A majority of dogs and cats display fearful behaviors while visiting the veterinary clinic. Members of the veterinary healthcare team can prevent further harm for these patients and improve the experience of patients that do not show fearful behaviors by practicing lower-stress handling techniques. The purpose of this article is to review the importance of lowering stress during the visit, review general handling techniques, and provide a step-by-step guide for specific techniques for dogs and cats. Take-Home Points
Handling patients in a way that prevents fear, anxiety, and stress (FAS), as well as pain, has become an essential part of veterinary visits. Our goal is to keep the happy animal happy to see us and the animal that is hesitant to walk through the door less hesitant. One of our goals as veterinary professionals is to “do no harm,” which includes causing no physical and/or mental harm. Positive humane and compassionate handling enables us to provide a better patient experience, reaffirm our professional values, and enjoy our workday.
Not every dog or cat that comes into the clinic shows signs of FAS. However, a majority do, although we may not always recognize it. Researchers have determined that 55% to 80% of dogs and cats display fearful behaviors in the veterinary clinic.1-3 In addition to using lower-stress techniques for fearful or anxious patients, we should strive to use them for every patient as these techniques not only reduce FAS but also prevent the patient from becoming fearful during that visit and subsequent visits. Appropriate handling techniques can minimize FAS, which is something we owe to our clients, patients, and the profession.
Because few patients make it through a veterinary visit without showing signs of FAS, instead of calling them “fractious,” “aggressive,” “land sharks,” or (the author’s favorite) “spicy,” let us call them what they really are: fearful. We need to recognize that what we do induces fear; therefore, a main goal of veterinary nurses should be identifying signs of FAS and addressing it to the best of our abilities. We can change how pets in our care view the visit by using positive, lower-stress handling techniques. This article covers practical tips to achieve these goals and help you finesse your handling skills.
General Handling Techniques
Two key tools for lower-stress handling are offering treats and letting the patient become acclimated to the examination room.
Treats
One of the best steps we can take is offering high-value food; however, always first consider whether food/treats are medically appropriate. Because food is inherently positive, if the patient will eat, it can develop positive associations with the veterinary clinic (FIGURE 1). Offering treats also gives us a good gauge of how the patient is feeling. If the patient stops eating during the examination or starts taking treats harder or faster, what we did was too intense. Be sure to have a selection of treats available. The patient determines what should be considered “high value.”
Figure 1. Dog looking at a treat being offered. Note the wagging (blurry) tail.
Although some dogs are very happy with hard biscuits, most will need something of higher value (e.g., hot dogs) to become comfortable in the exam room; for spreadable treat options, use peanut butter, baby food, or squeeze cheese. For cats, try canned cat food, crunchy cat treats, squeeze cheese, or—the author’s personal favorite—Churu (churuvet.com). Have several treat varieties on hand to find one the cat likes. If the patient is being fed a limited-ingredient diet, you can use that food. Asking the client to withhold the pet’s breakfast for a morning appointment or to feed only a small portion of the morning meal will ensure that the patient is hungry (but not starving) and will look forward to the treats during the visit. If the patient’s medical condition does not include anorexia but the patient is not eating the treats, either the food is not valuable enough or the patient is too fearful. Stop and reassess. Slow down and offer something of higher value.
Acclimation
Another step to reducing FAS is letting the dog or cat become comfortable with the exam room. As you talk with the client, allow the patient to explore, approach, and investigate. If there is only 1 patient in the room, tossing treats near and away can entice the patient to explore the room and get treats without having to approach a stranger. Many cats will come out of their carriers to investigate the room if you open the carrier door before taking the cat’s history. To initiate contact, if the patient approaches you, offer your hand or a pen (cats) to see if the patient will engage. Have a treat handy. If the patient eats the treat, great! If the cat rubs its face on the pen, great! You have now broken the ice and can move forward.
Dog Handling Techniques
While handling dogs, we want them to be active participants in their own care and positioning. This holds true for the happy Labrador retriever, the military working dog, and sometimes even the brand-new 8-week-old puppy. First ask the client what their signal/cue is to ask for specific behaviors (e.g., sit, lie down, roll over) and then try asking the dog in a calm, nonthreatening tone to respond. Reward positive responses by offering a treat. Lack of response to known cues might result from FAS; avoid repeating those cues over and over as doing so might increase the dog’s anxiety. Practicing cues to which the dog does respond can help the dog know what to expect and to feel more comfortable.
If the dog stops responding to the cue, pause and adjust your plan. It is always OK to stop, make a different plan, or execute that plan on a different day if needed. The veterinarian can send home anxiolytics or decide if sedation is the best option for that patient and procedure. Recommending specific types of medication or sedation is beyond the scope of this article and the role of veterinary nurses. There are many veterinary resources for reducing FAS, including Fear Free resources (fearfreepets.com).4
For dogs that do not come to you after a short period, slowly approach them from the side. Kneeling on one knee, parallel to the dog, allows you to jump away easily if needed. Give the dog a choice by first asking it to move into the desired position, using the cues such as “sit,” “down,” or “roll over.” Remember to keep offering food. Before touching the dog with a stethoscope, first offer it in your hand so the dog can sniff and approach it. If the dog allows you to make contact, keep your touch consistent and keep your hand on the dog at all times to avoid a startle response. If you need to use your other hand, put it over the one that is making contact, slide it to the desired location and then remove the initial hand. If something is out of reach, have a veterinary assistant or the client hand it to you.
All patients should be allowed to stand, sit, or lie on a soft nonslick surface for a procedure. If the patient’s signs of FAS increase; if the patient stops taking treats; or if you have to readjust more than 3 times, stop and reassess the patient’s level of distress and revise your plan. BOXES 1 AND 2 describe restraint techniques for cephalic and jugular vein blood collection, respectively.
- Gently yet securely guide the dog in a sitting position.
- Hold the leash in one hand (do not wrap it around your hand).
- Wrap the same arm around the dog’s neck to prevent it from moving forward or reaching around.
- Use your other hand to hold off a vein for blood collection or IV catheter placement.
- Support the dog in a comfortable and efficient way.
- Ask the dog to sit, facing away from you, with its tail end near your feet. You can then use your legs near the dog’s hind end to help it feel supported from behind.
- Using both hands, gently cup the side of the dog’s head/muzzle with thumbs toward the ceiling and index fingers under the chin. You can then grasp the collar with your other fingers below, and gently lift the head.
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Recumbent Restraint
First, ask yourself if the procedure required can be completed with the dog standing rather than recumbent; if so, proceed with the dog standing. Most recumbent procedures can be performed with the patient in a relaxed or “sloppy” down position, without having to be in full lateral recumbency. If full recumbency is needed, 2 people should help with restraint. Steps are outlined in BOX 3.
- Instruct the dog to lie down and reward compliance with a treat.
- A food treat can be used to try to lure the dog to turn its head back toward the shoulder you want facing the ceiling. This should help the dog lean over and put its weight on one hip.
- One person, standing near the head, should support the head and gently hold the front legs together, with a finger between the legs for comfort.
- If needed, a second person at the back of the patient can help encourage the dog to lie on one hip by gently rotating the “up” knee while sliding the “down” foot under the dog. This will rotate the hips in a comfortable and secure way.
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Towel Restraint for Small or Brachycephalic Dogs
It may be challenging to find a muzzle small enough for a 5-pound dog or one that will safely and comfortably fit a bulldog when you need it. Towels are in every clinic, so take advantage of them. Towel restraint allows brachycephalic dogs to breathe freely while secure control of the head is maintained for procedures. It also prevents panic secondary to airway restriction often associated with more intense restraint or a poorly fitted muzzle. Steps are outlined in BOX 4.
- Roll a towel into a long tube and gently wrap it around the dog’s neck, starting under the chin, while standing behind the dog.
- Hold the ends of the towel behind the dog’s head, so fingers are not within its reach.
Muzzle Restraint
Muzzles can and should be used with dogs at risk for reacting with aggression. Basket muzzles will allow dogs to pant, take treats, and drink, and also allow vomitus to clear more safely than sleeve muzzles. Clients can teach their dogs to voluntarily wear basket muzzles, which allows for a more positive and humane experience for everyone: dog, client, and veterinary team. See muzzleupproject.com for instructions, videos, troubleshooting, and myth-busting commentaries.
Cat Handling Techniques
Compared with dogs, cats are generally less likely to be trained to respond to cues and less accustomed to handling and/or travel to unfamiliar places. Most cats prefer to hide in their carriers or other small, confined places, like the sink. You can fully examine a cat while it is in its carrier or chosen hiding place. Offer food and—as with dogs—if the cat will not take treats after being offered several varieties, pause and reassess with your team. You might decide to try a different restraint technique, administer sedation, or send the client home with anxiolytics to give the patient before returning on a different day. Your team’s ultimate choice is going to depend on the situation and the goals of the appointment.
As with dogs, give cats a comfortable and nonslick surface to stand or sit on. Towels can be your friend with cats! A soft, warm, fluffy towel gives cats something to grip to, helps them feel secure and snug, enables them to hide their heads, and allows staff to maintain better control of the patient without increasing restraint.
Towel wraps enable you to accomplish more while avoiding scruffing and stretching the cat. Pairing the presence of the towel with a treat can create a positive association. To learn proficiency, first practice with a stuffed animal before moving on to real cats. A towel wrap covering the head enables auscultation, palpation, and sample collection from all parts of the cat except head and forelimbs (BOX 5).
- Grip the towel and fold it around your hands as you would when placing a surgical drape over a patient.
- Gently place the towel over the cat (head facing away from you, tail end nearest to you) with several inches left over past the nose. This will be used to help cover the head.
- Use your forearms over the towel to gently secure the cat on each side, and use your body from behind while the cat is under the towel.
- Curl the towel in front of the cat’s face, then over the cat’s head and front feet using your fingers. This creates that hiding spot and helps the cat’s front feet feel secure by gripping the towel.
- After the head is covered, you can use the towel and your forearms, with the help of an assistant, to gently lift the cat so the towel can be adjusted to one side.
- Have your assistant pull both ends of the towel to one side so that it is completely under the cat when you gently lower it back on the table.
- Keep your arm pressed to the table on the open side of the towel so the cat is swaddled between the towel and your arm, then reach over with your other hand to wrap both loose edges over the cat again. Hold the ends tight before removing your towel-covered arm.
If you need access to the cat’s face or if your patient prefers to see what is going on, the scarf wrap is recommended (BOX 6).5 When lifting the cat’s head for jugular vein access, do not stretch the front legs over the side of the table. This is extremely uncomfortable to the cat and activates its reflex to pull back when you pull its leg, increasing the risk of clawing. Instead, allow the cat to rest in sternal recumbency with the front paws resting near the edge of the table and lift the chin as described above.
- Allow the cat to lie on a clean, warm, soft towel with the long sides on either side of the cat. Allow its head to remain several inches from the long edge.
- Use those inches to cover the cat’s front feet before picking up the far corner end of one side of the towel to cover its back. As you do this, wrap the excess towel gently around its neck (towel between feet and chin) snug like a scarf.
- Securely hold the corner of the towel at the back of the cat’s head.
- Tuck excess towel around and under the cat’s body to help secure the cat gently and snugly on each side (FIGURE A).
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- Repeat steps 2 through 4 with the other towel end (FIGURE B). You can hold both ends of the towel in one hand at the back of the cat’s neck, thereby “scruffing” the towel and not the cat.
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Watch the steps for a feline scarf wrap below
Variation for front leg (e.g., cephalic vein) access (much more comfortable for the cat than pulling the leg out by the foot) (FIGURE C)
- Instead of wrapping the second part of the towel around the entire cat, pull the towel under the elbow of the outside leg and then continue to wrap the towel around the cat’s body and neck.
- Gently push the elbow forward so the leg is extended; an assistant can stabilize it for access (e.g., IV catheter placement, blood collection).
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Watch the steps for a feline scarf wrap with leg access below
Variation for head (e.g., jugular vein) access
- Gently place your thumb and middle or index finger on either side of the mandible with your palm over the back of the skull, and gently tilt the chin up to expose the neck.
- Use your other hand to hold the ends of the towel you used to create a scarf wrap.
A cat can be smoothly picked up from the table or crate with a towel. A towel wrap is a bonus if your patient prefers to hide its head when worried. Ensure that the towel is clean; large enough to cover the cat twice (i.e., bath towel); and free of any significant holes, stains, or threadbare areas. When the cat is completely wrapped in the towel with its head covered, you will be able to examine it by slipping your hand and arm under the towel from the tail end. By gently adjusting the cat into lateral recumbency while still wrapped, you can complete a medial saphenous blood draw, cystocentesis, or intramuscular injection safely, securely, and with lower stress. The towel and scarf wraps described here are modifications on the work of Dr. Sophia Yin.5
References
- Döring D, Roscher A, Scheipl F, et al. Fear-related behaviour of dogs in veterinary practice. Vet J. 2009;182(1):38-43 doi: 10.1016/j.tvjl.2008.05.006
- Glardon OJ, Hartnack S, Horisberger L. Analysis of dogs and cats behavior during the physical examination in veterinary practice. Schweiz Arch Tierheilkd. 2010;152(2):69-75. doi: 10.1024/0036-7281.a000016
- Stanford TL. Behavior of dogs entering a veterinary clinic. Appl Anim Ethol. 1981;7(3):271-279. doi:10.1016/0304-3762(81)90083-3
- Becker M, Radosta L, Sung W, Becker M. From Fearful to Fear Free: A Positive Program to Free Your Dog from Anxiety, Fears, and Phobias. Deerfield Beach, FL: Health Communications, Inc.; 2018.
- Yin S. Low Stress Handling, Restraint and Behavior Modification of Dogs and Cats: Techniques for Developing Patients Who Love Their Visits. Davis, CA: CattleDog Publishing; 2009.