The effects of PPE and implemented guidelines on the behaviour of canine and feline patients visiting veterinary practices during the COVID-19 pandemic

Veterinary professionals continue their brave effort to provide health care to patients in need during the COVID-19 pandemic despite the risks involved to themselves and their families. Unavoidable measures are continually being implemented by the government, the RCVS (along with professional associations) and by practice management teams to keep both staff and clients safe. The effects of such measures on patients and their behaviour when visiting practices has unlikely to have been considered, this is unfortunately due to the urgent time frame in which the profession has had to adapt. Visiting the veterinary setting for some patients is unfortunately already a negative experience, one which veterinary professionals already recognise and try to minimise. Part one of this blog will review how patient behaviour is affected with the newly added personal protective equipment (PPE) and implemented measures, part two will then look into how the patients experience can be made a more positive one.

Implemented changes and the effects they have on patients

The specific changes that are likely to have an effect on patient behaviour when visiting the veterinary setting include: social distancing, the increased use of PPE, the increased use of hand sanitisers and high strength disinfectants and the use of practice equipment rather than the patient's own familiar items.

Social distancing was implemented by the government at the start of the pandemic and is undertaken in the veterinary setting where possible, when dealing with clients it usually occurs in two situations. The first being when canine patients are examined at a distance with their owners present in an open outdoor space. Human behaviour displayed by both veterinary staff and clients are potentially altered during this type of consultation, ‘normal’ behavioural habits may not be displayed as a result of being cautious around others and the fear of catching the disease, sustained fields of vision and imposing postures are also potentially adopted when concentrating on assessing the patient. Dogs are likely to misunderstand this altered human behaviour (Miklosi, 2015). Owners will additionally be stressed with being at the vets during this difficult time, dogs are extremely receptive to their owners emotions and often mirror them (Rozenbaum, 2020). The second situation occurs when examining feline and canine patients without the owner present in a consultation room. ‘Normal’ human behaviour is likely to be altered again in the same way, with similar emotional responses, without owner presence and reassurance these could be heightened. Cats are often allowed to free roam in consultation rooms to help them feel more comfortable and relaxed within their environment (Atkinson, 2018), due to risks associated with spread of disease they are now unable to do so. Lack of owner presence in consultation may also lead to missed information regarding the patient, clients are often prompted by the evolving process of examinations and often inform staff of useful information and potential fears or phobias a patient may have. Patients could therefore be put into situations that would normally be avoided and therefore react accordingly.

Face masks have been advised by the government for use by the public in crowded places, although they have not yet been advised for use within the workplace most veterinary practices are using them as an extra step in PPE to protect their staff (See figure 1). Dogs have evolved alongside humans and benefit from being able to read facial expressions (Racca et al., 2012), evidence is lacking on whether cats are able to do the same as they did not evolve to live in such complex social groups (Fridlund, 2014), however this is something that should not be disregarded until further evidence is found. Studies have found that dogs will differentiate between human emotional facial expressions which in turn could play a major role in social interactions (Racca et al., 2012). This is therefore a major factor to consider when veterinary staff are covering their faces with masks. Sung (2020), raises an important consideration with pets lacking ability to read facial expressions due to the use of masks - pets may place more emphasis on human eye contact, something that is usually deemed threatening to them (Overall, 2013). Both dogs and cats could also react to face masks and other PPE items that have been put in place (face shields, aprons and gloves) due to them being novel stimuli, King et al., (2003) states that novel stimuli can induce fear in dogs which was later proved in their study, with dogs displaying heart rate changes and a slow/cautious approach to the stimuli. Cats are likely to behave in a similar way. In addition, animals that are already fearful of visiting the veterinary setting are more sensitive to their environment which veterinary staff unfortunately often witness. Noise sensitivity is something that is strongly linked to this and should be considered when wearing aprons and gloves, especially if putting them on or changing them in the presence of the patient due to the noise they create.

Figure 1 - Examples of face covering PPE being used in veterinary practices.

The use of hand sanitiser and high strength disinfectants within all areas of veterinary practice have been dramatically increased to help prevent the spread of disease. Visiting the vets for some patients can be scary with the strange smells associated with the setting (Overall, 2013). Dogs and cats have a much greater number of olfactory receptors than humans, with dogs having 220 million and cats having 150-200 million, compared to the 5 million which humans possess (Howell and Feyrecilde, 2018). They are therefore more sensitive to this change. It is well known that humans trigger emotional memories from smell (Zucco et al., 2014) this is likely to be the same for both feline and canine patients when visiting.

Practice equipment is now regularly being used when handling or transporting feline patients to and from consultations where the owner is not present rather than using the clients own item. It is recommended to use the patient's own cat carrier with the top section removed when examining them during consultations, especially if they are fearful or unsure of the veterinary setting (Overall, 2013; Rodan and Heath, 2015). Carriers and their contents may act as fomites (BSAVA, 2020) and risk spread of the disease and should therefore not be used. This is problematic when dealing with cats as their carriers contain: familiar smells from home (International Cat Care, 2018; Rodan and Heath, 2015), their facial pheromones that they have secreted and rubbed against items previously and synthetic F3 pheromones (i.e. Feliway) (International Cat Care, 2018) which have potentially been used by their proactive owners. Unfortunately these will no longer be available to them which are useful in helping them feel more at ease in unsettling times.

The implemented changes discussed could cause the patients to become nervous, fearful, anxious or stressed. These emotional states have components that interrelate with one another, often manifesting due to each other, i.e. prolonged fear can induce stress and/or anxiety (Stellato et al., 2017). They are therefore communicated in similar ways with varying degrees of behaviour. The emotional states in turn cause fight, flight, freeze or fidget responses (Tilley and Smith, 2016), they communicate these with a variety of signals which include their tail being down or tucked between their legs, ears back, eyes wide with dilated pupils, shaking, rigid or immobile bodys (Horwitz et al., 2002), stare or focus on an object (Low Stress Handling, 2017), yawning, lip licking, panting, aggressive threats (offensive or defensive) (Tilley and Smith, 2016), piloerection (Shaw and Martin, 2015), lowered posture (cowering), avoidance, hiding, tail movements, paw lifting (Stellato et al., 2017), hypervigilance, pacing, refuse food (Dr Sophia Yin, 2017), learned helplessness, noise sensitivity, sweaty paws, vocalisation (growl/bark/whine/hiss), urination and defaecation (Positively Victoria Stillwell, unknown). In addition cats will also lie on their sides flicking their tails, suddenly and/or excessively groom and ready themselves to jump (Low Stress Handling, 2017). The level of emotion and associated behaviours/signals that the patient will display will vary as a result of individual confidence levels, previous training, life experiences and socialisation, due to these factors some of the measures implemented may only cause minor negative events for the patient with lesser noticeable emotional displays of behaviour whereas others may cause major negative events with more obvious behaviours. The number of measures implemented in the same visit at any one time will also have a bearing, minor negative events can build up collectively acting as building blocks which can in turn cause a major negative event if the patient's threshold is reached causing behaviours/signals to escalate. The behaviours displayed in response to their emotional state will influence social interactions (Stellato et al., 2017) therefore making it harder for the veterinary surgeon to assess and examine them during the consultations which is detrimental during this time, urgent and emergency cases are time critical, and face to face contact should be minimised between clients, animals and veterinarians to reduce the risk of spread of disease.

The patient's experience can be made a more positive one when visiting the veterinary setting despite the newly implemented guidelines and PPE discussed. Part 2 of this blog will look into what can be undertaken by veterinary professionals and clients to achieve this goal.

Anthony Turner RVN, BSc (hons.) Applied Animal Behaviour and Training.

Anthony is a night RVN at Northwest Veterinary Specialists. He qualified in 2018 at an independent general practice where he had been working for four years. He also has a BSc (hons.) degree in applied animal behaviour and training which is a special interest of his. He has gained experience in this area from working at the RSPCA, running his own dog
behaviour and training company and from his time in general practice where he also ran
behaviour and training consults, often taking on referrals from other local practices too.

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