BA, LVT, VTS (Behavior)
Monique is a Veterinary Technician Specialist in behavior, working full time in small animal practice near Seattle, Washington. Monique strives to provide pragmatic solutions based on her extensive practical experience to groups of every size, from individual clients and clinics to the largest of veterinary conferences. When strangers ask what she does, Monique answers, “I teach veterinary professionals how to fulfill their love of animals by empowering them to be kind to patients.” In addition to writing for online courses, magazines, and journals, Monique released her first book, Cooperative Veterinary Care, in April 2018.Read Articles Written by Monique Feyrecilde
Experiencing unpleasant stimuli associated with veterinary visits can classically condition patients to have a stress response.1 The physiologic effects of fear, anxiety, and stress (FAS) can, in turn, compromise physical welfare, examination findings, and test results (BOX 1)
- Increased respiratory rate
- Increased heart rate
- Increased blood pressure
- Increased cortisol levels
- Blood glucose, stress leukograms
- Delayed wound healing
- Stress colitis
- Stress-induced feline idiopathic cystitis
Protecting the emotional welfare of pets and people while providing excellent medical care to help restore physical health, prevent animal disease, and prevent suffering is the foundation of Fear Free veterinary care (BOX 2). As part of this goal, Happy Visits and Victory Visits can be great aids in empowering pets and medical teams to work together in an emotionally safe and even enjoyable place for patients and clients.2
Inviting Pets to Enjoy the Veterinary Experience
Setting the stage for successful visits—whether medical, Happy, or Victory—begins with some basic measures throughout the practice.
Preparing the Environment
Every patient area should be prepared with the goal of increasing comfort and decreasing FAS (BOX 3). Some suggestions include:
- Provide nonslip surfaces for patients on the scale, along walking paths, and in all examination and treatment areas.
- Keep wonderful treats on hand near the entrance and the scale and in every examination and treatment area.
- Have tools to dispense food, mats, and regular pet dishes in all examination rooms and treatment areas.
- Use pheromones throughout the hospital to help improve feelings of patient wellbeing.
- Play music demonstrated to calm pets, to contribute to a relaxing “spaw” atmosphere.
- Yoga mats
- Rubber backed mats and rugs
- Anti-fatigue mats
- Pet Vet mats
- Table covers
- Towels and blankets
- Area treatments
- Acoustic therapy
- Dimmable lights
- Nut butters
- Cheeses (e.g., squeeze cheese, cream cheese)
- Canned pet diets
- Hot dogs
- Baby food
- Pureed specialty foods
- Commercially made treats (moist, semi-moist, crunchy, flakes)
- Pretzel rods
- Cooking spoons
- Paper plates and bowls
- Pet bowls
- Textured silicone mats
- Water bowl
- Food dispensing toys
- Other toys (ball, tug)
- Basket muzzles
Preparing the Team
Every team member who interacts with patients should have the skills to evaluate body language for signs of FAS and know how to modulate their interaction to stay within the comfort level of the individual patient. Team members must also be able to coach pet owners in cooperative patient movement methods, such as keeping leashes loose and offering food lures or treat trails to encourage patients onto scales and into examination rooms. Team members should also be able to help clients understand the signs of FAS and how to respond if a patient’s FAS level is increasing.
Assessing the Patient
Every patient interaction should be conducted in a way that is mindful of both physical and emotional welfare. A patient’s emotional welfare can be judged, at least in part, by assessment of body language and interactions to determine its FAS score (TABLE 1). Patients with low levels of FAS interact readily with team members, show few signs of stress, and accept preferred items, such as treats, toys, and tactile interactions. As FAS increases, the frequency and intensity of stress signals increase (BOX 4).
To avoid compromising emotional welfare, the goal should always be to maintain a low FAS score. Signs of increasing FAS mean that team members need to slow down and work at the patient’s pace. If a patient begins to show increased stress during a visit, team members should immediately pause and return to the last area or interaction at which FAS was low or absent. Once the pet is calm, make a new plan for careful reintroduction of the next step before trying again.
- Lip licking
- Pupillary dilation
- Looking away from team members
- Attention seeking
Moderate FAS (Score 2-3)
Signs of low FAS, plus:
- Taking treats roughly when previously gentle
- Moving away from team members
- Showing the whites of the eye (if not normal for breed)
- Dilated pupils
- Rapid panting
High FAS (Score 4-5)
Signs of low and moderate FAS, plus:
- Efforts to escape and avoid
- Defensive displays (e.g., growling, snarling, barking, lunging, snapping, biting)
Over repeated visits, patients that previously displayed low levels of FAS may show increases in FAS. Preventive steps, such as Happy Visits, are appropriate for patients with low FAS as a maintenance strategy for a good comfort level. Patients displaying moderate or high FAS require intervention, such as Victory Visits, for FAS reduction. Taking steps to prevent escalation and reduce FAS leads to a decrease in defensive aggression by patients, improving not only patient welfare but also safety for the veterinary team.
Nonmedical Happy Visits (also called Fun Visits) are designed to strengthen a patient’s positive experience. Happy Visits can be used to maintain a positive emotional connection with the veterinary clinic or to attempt to reverse very mild fear of the veterinary setting. Patients with FAS scores of 0 to 2 are often appropriate candidates for Happy Visits (FIGURE 1).
Preparing the client is key to a successful Happy Visit. Clients should be encouraged to schedule Happy Visits when their pet is hungry (to make treats given at the clinic even more desirable) as well as to bring a generous supply of the pet’s favorite treats, a favorite toy, and a preferred bed or mat, if appropriate. Clients should expect to guide themselves through the visit to some extent and be willing to spend a few minutes building a positive emotional connection with coming to the clinic—for themselves, as well as their pets!
A Happy Visit might look something like this:
- Client arrives with pet and gives the pet treats
while in the parking lot and while walking
through the front door.
- Client walks pet through the lobby and an examination room, pausing several times for “treat parties.”
- Pet is allowed to investigate and become familiar with the scale and is given treats for weigh-in.
- Pet receives treats from team members if
Happy Visits are generally free of charge for the client, but they bond the client to the practice. Increased face time with the team, increased time spent in the veterinary clinic, and normalizing frequent contact with the veterinary hospital are all side benefits of Happy Visits that can boost revenue over time.
Because Happy Visits can involve spending time in the lobby or examination rooms, scheduling them can help prevent “traffic jams.”
Happy Visits are not appropriate for every patient. Patients that require pre-visit prescriptions to visit the hospital, experience travel distress, are reluctant to enter the veterinary clinic, or display signs of moderate to high FAS should be scheduled for Victory Visits or other behavioral intervention rather than Happy Visits.
Victory Visits are a tool to assist patients that are experiencing higher FAS, especially pets stressed by specific activities (e.g., physical examination, vaccination, blood collection). Victory Visits are generally appropriate for patients with FAS 2 and greater. Victory Visits are also useful for clients who are highly motivated to minimize the use of manual restraint and wish to teach their pets to be active participants in their own husbandry and medical care. During Victory Visits, the veterinary team (or a qualified trainer, if no one on the veterinary team has the necessary skills) uses techniques such as desensitization, classic counterconditioning, and operant conditioning or counterconditioning to teach the patient how to participate in veterinary care. Victory Visits may also include medical intervention for FAS and advanced training techniques (e.g., restraint-free Cooperative Veterinary Care3).
Victory Visits are a step beyond Happy Visits. Happy Visits help pets learn to anticipate fun and treats in the veterinary hospital, while Victory Visits, which are held at a scheduled appointment time, prepare pets for specific procedures.
An early Victory Visit might include:
- Patient comes into an examination room.
- Patient moves onto a mat or the examination table.
- Patient’s most trusted veterinary team member performs a mock physical examination or short examination segments (FIGURE 2).
- Patient practices targeting or gains familiarity with equipment such as stethoscope, otoscope, syringes, and swabs.
As the patient and team become more proficient, Victory Visits might include:
- Patient moves into the examination room and the examination area.
- Patient’s most trusted veterinary team member performs a physical examination (FIGURE 3).
- A novel team member(s) performs a mock examination or small examination segments (“transfer of skills”).
- Patient’s most trusted veterinary team member uses equipment (e.g., stethoscope, otoscope, syringes) to touch the patient and gradually to simulate their actual use.
- Patient learns specific trained behaviors to facilitate restraint-free care (e.g., physical examination, venipuncture) (FIGURE 4).
When Happy Visits and Victory Visits Are Not Enough
Some patients have a high level of FAS (score of 4 or 5) and need more help than Happy Visits and Victory Visits alone can provide. Because treating FAS is crucial to restore physical welfare as well as emotional welfare, a total healthcare plan must be made for intervention for these patients. Often, patients that show high FAS for handling have comorbid behavioral diagnoses and benefit from behavior consultation.
For immediate medical needs, high FAS patients should be sedated not only to facilitate care but also to avoid creating long-term emotional scars that are sometimes unrecoverable. Over the long term, these patients need a combination of pharmaceutical intervention to treat FAS; a more advanced behavior modification and training plan that includes desensitization and classic and operant counterconditioning; and specific skill training to expedite future visits. While veterinarians will be responsible for choosing appropriate short-acting anxiolytic supplements and medications, it is worth noting that the use of acepromazine as a single agent for fearful and especially defensively aggressive patients is contraindicated.
Making the Investment
Victory Visits and Happy Visits are an investment in long-term patient comfort and medical care, and the whole team needs to be committed to the process for them to be successful. From the beginning, client communication needs to be constructive to set clients and teams up for success. For example, avoid labeling the pet as mean, uncooperative, bad, difficult, or fractious. Objective descriptions of experiences and the goals of treatment are more appropriate talking points.
An opening conversation might sound like:
“Mrs. Smith, I can see that Fluffy is moving away from me. When she sees my syringe, she looks away and her body language changes completely. Clearly Fluffy is really clever and has connected the idea that this syringe means something she doesn’t enjoy happens next. I think we should pause this visit for now, and sign you up for some Victory Visits. During those visits, I will teach Fluffy that injections are nothing to fear, and how to happily accept them. We can then vaccinate her without causing unnecessary stress.”
Victory Visits require a time investment and special skills on the part of the veterinary team. However, they are also an investment in the practice. It is appropriate to charge for Victory Visits, and clients will pay for them if they understand the value.
In one survey, up to 38% of clients said they feel considerable stress just thinking about bringing a pet to the veterinarian.4 More than half perceived that their pets experience significant stress within the veterinary environment. Committing to protecting the emotional and physical health of patients requires the team to devise medical as well as behavior modification strategies to decrease FAS. Happy Visits are easy for any team to start at any time, while Victory Visits require a bit more knowledge and experience to implement. For patients with FAS scores of 4 and 5, medical management is an easy first step, and providing more advanced training visits, either with the clinic’s own team or on a referral basis, is indicated. Try these techniques and watch patients relax and begin to participate more willingly in their own care.
- Fear Free Certification Courses. 2016-present. http://www.fearfreepets.com.
- Shaw J, Martin D. Canine and Feline Behavior for Veterinary Technicians and Nurses. Wiley Blackwell; 2014.
- Howell A, Feyrecilde M. Cooperative Veterinary Care. Wiley Blackwell; 2018.
- Volk JO, Thomas JG, Colleran EJ, et al. Executive summary of phase 3 of the Bayer veterinary care usage study. JAVMA 2014;244(7):799-802.