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Fall 2021, Personal/Professional Development

By Appointment Only

Veterinary nurse–led appointments have many positive effects, including full skill utilization, a stronger VCPR, and improved patient outcomes.

Nicola LakemanPGDip, RVN, CertVNECC, CertSAN, VTS (Nutrition)

Nicola works as the Head Medical Nurse at Plymouth Veterinary Group. She has written for many veterinary publications and textbooks and is the editor of Aspinall’s Complete Textbook of Veterinary Nursing. Nicola has won the British Veterinary Nursing Association/Blue Cross award for animal welfare, the Suitably Qualified Person (SQP) Veterinary Nurse of the Year award, and the SQP Nutritional Advisor of the Year award. She is currently studying for a master’s degree in advanced veterinary nursing with Glasgow University. 

By Appointment Only
Jarom Vogel
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Veterinary nurses play a critical role in a well-run practice, and veterinary nurse–led appointments are necessary to fully utilize their skills. These appointments help build the trust between the client and the entire veterinary healthcare team, empower veterinary nurses to more fully display the skills they have acquired, and allow veterinarians to save time and money for the clinic.1

Veterinary nurse/technician clinics are successfully utilized in many veterinary practices, whereas in some practices, no veterinary nurse clinics are run at all. Surveys have been conducted looking at why this might be. Reasons given have included staff numbers, lack of consulting rooms, practice owners not allowing the veterinary nurses to run clinics, veterinarians being unsure on what they can delegate, and the general interest within the veterinary nursing staff.2 BOX 1 lists ways that veterinary nurses can initiate the conversation to increase the use of veterinary nurse–led appointments in their clinic. 

As with all clinical duties, veterinary nurses need to establish their ability to successfully lead appointments. Registered Veterinary Nurses (RVNs) in the United Kingdom have a list of day-1 competencies that they are able to undertake competently on initially qualifying. Veterinary nurse clinics are part of this list, as is diagnostic testing such as venipuncture and blood pressure measurement. 

Each U.S. state will have legislation regarding what tasks can be delegated to veterinary nurses/technicians, so it is important to check your local laws and guidelines. This article lists some general skills that could be useful for veterinary nurse–led appointments. 

BOX 1 Advocating for Increased Veterinary Nurse Appointments

  1. Be reasonable. Consider the desired outcome of your ask. Is it in direct proportion to your relationship with the supplier of the “yes?” Build relationships before you ask for anything.
  2. Keep it simple. Research indicates 1 reason gets the best results. Avoid the need to pile on the reasons for someone to do what you want.
  3. Draft your request before making it.
  4. Be kind, honest, and professional.
  5. Be specific and brief.
  6. Provide an easy out. Make it easy for someone to say “no” without damaging your relationship. You might need a different approach.
  7. Show your gratitude.
  8. Be willing to give in return.
  9. Make it WIIFM compliant. WIIFM stands for: what’s in it for me? It’s the question that subconsciously goes through the mind of each provider of a “yes.” If your request is WIIFM compliant, your “yes” broker will quickly see that your request imparts something for them as well.
  10. Ask clearly and follow up politely if you don’t hear back.

Diagnostic Testing and Monitoring

The veterinary nurse’s role is ideal for aiding the veterinarian in the collection of samples for diagnostics. The veterinary nurse should be utilized in the procedure of blood sampling, blood pressure monitoring, Schirmer tear testing, skin sampling, and urinalysis—all of which are an integral part of veterinary nurse–led visits. Veterinary nurses are not permitted to make a diagnosis but are adequately trained in the preparation of the animal and the collection of samples for the veterinarian in order for them to make a diagnosis. The veterinarian needs to make the decision for the blood sample to be taken but can then delegate the task to the RVN. Owners may need guidance on methods on how to obtain urine samples, pre-starving for blood sampling, and protocols for sampling, all elements that can be covered by the RVN. 

It makes financial sense for RVNs to be undertaking roles that they are trained to do, rather than the veterinarian undertaking these roles. Good, clear instructions from and for the veterinarian in the clinical history are required. RVNs need to record the timing of the sampling, where the samples were taken (e.g., jugular sampling), whether the animal was pre-starved, when any medications were taken, and whether the sampling procedure was stress-free, with any problems being noted. 

Veterinary nurses play a particularly helpful role when repeat monitoring of parameters is required before repeat prescriptions for long-term medications can be given. This could be repeat electrolytes for Addison’s cases or fructosamine levels for animals with diabetes. Owners should make an appointment with the veterinary nurse (preferably before their repeat prescription runs out). Then, the veterinary nurse can take a full clinical history and perform any diagnostics that the veterinarian has requested (e.g., bloods, blood pressure, urine sampling, nutritional assessment).

The appropriate laboratory tests are then performed and the owner comes back a couple days later (or within a suitable timeframe) to see the veterinarian for a clinical exam and discussion of the results. The veterinarian can then write a repeat prescription for the medication and state in the history when the animal is to be seen next and what diagnostics (if any) should be performed. This works exceptionally well for practices, as it removes the issue of what happens when the owner runs out of medication and the repeat prescription has also expired. The veterinary nurse appointment, all pre-booked, helps to remove these issues. 

Dermatological Sampling

RVNs are also exceptionally well placed to undertake hair and skin samples to aid in the diagnosis of dermatological issues. Veterinary nurses can take scrapes, plucks, cytology swabs, and brushings to help identify parasites, bacteria, yeasts, and cells. Guidance can be given to the pet owner on parasiticides, ear cleaning, administration of medications, and nutritional advice (diet trials for dietary sensitivities). Utilization of in-house laboratory analysis of ear swabs can aid the veterinarian in the more appropriate use (or not) of antimicrobials in these cases and are a good way of beginning to develop your dermatology skills. Ackerman showed that by including the analysis of ear swabs in a healthcare plan, the use of antimicrobials can be decreased while still increasing revenue.3

Nutrition

The role of nutrition is very important in aiding in the longevity and quality of life of all animals. By understanding the ideal nutrient requirements for each animal with each specific condition, guidance can be offered when owners wish to prepare homemade diets or when feeding a commercial or veterinary diet. It is more common for animals to have a combination of different conditions and in these situations a compromise might need to be made in the choice of diet to benefit the animal the most.

Supporting the owner during the transition period of diet change is important, as the majority of affected animals are older and can be more fastidious, some of which can have very precise food preferences. A list of foods, which should not (or could) be added to any commercial clinical diet, can prove to be useful for the owner. Guidance on treats and human foods should be made. Don’t forget that obesity is a chronic medical condition; therefore, many veterinary nurses that feel that they wouldn’t have the confidence to run appointments are already doing it in this regard alone. All animals need to have a nutritional assessment (i.e., weight, body condition score, muscle condition score) performed and recorded on the clinical history at every point of contact.

Client Compliance

Compliance is achieved when the owner fully understands the requirements of what is required and can undertake these requirements. Compliance has 3 beneficiaries: the pet (increasing its health and welfare), the owner (being able to have a happier healthier pet), and the practice (increasing client service, profits, and staff motivation). 

Compliance can break down and lead to less healthy pets and fewer bonded clients. This can occur through a number of different reasons: many clients don’t understand the nature of the disease, the requirement for continued long-term treatment, or the instructions from the veterinary healthcare team. In some cases, the owner can be too embarrassed to ask the veterinarian for further clarification. These cases tend to present as the owner stating that they felt that the pet seemed better, that they were unsure of what the term “chronic” meant, and that they felt or understood that just one course of the treatment was required. Few clients state that cost is an influence in why there has been a breakdown in compliance. Apathy can be a large cause of compliance breakdown, but with good support and client education on the importance of why medications should be given or why weight loss should occur can help to reduce apathy in pet owners. Veterinary nurse clinics are an ideal opportunity to discuss these matters with the pet owner, to encourage and motivate the client, and to help problem solve where needed; all of these will in turn increase compliance and help improve patient outcomes. 

If medications are prescribed for patients, it is important that the veterinary nurse discusses with the client in the clinic whether they are able to medicate their pet. Owners may need guidance on the administration of medications and the importance of compliance. Veterinary nurses cannot change prescriptions, but if the owner is having difficulty administering tablets and would prefer a liquid formulation of the medicine, the RVNs can act as a conduit to discuss with the veterinarian responsible for the case and have them prescribe an alternative.

Conclusion

Veterinary clinics are an easy way to help your clients in improving the clinical outcomes of medical cases. There are many benefits to these clinics, as discussed, but increasing the welfare and quality of life for these patients must be the most important. Don’t underestimate the worth of the RVN, and ensure that you are charging for your time. In many cases the RVN is doing exactly the same thing that the veterinarian would have done. The client would have paid the veterinarian’s consultation fee, so why not the veterinary nurse? Many RVNs state that when they are starting out with clinics, they don’t want to charge the full amount until they are more confident. But we don’t do this for newly qualified veterinary surgeons—so why do this for veterinary nurses? Increasing opportunities for veterinary nurses to gain experience and increase confidence and comfort in seeing clients will help practices run more smoothly and veterinary nurses to feel more empowered. Confidence is not something that can be learned like a set of rules; confidence is a state of mind. Positive thinking, practice, training, increasing underpinning knowledge, and talking to other people are all useful ways to help improve or boost your confidence levels. 

References

  1. Fanning J, Shepherd AJ. Contribution of veterinary technicians to veterinary business revenue, 2007. JAVMA. 2010;236(8):846. 
  2. Girotti R. Maximising revenue from nurse clinics. Veterinary Nursing Journal. 2013;28(1):20-22.
  3. Ackerman N. Improving utilisation of RVNs in dermatology cases. The Veterinary Nurse. 2020;11(2):70-74.

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