evolution of human society throughout the pandemic.

Some changes in practice may well reduce the levels of stress experienced by pets upon visiting the practice, but overall the effects of increased pressure and stress on staff may well have a negative impact on development of more stress-free approaches, as sadly, the additional pressures of COVID-19, have moved anything but the core business to a lower priority. Some practices which had started to consider ways to become more dog- and cat-friendly, or that are considering the possibility of working more closely with, or even employing, a behaviourist, may no longer be in a position to do so. Behaviour issues may well be seen as less important compared to medical conditions, an effect likely to be magnified by the pandemic. There may well be some stress-reducing improvements in practice, but overall the pandemic is not good news for providing stress-free veterinary practices.

While a vet visit is unlikely to be able make the majority of pets completely happy, there are several key approaches which can be used towards the goal of minimum stress:

• Teaching staff to be aware of possible fear, anxiety and stress in their patients
• Encouraging and helping clients to prepare their pets for the clinic visit
• Evaluating and modifying the physical environment, protocols and procedures with the goal of reducing stress
• Provision of up to date, evidence-based information for clients about behaviour, fear, anxiety and stress.

Familiarity with the details of your local ABTC clinical animal behaviourists (www.abtc.org.uk) would be a simple first step that practices could take, so that clients can be guided towards appropriate support when the practice's level of behavioural expertise is exceeded.

KEY POINTS:

• With planning and preparation the vet visit can be made less stressful for the majority of animals though adjustment of environment, protocols and processes.
• Staff training for recognising anxiety and fear in the species commonly seen in practice (dogs and cats in particular) is essential for maintaining the highest levels of welfare with regard to emotional state and wellbeing during vet visits.
• Staff behaviour is likely to have a significant impact on the animals' anxiety and fear levels, so training on how respond in the least confrontational and challenging ways is essential to avoid increasing anxiety and fear levels.
• The pandemic has brought new challenges to the practice for staff to deal with including significantly increased demands and pressure on staff. However, some of the resulting changes may lead to an improvement in the vet visit experience for anxious and fearful animals if the mental health and wellbeing of patients is considered.