The Development of a Veterinary Nurse-Client Communication Matrix

This paper reports on a research project to develop a framework for consultations by veterinary nurses with their clients. The resulting framework, the Veterinary Nurse-Client Communication Matrix (VNCCM), identifies the components of communication between veterinary nurse and client and outlines the skills and approaches that can be used to achieve these components. Specific inclusion of techniques such as motivational interviewing, shared decision-making, achieving informed consent and reflection highlight the innovative approach to communication offered by this new model. The paper discusses the processes that led to the creation of the VNCCM, the relationship of the VNCCM to other communication models/frameworks, and what the VNCCM offers in addition to previous models. In conclusion, the paper highlights the need for dissemination of the VNCCM to the veterinary professions and for its incorporation into continuing professional development to facilitate ongoing development of veterinary nurse-client communication.


Introduction
In setting out to develop a veterinary nursing-specific consultation model, it is first necessary to explore why the profession requires its own consultation model. Veterinary nursing was recognised as a profession in the United Kingdom (UK) in 2015, through the Royal College of Veterinary Surgeons' (RCVS's) Supplemental Royal Charter (RCVS, 2015). The achievement of professional status has expanded the job role of veterinary nurses; running their own consultations and clinics is now a routine part of their work (Ackerman, 2015;Wiggins, 2016;Wild, 2017). The RCVS, which is also the regulator for Registered Veterinary Nurses (RVNs) in the UK, lists communication skills as important 'day one skills' for veterinary nurses, noting that "Communication models should be followed where Accordingly, the concept of developing a specific consultation guide for veterinary nurses arose when several of the authors were involved in developing communication skills content for veterinary nurses and realised that reliance on the GVCCCM was not always appropriate. Proposing that veterinary nursing deserves a distinct consultation framework requires awareness that human nursing still lacks its own framework; however, in the same way that veterinary medicine borrowed heavily from human medicine for veterinary communication skills training in its early development, perhaps the development of a veterinary nurse-specific consultation framework could provide an opportunity for sharing in the reverse direction. Hence, the aim of this research project was to develop a framework for consultations by veterinary nurses with their clients. The specific objectives to achieve this aim were developed by the panellists as part of the Delphi method, with results contained in Table 3.

Ethical Approval
The project received ethical approval following submission to the RCVS's Ethics Review Panel (Reference 2018-04-Macdonald).

The Delphi Technique
Consensus techniques are being used increasingly in health care research to determine the extent to which practitioners agree about, for example, clinical guidelines or curriculum development (Lloyd-Jones et al., 1998;Shawahna et al., 2016). Two techniques with a long history have been used to develop consensus -the Delphi method, with multiple rounds of question and statements, and the Nominal Group Technique, a structured method used typically at one meeting of a group (Carrasco et al., 2015;Fink et al., 1984).
The Delphi method was used in this study because it enabled open-ended questions and statements in multiple rounds to be put to many people who could remain anonymous. After each round the results were compiled into further questions and statements and recycled back to the participants asking them for further comments and to rank their level of agreement (Bowling,1997). These iterations continued until there was a consensus on the components of the communication matrix and on the skills and approaches that can be used to achieve those components.
The advantages of the Delphi method in the context of this research include anonymity for each participant, flexibility with the questions and statements, and the provision of extensive feedback; the disadvantages include the Macdonald J, Gray C, Robbé I MedEdPublish https://doi.org/10.15694/mep.2021.000144.1 Page | 5 difficulty of selecting a broad range of practitioners, the challenges for the researchers in managing 'free text' responses together with quantitative rankings, the resulting implications for validity and reliability, and fatigue amongst the participants (Hasson, Keeney and McKenna, 2000).

Panellist selection and inception
Purposive sampling from a broad section of the veterinary and medical professions recruited panellists due to their previous interest and experience in veterinary and/or medical communication, provision of nurse-led clinics and medical consultations and/or experience with developing and teaching medical, veterinary and veterinary nursing communication, together with interested members of the profession who contacted the project leader and requested to join. Diversity in experience, background and current work environment was achieved in the final panel of thirtysix, with participants from both veterinary and human medical professions, including those in frontline practice, education and other roles. Panellist input was entirely voluntary throughout the project and panellists were free to leave the project at any time.

Administration of surveys
Surveys were administered by email, using commercially available software (Cognito Forms, Cognito, LLC), which enabled operator flexibility in creating survey format, preserved the anonymity of responses and facilitated collection of data. It also provided user flexibility through ease of access, adding comments and submission.
The surveys contained supporting information, requested agreement to statements or sections of the VNCCM already completed, and/or provided free text boxes for input of further panellist recommendations or comments.
At the outset of the project, panellist opinions were sought on the value, relevance and need of this work, thereby ensuring that they considered it a viable project. The initial survey canvassed panellists on the benefits of developing a specific framework for veterinary nurse-client communication and invited contributions to the final list of project objectives. Next, a graphical representation of the VNCCM offered a summary of key stages to be used for reference as the project unfolded. Subsequent surveys enabled the panel to reach consensus on the graphic, establishing its usefulness regarding simplicity, while recognising that the content of the resulting VNCCM would need to be outlined fully to be useful for practice and educational purposes. The remaining surveys requested panellist input on different stages of the consultation process, overarching skills that may be required during any client interaction, and specific areas of consideration including motivational interviewing, shared decision-making and informed consent (see Table 1).
Feedback on each survey was sought via subsequent surveys, and on the final version of the completed work. The project leader, whose contact details were available throughout the project, invited questions or feedback from panellists.

Benefits of developing a model
Panellists asked for benefits of developing a consultation framework focussed on veterinary nurse-client communication.

Objectives and aims
Suggested objectives offered, panellists given opportunity to agree with these, suggest adaptations and/or additions.

Physical Examination
Basic concepts suggested, and further comments sought on components and skills.
Panellists also asked to comment on whether physical examination should be a separate 'phase' or integrated into gathering and giving information.

EIGHT 4 th May 2017 3
Closing and Reflection (presented as two separate sections on the survey).
Basic concepts for suggested, and further comments sought on components and skills.

Final review of content
Survey containing full VNCCM content shared, with invitation to agree or disagree with any elements or provide any further comments.

Results/Analysis
The initial survey asked the panellists to comment on the benefits of developing a consultation framework particularly focussed on veterinary nurse-client communication. Responses identified that veterinary nurses require specific skills and confirmed the lack of current communication guide that met the purpose of the veterinary nurse's role and nurse-client interactions ( Table 2).  Table 2. Panellist responses to initial survey question "Allows student VNs a framework to work to and RVNs a framework to adhere to" "To provide a consistent holistic approach to client and patient care within the practice" "I believe both clients and nurses will benefit from a framework. It can help ensure nothing is missed and the client and pet is getting the best care and advice during consults. It could also be used to build confidence for nurses consulting and give something to follow through providing a structure." "To advance the status of the RVN profession, we need clients to understand and appreciate the benefits of trained nurses. An important way of demonstrating our professional role is taking a front of house role in preventative healthcare and appropriate consults. But in order for these client facing contacts to go well, veterinary nurses need to have a clear framework from which to work. Communication is a skill like any other, which needs continuing education." "Improved communications between the client and the veterinary nurse will benefit the animal (patient)" "Beneficial to those involved in teaching to provide a model which can be presented and followed within the course -the students can then take this into practice and use it within their NPL*."

*NPL -Nursing Progress Logs -refers to a placement training log commonly used by student veterinary nurses and clinical coaches, provided by the RCVS.
A "wordcloud" created from responses ( Figure 1) indicated the key benefits identified by panellists as client experience and relationships; access to a framework for guidance and for teaching and assessment; and building confidence in client interactions. Specific objectives were constructed through asking panellists to reflect on the stated aim and to suggest relevant objectives (Table 3).  To promote best practice in terms of animal welfare through developing a framework particularly focussed on veterinary nurse-client communication.
Project objectives: 1) To reach a consensus on the framework consisting of the necessary components for the Veterinary Nurse-Client Communication Matrix (VNCCM) 2) To ensure that the framework is relevant and applicable to both practice and teaching, that it is straightforward and accessible, that it promotes best practice and, that it aligns with guidance on professional conduct 3) To incorporate into the framework components of professionalism, self-awareness and mindfulness by the veterinary nurse towards animals, clients, other members of the healthcare team, and the wider society 4) To disseminate the framework to the profession, and to facilitate the ongoing development of veterinary nurse-client communication

Graphical representation of the VNCCM
An initial draft of a graphic consultation structure produced conflicting feedback from panellists, many expressing that it was too 'busy' and therefore confusing ( Figure 2). Such feedback highlighted the need for simplicity of the practice-oriented version, with further detail provided as an adjunct. A revised draft was created, and consensus reached on the simplified graphic ( Figure 3), with further information being revealed on 'hovering' over the components of the consultation. The cyclical nature of the finalised graphic signposts the further development of skills through reflective practice, and provides the 'baseline' components of a veterinary nurse consultation. Further key stages were explored through subsequent surveys.  The concept of 'sharing information'.
The traditional use of 'gathering' and 'giving' information as descriptors in clinical communication models are suggestive of nurse-led communication, however the communication between nurse and client is a fluid and interchangeable dialogue, involving the sharing of information from both parties. The VNCCM is expected to be employed as a teaching tool, and it was considered important to instil an ethos of flexibility and inclusiveness in communication.
The first key stage of 'sharing information' was addressed during a dedicated survey, and consensus was reached that this was an appropriate term to represent nurse-client dialogue. A graphical representation of the concept was also developed. (See Figure 4). Expansion of the components of each stage of the consultation is provided in Table 4, which demonstrates how the sharing of information permeates most stages.

The physical examination
The second key stage of physical examination of the patient is an important contributor to the information exchanged between veterinary nurse and client. Often a non-verbal procedure, it can inform the questions asked by both parties. The physical examination can be conducted as a discrete part of the consultation, or it can be performed at the same time as other verbal communication tasks. Panellists were asked to comment on whether they considered that physical examination should be a separate phase or integrated with other aspects of the proposed structure. In response, panellists shared their perspectives both as veterinary professionals and clients.
Although there was no clear consensus on whether history-taking and physical examination should be separate or integrated (Table 5), the comments demonstrated that whilst it may offer a better experience for the nurse and the client to gather the majority of information before examining the patient, there will also be some elements of overlap and integration. It was also noted that the physical examination begins as soon as the patient first arrives, for example, through observation of the animal's behaviour, gait and body condition. Whilst the merits of both methods were highlighted, it was felt important to demonstrate a need for flexibility in the timing of the physical examination within the structure of the consultation.

Table 5. Panellist comments regarding integration or separation of the physical examination
"It is inevitable that questions will occur during examination; this might be for clarification, to jog our own memories, or in response to findings. The separation necessary is centered on the need to give our full attention to the client in the initial phase, so that we are able to summarise and reflect their concerns, opinions and priorities BEFORE commencing the exam. This process need not be perfectly whole, flawless or unrepeated, but it is sufficient to avoid the examination so distracting the client and focussing the nurse that the need isn't met." "Usually isn't time to separate so not realistic.
[…] ask questions as you go along with your examination." "Separation: enables concentration on the animal by the nurse; offers time for cognitive activity by the nurse about the consultation so far; provides space for the client to think and to observe the nurse in action; eye to eye contact can be restored after the examination; it is challenging enough to gather and give information without trying to examine simultaneously." "Integration: quicker!" "As a client I prefer separation." "I tend to take the initial history with all of the complex details at the start and check the information back with the owner before I examine the patient. Whilst I'm doing the examination, I ask the clarification questions and general background stuff. It helps me concentrate on the history and then focus my examination a bit." "I find it hard to do the multitasking involved in taking the history and doing a physical exam at the same time." "Integrated: it starts at the "opening" stage when you are assessing the animal's physical condition as the client enters the consulting room. You will probably also observe the animal continuously during the subsequent phases of the consultation before actually getting 'hands on'" "I would prefer integrated, as I will ask the client questions as I am doing the PE, and adapt accordingly." The stages of the VNCCM are expanded upon in Supplementary File 1, with addition of the skills to achieve the components listed.

Discussion
Inevitably, parallels can be drawn between the VNCCM and the GVCCCM and the familiar stages of "prepare, open, share information, examine the patient, discuss treatment and close" is visible in both models. However, as the project sought to specifically consider how veterinary nurses can best communicate with clients in developing effective relationship-based communication, there were several additional areas of focus and content. Additionally, the cyclical reflective shape of the VNCCM sets it apart from other longitudinal and/or unidirectional models.

Relevance
The VNCCM makes provision for both an overview of a veterinary consultation, in the form of the graphical outline and key components; and for more detail and guidance in the form of the full guide which explicitly covers the skills required for each component of veterinary communication. It provides a broad scope of reach in the veterinary nursing profession as a reference for student nurses and nurses in practice or industry, a guide for continuing professional development, and provision of a reference point and structure for those in teaching and assessment roles.
Panellists included frontline nurses who perform consulting work on a regular basis, and those in teaching and educational development roles, thereby ensuring relevance of the final content. The value of components such as shared decision-making and reflective practice, and their importance in everyday communication with clients, was reinforced by the feedback from the panellists.
The RCVS VN Day One Competences (RCVS, 2015) which are expanded upon in the Day One Skills for Veterinary Nurses -small animal (RCVS, 2016), stipulate the minimum essential competencies in communication skills required of registered veterinary nurses (Table 6).

Table 6. RCVS VN Day One Competencies. Communication. (RCVS, 2016)
5. Communicate effectively with clients, the public, professional colleagues and responsible authorities, using language appropriate to the audience concerned 6. Prepare accurate clinical and client records, and laboratory reports when necessary, in a form satisfactory to colleagues and understandable by the public 7. Work effectively as a member of a multi-disciplinary team in the delivery of services 8. Understand the economic and emotional context in which the veterinary nurse operates 9. Be able to review and evaluate literature and presentations critically 10. Understand and apply principles of clinical governance, and practise evidence-based veterinary nursing 11. Demonstrate ability to cope with incomplete information, deal with contingencies, and adapt to change 19. Communicate clearly and collaborate with referral and diagnostic services, ensuring they receive an appropriate history from the veterinary surgeon. 31. Understand the appropriate need for euthanasia; sensitively support the owner and others with due regard for health and safety of those present; advise on disposal of the carcase 32. Advise clients on programmes of preventative medicine appropriate to species The RCVS Code of Professional Conduct for Veterinary Nurses (RCVS, 2020a) provides more detailed guidance on interactions with clients, with specific focus on the client relationship, informed consent and discussion of fees. Whilst offering veterinary nurses clear foundations for effective and respectful communication and incorporation of the client's views and wishes, it does not offer comprehensive detail to help nurses and nursing students appreciate the many elements relevant to how effective communication can be achieved. However, neither should it, since the Code of Professional Conduct is intended as a guide to the responsibilities and principles underpinning professional practice, rather than as a teaching tool.
The detail provided by the VNCCM aims to facilitate a level of understanding that will assist nurses in achieving a standard of professional communication that aligns with the Day One Competencies and Skills and supporting Macdonald J, Gray C, Robbé I MedEdPublish https://doi.org/10.15694/mep.2021.000144.1 Page | 30 guidance on communication provided by the RCVS.
Aligning with the concept of the 'vet-led team' outlined by the British Veterinary Association (BVA, 2019), the veterinary nurse's role within this system and the need for intra-professional communication to be exemplary in order for the team to function efficiently; communication with other team members and para-professionals is also highlighted in the VNCCM.
Specific priority areas of professionalism in communications by veterinary nurses were identified by the panellists. These areas were motivational interviewing, shared decision making, gaining informed consent, and reflective practice, which merit further discussion.

Motivational interviewing
Motivational interviewing (MI), developed by Rollnick andMiller in the 1980s (Rollnick, Miller andButler, 2008), is an evidence-based, client-oriented communication methodology, which stimulates and encourages behaviour change. Whilst it may not be immediately apparent that conversations with pet-owning clients would benefit from instigating behavioural change, clinical situations such as pet obesity, management of long-term conditions such as diabetes or osteoarthritis, and animal behaviour problems require helping clients to embrace the concept of change. Use of MI techniques could promote adherence to veterinary advice and treatment, thus benefitting the long-term management of these and other patients.
MI is not a simple method, and ongoing training, practice and feedback is required in order to be able to develop and maintain proficient use of this skill (Schwalbe, Oh and Zweben, 2014). However, offering the basic principles of MI provides a useful foundation on which to build skills for eliciting behaviour change in clients, and in strengthening the concept of client-and relationship-centred care. Clients are better informed through external sources (Belshaw et al., 2018), many wish to become more involved in decision-making about their pets' treatment, and veterinary nurses need to develop the skills to help them embrace the shift away from a more paternalistic approach to healthcare, and work towards involving pet owners in making decisions for their pets.
The teaching of MI as a component of communication skills training for veterinary nursing students is likely to yield more favourable results than introducing the method to a trained nurse who has been practising for a period of time with the use of traditional communication skills. (Svensson et al., 2020) It is therefore beneficial for MI to be introduced to student veterinary nurses whilst they are learning about communication during their training. The VNCCM offers a brief overview of MI and a basic introduction to the key principles that may be applied in veterinary communication, including the four key components of MI (engaging, focusing, evoking and planning) and the skills that are useful in achieving this. The four guiding principles are outlined using the RULE acronym (Resist the righting reflex, Understand client's own emotions and motivations, Listen with empathy and Empower the client) (Rollnick, Miller and Butler, 2008).

Shared decision-making
The goal of sharing information is ensuring that both parties have been given the information that they need to have equal input to decision-making for the patient. Shared decision-making (SDM) is a stated goal of human medical consultations, with clear stages to enable its inclusion in healthcare professional (HCP)-patient encounters (Elwyn et al., 2012). Specific communication techniques are utilized by both HCPs and patients to facilitate SDM, even when there is only one option available for treatment (Land, Parry and Seymour, 2017). Christiansen et al. (2016) have clarified the difficulties involved in implementing SDM techniques in veterinary end-of-life decision-making. The shared decision-making approach to veterinary communication is therefore not a new concept and carries a great deal of weight in terms of ensuring that the client's expectations and wishes are met when discussing potential treatment plans for animal patients. Veterinary nurses may be unaware of this concept, despite often using it unconsciously in their communication with clients; they may not appreciate the skills that can be used to ensure that the client is fully involved in the decision-making process. It was therefore felt imperative that a distinct section of the VNCCM provided guidance on achieving this in communication with clients.
The components included in the SDM section of the VNCCM were as follows: adhering to SDM values in terms of valuing the client's contribution; explaining possible options; prioritizing these options in response to client input and reaching a mutual decision. Comparing these with Elwyn's guide (Elwyn et al., 2012) to SDM in practice, the stage of 'choice talk' correlates with the VNCCM stage of explaining possible options, the stage of 'option talk' correlates with prioritization of options; in the VNCCM the prioritization of options involves interpretation of the client's input and preferences to enable the veterinary nurse to present a priority list of options. Elwyn's final stage of decision talk matches the VNCCM stage of reaching a mutual decision. Underpinning the components of SDM are the skills involved, which draw on more general consultation skills such as allowing space for the client's contribution and taking time to properly explain the costs, risks and benefits of treatment options. There is thus some crossover between SDM and informed consent.

Informed consent
Gaining informed consent (IC) from clients and agents is a process that is often delegated to veterinary nurses and student veterinary nurses, particularly for routine, elective procedures. Clients may prefer to speak to veterinary nurses, who are seen as having more time and being able to explain things better (Gray, 2019). The supporting guidance to the RCVS Code of Professional Conduct (RCVS, 2020a) offers a comprehensive overview of IC and provides an essential adjunct to the information offered in the VNCCM. However, from a communication aspect, two key requirements for IC are the transfer of knowledge and regarding the process as an exercise in communication skills (Convie et al., 2020).
The components of the IC section of the VNCCM include both legal and communication requirements: ensuring that the correct person is giving consent (owner or owner's agent), has capacity to give consent and that their consent is recorded in some way, are prerequisites to the communication skills required to inform the client of the risks and benefits of the procedure, facilitate client understanding and reach a shared decision about the chosen option. The underpinning skills for this section include giving information with a suitable level of detail, language and format for the client; picking up on client cues and encouraging questions; and giving sufficient time to consider options and reach a decision.

Reflective practice
Reflective practice is a fundamental component of professional and personal development and can provide an opportunity to encourage further self-directed learning (Fontaine, 2018). It can also be used as a powerful tool to increase confidence, through considering the skills that were effectively utilised, how engagement with the client provided a positive outcome, and through promoting repetition of the skills and methods that were beneficial. Reflection was therefore deemed to be a key stage in any client interaction. By using a cyclical format for the final