Clinical and communication skills

Veterinary nursing

Why is it important to communicate?

Building trust, Accurate diagnosis, client education, emotional support

What are the 5 key skills when communicating?

Active listening, Clarity and simplicity, empathy, non-verbal communication, and questioning techniques

What are the 3 challenges when communicating in the veterinary practice?

Emotional situations, Time constraints, cultural differences

How do we improve veterinary communication in practice?

Training and workshops, feedback and reflection, technology (like emails)

Why is effective communication essential?

For providing high-quality care and ensuring positive outcome for pets and owners

What can a nurse do during a consultation to be an effective communicator?

Active listening, clear explanations, body language, open questions

What is verbal communication?

• Use of spoken workds to convey messages

• Occur face to face, phone calls, video conferences, public speaking

• Requires clarity, active istening and appropriate responses to ensure message is understood as intended

What is tone of voice, and how can we use it in practice?

• Involves voice volume, emphasis on words and the emotion that you communicate

• it can change what is said to client and how clients interprets the information

What are some non-verbal communication components?

• Facial movements and expression (and micro expressions)

• Gaze and eye contact

• Head movements

• Body movements and posture

• Proximity

• Interpersonal touch

• Voice or paralinguistic features

• Personal appearance (clean clothes, neat hair, clean hands etc.)

• Environmental cues

• Time

Why do we use non-verbal communication?

• Convey emotional states

• Convey feelings towards another person

• Can support or contradict the verbal communication

• Give the receiver cues about what is being communicated

• Adds meaning to verbal communication

• Substitute for language when speech not possible

• Regulatory function

What are the 2 types of listening?

Passive and active listening

What are some barriers to effective communications?

Client no understanding or misunderstanding, medical terms, time constraints, lack of accessibility, clients’ acceptance of medical advice, difficult clients, client impairments, language barriers, cultural differences

What are the impacts of communication barriers?

Quality of care, client satisfaction

How can we address communication barriers?

Using clear, non-technical language, giving enough consultation time, accessible for follow-up, collaborative environment, building strong relationships

Why do we use communication models?

To structure our client consultations

What is an example of a communication model?

Calgary-Cambridge model

What are the 5 steps to the Calgary-Cambridge model

1. Initiating the session

2. Gathering Information

3. Physical examination

4. Explanation and planning

5. Closing the session

What do we do in step one of the Calgary-Cambridge model?

- Preparation

- review patient history and reason for visit and a welcoming environment.

- Building rapport - greet the client and patient warmly, established through small talk (ice breaker, showing an interest to the client)

- Understanding the client perspective - Ask open ended questions to understand concerns and expectations. This encourages clients to open up, tell a story, discuss issues, can get unexpected information. Close questions are yes/no answers, easier to control, can make client feel threatened. Other question include: reflective, probing questions.

What do we do in step two of the Calgary-Cambridge model?

- Biomedical perspective

- ask specific questions about animals symptoms, behaviour and medical history

- Client experiences

- Explore client observations and concerns

- Contextual information

- Gather information about animals environment, diet, lifestyle

What do we do in step three of the Calgary-Cambridge model?

-Integration with communication

- Explain each step of the examination to the client, Use layman's terms to describe findings. Context to what is happening and normal

- Nonverbal communication

- Maintain eye contact and use appropriate body language, Show empathy and attentiveness

What do we do in step four of the Calgary-Cambridge model?

- Sharing findings

- Summarize the results of the examination clearly, Use visual aids if necessary

- Decision-making partnership

- Discuss treatment options and involve the client in decision-making, Address any questions or concerns the client may have

What do we do in step five of the Calgary-Cambridge model?

- Summarising the plan

- Recap the agreed-upon treatment plan and next steps

- Ensuring understanding

- Ask the client to repeat key points to confirm understanding

- Building long-term relationships

- Schedule follow-up appointments and provide contact information for further questions

What are the 6 types of clients?

Worrier, Demand maker, sceptic, complainer, high maintenance client, always late client

What is a Human companion animal bond (HCAB)?

A mutually beneficial relationship between people and their animals.

What are the benefits of the human companion animal bond (HCAB)?

• Improve mood, reduce depression

• Lower blood pressure

• Lower cholesterol levels

• Lower the risk of a heart attack

• Motivate and encourage exercise

• Reduce and prevent stress

• Help to prevent disease

• Increase self-esteem and sense of personal competence

• Lessen loneliness, encourage and enable socialisation

• Provide a source of social support

• Provide an unconditional acceptance and warmth

• Boost the immune system

• Decrease the number of visits to your GP

• Act as a health warning; recently, dogs have been known to detect and identify certain cancers

What circumstances can lead to the loss of pets?

• Acute illness

• Life limiting condition

• Euthanasia

• Accidental death

• Human illness

• Rehoming pet

• Moving abroad

• Straying

• Theft

• Behaviour

• Imprisonment

• Divorce/separation

• Forced to give up a pet

• Mandatory euthanasia – dangerous dog

What losses are associated with pet bereavement?

Psychological loss (companionship, feeling needed and loved, fun)

Social loss (social conversation, reason to get up and go out, security)

Physical loss (opportunities/motivation to exercise)

Why do clients need support during the loss of a pet?

• Pet loss is largely unrecognised as a loss in the UK

• No compassionate leave

• No tradition of community support

• Not universally experienced, understood or recognised

• Experiencing grief and mourning the death of a pet may be perceived by some people as ‘trivial’ or ‘ridiculous’

• Often alone with their grief

What are the 5 stages of grief?

Denial, Anger, Bargaining, Depression, Acceptance

What happens in the denial stage of grief?

- Individual refuses to accept their loss or news of impending loss

- Denying the truth

- Demanding 2nd opinion, internet research, disappear from surgery

What happens in the anger stage of grief?

- Overwhelmingly angry, anger directed at vet, themselves, relatives/friends, medical community

- Rarely rational but overwhelming and consuming

- Physical, verbal, irrational

What happens in the Bargaining stage of greif?

-'If you take away the pain, then I will.....'

- The individual may beg for their pets life in exchange for whatever price such as bargain

- Money, prayer, time

What happens in the depression stage of grief?

- Individual begins to realise that there situation is irrevocable

- Must continue to live without the presence of their pet in their lives

- Feel sad, anxious, regret, guilt

- Apologising to pet, needing support, become withdrawn

What happens in the acceptance stage of grief?

- Accepting that their pet has limited time

- Acknowledging the fact that their pet is not returning

What is anticipatory grief?

• Grieving that begins BEFORE that actual loss

• A known life limiting condition - lymphoma, renal disease, heart disease

• Type of grief requires provision of pre-euthanasia bereavement care

What is responsibility grief?

• Veterinary euthanasia results in a distinct category of grief

• Owners have actual personal responsibility for the death of their pet by euthanasia

• This may result in feelings of guilt, self blame and doubt

How can we as VN respond to responsibility grief?

• RVN continuing care clinics (palliative care, pre-euthanasia)

• Involvement & empowerment of owner in palliative treatment and care of terminally ill patient

• QOL assessment – include owners

• Do not rush clients into euthanasia decision making

• Choices & options to be explored e.g. location, after death body-care

• Validation of euthanasia decision

• Allow opportunities for discussion, questions

What is a Quality of Life (QOL) assessment?

An assessment that measures an individual’s overall well-being mentally and physically

What things get assessed in Quality of life assessment?

Hurt, Hunger, Hydration, Hygiene, Happiness, Mobility, More good days than bad

What are some reasons for euthanasia?

Terminal illness, palliative care is insufficient, behaviour/aggression, financial, unable to rehome

What are somthings’s to remember in the euthanasia process?

You need IV access, time, quite environment, give client personal space, provide option for linking items

How can we support our client in times of euthanasia?

Sensitive communication, show empathy, give client time to kink, speak slow, make procedure goes smoothly

What are some after-body care options?

Communal and individual cremation, burial at home or pet cemetery

What linking items can we offer to clients?

Smally amount of fur, collar, clay paw mould/ink footprint

What post euthanasia support can we offer?

Pet bereavement support (Blue Cross), Samaritans, contact number for pet loss group (trained counsellor), self and team care

What drug do we usually inject an animal with in the euthanasia process?

Pentobarbitone

Why do we see twitching or hear gasps of air after the euthanasia process after the injection is administered?

It’s the reflexes as the nervous system shuts down. They are NOT signs of life

What is rigor mortis?

It can start 10 minutes after death or a couple hours after. Its where the body goes stiff

What is SPIKEs model of communication around euthanasia?

Setting, Perspective, Invitation, Knowledge, Empathise, Summarise

What is compassion fatigue?

Is a state of emotional and physical exhaustion cause by continuous exposure to suffering

How does compassion fatigue develop?

1. Repeated exposure

2. Emotional investment

3. Cumulative stress

4. Lack of recovery time

What are the signs and symptoms of compassion fatigue?

Emotional symptoms: Feeling numb, detached, irritable, overly emotional

Cognitive Symptoms: Difficulty concentrating, decision-making challenges

Physical Symptoms: Fatigue, headaches, digestive issues

Behavioural Changes: Avoiding euthanasia cases, withdrawing from colleagues, decreased job satisfaction

What is moral stress?

It occurs when you know the ethically "right" things to do but feel powerless to act due to external constraints.

Unlike general stress, moral stress is deeply tied to ethical dilemmas and can create lasting emotional turmoil.

What is the purpose of an admit appointment?

• Confirm purpose of admission

• Check relevant history

• Pre-admission examination of pet

• Discuss what is going to happen

• Discuss potential risks

• Obtain consent for planned procedure

Who can admit patients?

Under the RCVS guidance, it would be the veterinary surgeon, but it can be delegated to someone else who is suitably trained and has sufficient knowledge of the procedure or treatment and understands the risks involved

Who can give consent for a procedure?

It can be given by the owner or an agent (acting on behalf of the owner)

Consent can be given from 16 years old, but they can’t enter a binding contract under 18 meaning they would not be liable for any fees

What is the purpose of discharging appointment?

• To return the patient to the care of their owner

• To advise the owner on post-procedure monitoring

• To advise the owner on post-procedure care

• To advise the owner of any prescribed medications and their use

• To advise the owner of followup appointments needed

• To advise the owner what to do in the event of any concerns including out of hours

What guidance do the RCVS give on discharging patients?

Discharging animals should be in place for on-duty staff

• Plan the date and time of discharge early

• Identify whether the patient has simple or complex discharge needs and consider how these will be met

• Review the clinical management plan regularly, take any necessary action and update this towards the discharge date.

• Coordinate the discharge process through effective leadership and handover responsibilities

• Confirm that clients have been provided with the necessary information on discharge

• Confirm that clients have been given any required medicines or items (e.g. collars, bandages) on discharge

What wound care instructions would you give an owner after a procedure?

• Prevent interference with the wound. Wear a cone collar, inflatable collar or protective bodysuit while the wound heals (approximately around 10 days). Most animals can eat/drink fine with these on, but may need to remove and replace immediately after

• Check wound a few times a day, looking for redness, swelling, discharge, tight or loose/missing sutures. It might be worth showing owner wound so they know what it looks like and what changes to look for.

• When you bring the patient through, if possible show the client what the wound looks like now so they have something to compare to.

• No cleaning or applying any creams to the wound unless advised by the vet

What bandage care instructions would you give an owner after a procedure?

Check bandage at least once a day, looking for:

• Slipping or complete loss of the bandage.

• Signs of chewing/scratching at the bandage.

• Any wet areas.

• Any bad smell or leaking fluid.

• Rubbing of the edges of the bandage on your pet’s skin.

• Swelling of the skin around the bandage

• Must be protected from getting wet/dirty - cover bandage if they go outside

• Do not try and reapply bandage at home if any issues contact practice

When should you seek immediate veterinary attention after a procedure?

• Make sure you are aware of any procedure specific concerns

• Extreme tiredness/unable to stand

• Low energy for over 48 hours post anastatic

• Pain or discomfort - pain management in place i.e. pain relief

• Problems toileting

• Excessive redness, swelling, bleeding, or discharge around wounds

• Vomiting- more than 2 episodes in 24 hours

• Diarrhoea- more than 2 episodes in 24 hours

• Refusing to eat for over 24 hours (dogs and cats)

What are some examples of non-surgical procedures?

• Blood sample

• Re-dessing

• Vaccinations

• IV caffiter

• Nail clip

• X-rays

• Skin scapes

• Urine sample

• Consults/check-ups

What should you do before handling a patient?

• Secure room

• Transport all patients safely and securely

• Muzzles and handling restraints - check previous notes

• Assistant availability?

How long should an animal fast for for a fasting blood sample?

8-12 hours pre sampling

Why do we do fasting blood samples (what does it reduce)?

This reduces the risk of samples becoming lipemic - fat layer, which could affect the results

What are some examples of blood tests might an animal might need to be fed for?

bile acid stimulation, glucose levels

How would we prepare the site for a blood sample?

Clip sample site

Use of 'hibiscrub' as a skin cleanser, followed by alcohol swap

What are some common sites for blood samples for cats and dogs?

• Jugular (neck)

• Cephalic (fore limb)

• Saphenous (hind limb)

What are some common sites for blood samples for rabbits?

• Jugular vein (neck) - more blood volume

• Cephalic vein (fore limb) - bigger breeds

• Marginal vein (ear) - reserve for IV catheter, easily callaps

• Auricular artery (ear) - haulier gas, oxygenated

What equipment do we need for a blood test?

• Electric clippers with no. 40 blades

• Skin cleanser e.g. chlorhexidene

• Gloves

• Surgical spirit

• Cotton wool

• Needle of suitable size (normally a green needle – 21Gx 5/8) smaller needle for rabbits (blue)

• Syringe of appropriate size - usually 2 ml

• Appropriate blood container - depends on test

What needs to be on the label after a blood test?

Clients name, patients name, date

How do we position a needle on the syringe correctly?

The bevel of the needle should face upwards

What are some methods of collection a urine sample?

Mid-stream collection, manual expression of the bladder, catheterisation, cystocentesis

How does cystocentesis work for a urine sample?

The procedure involves the passage of a needle, through the abdominal wall into the bladder

What are some methods of collect a faecal sample?

Ground collection, litter tray collection, rectal collection

How should we store and preserve a faeces sample?

Containers need to be sterile and airtight, need 2-5g to fill the container, label the container, examine the faeces 2 hours after collection or store at 4 degrees int the fridge to prevent anything developing for 7 days

why do we do bacteriology swabbing?

Bacterial culture is useful to check the antibiotic sensitivity of bacteria eg a chronic ear infection and doing a swab lets us know what bacteria is growing in the cavity, need to make sure 3 days before swab needs to stop antibiotics

How should you prep a patient for a Bacteriology swab?

• Antibiotics should have been stopped three days prior to taking the sample

• If swabbing a pustule, remove the hair over the site with scissors

• Do not perform any skin preparation (Why? - disinfectant will kill the bacteria just needs to be clipped but use scissors not clippers)

Why don’t we perform any skein preparation for a bacteriology swab?

Disinfectant will kill the bacteria, just needs to be clipped, but use scissors, not clippers

What are the laboratory requirements for a sample?

• Proper storage (refrigerating) and labelling

• Complete and accurate paperwork (lab forms - details of: practice, owner, animal. Where sample was taken from)

• Adherence to guidelines to prevent pre-analytical errors (fasting?, little detail for the test to get accurate results)

What are the packaging requirements for a sample?

• Protecting handlers and sample integrity (e.g. person packaging it and the person resaving it)

• Use of appropriate packaging materials (e.g., slide holders, bubble wrap, absorbent material, paper work doesn't go into the same pocket as sample)

• Proper labelling and absorbent materials

• posting bag - needs a 'biological substance' and a 'category ...' on it

How can we control the temparture of a sample when sending it off to a lab?

• Wet ice for 2–8°C storage (negative - it melts = polystyrene box help with temp control)

• Dry ice for -20°C to -80°C storage (safety precautions - burns)

What laws apply to waste management?

• Environmental Protection Act 1990

• Special Waste Regulations (amended) 1996

• Hazardous Waste Regulations 2005

What commercial waste documentation does a practice need and why?

Section 35(5) of the Environmental Protection Act 1990 makes it essential for commercial properties to have evidence on where the waste is going and this needs to be kept for 7 years

What do you need to consider when handling waste?

• Protect yourself!!

• Have an understanding on the type of waste you are dealing with

• Only handle what you have been trained to work with

• Wear PPE (this will vary for each type of waste)

• Good general/personal hygiene and infection control standards

What are some examples of Non-hazardous waste?

Domestic waste, Offensive waste, Pharmaceuticals, Cadavers (unless they have a notifiable disease)

What colour bin bags do offensive waste go into?

Yellow bag with a black strip in the middle of it

What are some examples of hazardous waste?

Infectious/clinical waste, sharps, cytotoxic and cytostatic waste, photographic/radiographic chemicals

What may offensive waste include?

Faeces, Bedding, clinical materials that are not infectious

What regulation regulates controlled drugs?

Regulated by the Misuse of Drugs Regulations 2001

What colour bag is used for Infectious/ clinical waste?

Yellow bag with a hazard sign

What colour bin do sharps go into that are contaminated with bodily fluids and pharmaceuticals?

Yellow lidded bins

What colour bin do sharps go into that are not contaminated with bodily fluids and pharmaceuticals?

Orange lidded bins

What does cytotoxic mean?

Toxic to cells (kills cells)

What does cytostatic mean?

inhibition of cell growth and multiplication (stop cells growing) - used more

What bins does cytotoxic and cytostatic waste go into?

sharps bin with purple lid

yellow bag with purple stripe or purple bag

What are some consequences of poor waste disposal?

Environmental damage

• Infectious / zoonotic diseases

• Risk of wildlife health with chemicals

  Human injury

• Sharps put in plastic bags

• Risk of injury from chemicals

  Prosecution of organisation and individual

• Failure to produce commercial waste documentation, breach of Section 34(5) of the Environmental Protection Act 1990 (£300)