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Theoretical Aspects of Nurse Consulting

Veterinary nurses/technicians have quite a unique and important role as veterinary professionals. Whilst working under the direction of the veterinary surgeon, VN/Ts also have elements of autonomy and are responsible professionals. Occasionally, VN/Ts must convey a vast amount of very technical clinical information to pet owners in a non-patronising, yet informative format, whilst in a potentially highly emotionally stressed setting. Communication skills are the most important of all the 'soft' skills that veterinary professionals need to master (Box 2.1).

The way in which we communicate is very important, not just the content but also how this is conducted. Narrative medicine is making large inroads into veterinary practice; it is something that isn't new, but has always been undertaken, though not widely recognised in its importance. Research has been conducted looking predominantly at veterinary surgeons, rather than nurses/technicians. The veterinarians predominantly relied on asking questions, giving information and persuasive talking, suggesting a paternalistic communication style, when attempting to motivate a client (Enlund et al. 2021). The veterinarians dominated the conversations and made minimal attempts to involve the dog owner, resulting in a power imbalance between the veterinarian and the client (Enlund et al. 2021). The research concluded that veterinary communication and, thereby, client adherence to medical recommendations may improve if client-centred communication styles such as motivational interviewing (MI) and narrative medicine are introduced and implemented in veterinary practice (Enlund et al. 2021).

Box 2.1 The difference between soft and hard skills

Soft skills: Non-technical skills that relate to how you work. They include how you interact with colleagues, how you solve problems and how you manage your work. They include interpersonal (people) skills, communication skills, listening skills, time management, problem-solving, leadership and empathy.

Hard skills: Technical skills that can be taught (e.g. intravenous (IV) cannula placement and blood sampling).

What is narrative medicine?

Narrative medicine considers all aspects, not just the medicines but also the diagnostic tests that are required. The owners and pet's narrative (their back story) needs to be understood to work together towards a treatment plan. Each owner and pet will have a unique narrative (story) that needs to be understood (Fine 2020).

VNs are excellent at acting as advocates for their patients and owners. Ultimately, the best care that can be provided for the patient is reflective of the owner's/pet's narrative. What might provide the best care plan for one patient will not be the best care plan for the next. Their narrative might be different. Balance is vital to achieve the best clinical outcomes for the patient. The term 'gold standard treatment' is no longer used as it can mean different things to different cases; it will depend on their narrative and to different veterinary professionals depending on their knowledge and experience. Understanding the narrative will help with concordance and compliance with the treatment care plan. This means that veterinary professionals are providing treatment plans that are achievable. This all goes back requiring good communication skills. It doesn't matter what form of communication is being utilised (in person or telemedicine); if the owner/pet narrative is not considered, there is a potential that clinical goals and therefore outcomes won't be achieved.

Discussions have been made on the influence that narrative medicine has on the well-being of veterinary professionals. Narrative medicine has been shown to help reduce burnout and fatigue within practitioners (Fine 2020), by providing tools and strategies to help reduce burnout and compassion fatigue, minimise guilt and manage distress. Every veterinary professional should be equipped with skills that can be readily utilised in practice to help both the clinical outcomes for the patient and patient welfare, support the owner's narrative and their own well-being and aid in teamwork within the practice.

Consultation models

Consultation and communication models are widely referred to as veterinary nursing, but these tend to be adapted from the human medical field or from veterinary surgeons (Calgary-Cambridge consultation model) (Figure 2.1) (Kurtz and Silverman 1996). The Veterinary Nurse-Client Communication Matrix (VNCCM) (Figure 2.2) has been suggested as a model that incorporates the Veterinary Surgeons Act and the RVN Code of Professional Conduct (from the United Kingdom) as more appropriate communication consulting model for the RVN profession (Macdonald et al. 2021). Sharing information is not just with the owner but also with the larger veterinary professional team. In some clinical cases, confirmation with the veterinary surgeon may be required. The matrix isn't bound by time, as reflection and planning can occur after the face-to-face elements of the consultation (Macdonald et al. 2021).

Figure 2.1 Calgary-Cambridge consultation model.

Figure 2.2 Veterinary Nurse-Client Communication Matrix graphic.

Source: Kurtz and Silverman (1996) / with permission of John Wiley & Sons.

Difficult conversations

Difficult conversations aren't just about bad news for the pet but can also be about a client who is unhappy about a situation or when having to explain that something has gone wrong. Before you put yourself in this situation as the deliverer of this information, plan. Whether this is written down or not but ensure that you are mentally prepared. It is vital that you distinguish feelings and emotions from facts and you need to remain calm in these situations. Check any assumptions, and gather evidence (whether it is hospitalisation sheets, times of phone calls to the client, etc.).

Key step Description Prepare Set your goals clear, anticipate questions from them, get all the facts from clinical histories and other parties and choose a setting. Plan Prepare an outline of your discussion, practice, follow a logical approach and think about timing. Ask or enquire Be empathic, use open-ended questions and don't assume. Acknowledgement Showing that you have heard and listened - acknowledgement is not the same as agreement; using pauses, summarising and writing key points down show you are listening. Approach Rather than having assumptions, try to approach from a neutral perspective. Problem-solving - make a plan Build solutions - this is not an 'I want to win' situation. We need to build a plan together to move forward.

Breaking bad news

Tone of voice

In these very highly emotive situations, people really do remember some of the strangest details about a conversation. Keep brief, keep to the facts. It is sometimes better to deliver the news and stop. Follow-up discussions about the details can occur later, but inform the person that this is available to them. People will have questions, but in a highly emotive state, they might not be able to formulate what they want to know at that time.

Motivational interviewing

MI is a client-centred, evidence-based counselling method aiming to strengthen a person's motivation and commitment to behaviour changes (Enlund et al. 2021). MI is a technique that requires the VN/Ts to discuss and ask questions to the owner to discover their 'motivation'/understanding/reasoning behind a certain task. Why do they believe their pet is not overweight, for example? Or what is their reasoning for feeding a certain diet? By fully understanding the owner and their understanding of the situation, you can help succeed in building a plan together for the mutual benefit of them, their pet and the practice (Miller and Brown 1994). There is an overlap with Narrative Medicine, in that you want to be able to understand the owner's motivation (Miller and Moyers 2017). Another term that is also used is Brief Interventions. Mainly used in human medicine, this term relates to a technique used to initiate change for unhealthy or risky behaviours such as smoking, the lack of exercise, obesity or an inadequate diet (Miller and Rollnick 2017).

Six key aspects of brief interventions have been identified - they are denoted by the acronym FRAMES. FRAMES can be utilised in the veterinary profession and can help in the understanding of behaviours of owners as caregivers to their pets.

1. Feedback on personal risk or impairment
2. Responsibility for change
3. Advice to change
4. Menu of alternative change options
5. Empathy on behalf of the practitioner
6. Self-efficacy or optimism in clients facilitated by practitioners.

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