ABSTRACT: The issue of owner compliance – or lack thereof – is a wide-ranging problem through all genres of veterinary medicine and, indeed, medicine worldwide. This article provides a discussion of issues commonly presented in relation to client compliance in the UK, and compares and contrasts these problems with issues in human medicine and in veterinary medicine around the world. Protocols are then presented to improve compliance within veterinary medicine, through the use of a diverse range of communication channels and methods.
‘Non-compliance’ – the extent to which a course of recommended treatment is not carried out (termed ‘non-adherence’ where specific to medications) – is a well-documented subject in human medicine. Indeed, studies have been undertaken to compile the results of the many reports published.
One study indicates that the cost of non¬compliance in America is in excess of $100 billion per annum, derived from adverse outcomes such as hospitalisation, development of complications, disease progression or death.1 Approximately 125,000 people with treatable ailments die each year because they do not take their medication properly.1 In human medicine, multiple factors, such as denial of illness by patients and confusion or physical difficulties associated with taking medicines, are associated with poor compliance.1
It is reported that up to 80 per cent of UK patients may be non-compliant; with those prescribed preventive medications most likely to display non-compliance.2-3
This problem of non-compliance is transposed into veterinary practice worldwide. The American Animal Hospital Associations (AAHA) pioneering studies in 2003 and 2008 found many of the factors associated with non-compliance in humans applicable to veterinary medicine.
Owners reported ‘significant gaps’ between the communication they would find useful and those actually adopted by veterinary practices.4 Owners listed the six most important forms of communication, which were significantly lacking and which contributed to non¬compliance, as:
• demonstrations
• suitable length of appointment
• written information
• calls
• reminders for chronic medication
• continuity with the veterinary surgeon.
UK research suggested that only 37 per cent of clients are fully compliant with medications or follow-up practices recommended by their veterinary surgeon. Some 70 to 85 per cent of clients give, at best, only one third of the required doses on time.5
Owner compliance has been analysed in the context of various treatment regimens. The results of a 2010 equine wound management survey showed that owners often found difficulty in applying or maintaining dressings as requested in their animals’ follow up treatment plan (Figure l).6 Many consequently left the area undressed for fear of applying a dressing incorrectly.
Figure 1: Owner non-compliance prevalence in equine wound care6
Incidentally, veterinary surgeons reported that they too found difficulty keeping dressings in place – around 20 per cent of the time – which may indicate that some are not confident giving owners sufficient direction with regard to bandaging techniques, thus exacerbating non¬compliance. This is certainly an area where improved communication can have a significant impact on patient outcomes.
Another compliance issue is the high frequency of premature dressing removal, which is likely to cause an increase in time to wound-healing, scarring prevalence and impact upon final healing outcome.6 This survey found that all veterinary surgeons experienced issues with owners removing dressings prematurely, with 60 per cent finding this to be a relatively frequent occurrence (Figure 2).
Figure 2: Frequency of premature dressing removal in practice 6
Veterinary surgeons often report compliance issues when advising owners to utilise moist wound healing (MWH) techniques, with 55 per cent reporting that owners are completely unaware of the concept (Figure 3). This suggests that increasing owners awareness of MWH through better education could aid compliance. Non-compliance is not restricted to owners of particular species. A recent canine case study, involving a four-year-old crossbred Collie, highlights another factor for consideration in understanding reasons for non-compliance (Case study 1).
Figure 3: Owner perception of moist wound healing concept. Loftus, 2011.7
Owner education and understanding of owners’ personal circumstances are important factors in improving compliance. Case study 2 discusses how these are used to increase compliance in the developing world.
Reducing non-compliance
There are a number of simple but effective methods to reduce non compliance. Many of these centre on improved communication and improved client-clinician relationships.
In the consultation
• Consider whether the clients non¬verbal communication (body language, such as pos
ture and facial expressions) contradict what the client is saying.
• Encourage clients to talk by asking open-ended questions beginning with ‘what’ or ‘how’. Avoid ‘why’ as this can seem accusatory. Sentences beginning with ‘when’, ‘where’, ‘did’, ‘is’ or ‘who’ often encourage monosyllabic responses.
• Show empathy – acknowledge the client’s emotions either verbally or through non-verbal gestures.
• Listen, understand, respond – show that you are listening by responding verbally or via facial expressions/ posture changes.
• Practice active listening – repeat what the client has said back to them to check your – and their – understanding of the situation and encourage them to expand their explanation.9
• Accept, don’t judge – this will increase the likelihood of honest communication between client and clinician, through issuing non-judgemental statements, personal experiences, and expressing normal expectations.
Other methods
• Improve client education and understanding – especially of conditions and procedures associated with their pet.
• Repeat – clients are unlikely to take in all of the information if delivered only once, especially in traumatic situations. Evidence has shown that the same information delivered by a series of people can increase its impact; for example veterinary nurse, veterinary surgeon, reception staff and finally reinforced with printed material.10
• Demonstrate – show the client how to administer the required treatment and encourage them to practise in your presence to increase their confidence.4 It is often beneficial to conduct the first dressing change or administer the first dose of medication in the presence of the owner to ensure that even those who deem themselves competent take time to watch the techniques required being put into practice.
• Give ‘top tip’ handouts to clients, explaining how to complete common tasks, such as tablet administration, wound flushing or applying ocular ointments.
• Organise client information evenings specific to different species or issues – this adds value to your service and builds a stronger client-practice bond. Ensure that the staff receive training and regular participation in CPD so that they can provide appropriate and valuable advice to clients.
• Use computer software that provides a client-reminders service (and will deactivate in the case of euthanased pets) and ensures that follow-up calls are made in a timely manner.10 Add value by making the practice accessible through various communication channels, including telephone, e-mail, post, text and social-networking media.
Summary
With some thought – and minimal procedural alterations – all clinicians and veterinary nurses can improve communication and education in practice. This will help to reduce the incidence of non-compliance, thereby improving patient outcomes and increasing the strength of the relationship with their clients.
Author
Loni Loftus BSc(Hons)
After attending university to study Business Studies, Loni owned and ran a training, livery and competition yard for a number of years. She has recently completed a BSc in Equine Science with The Open College of Equine Studies (TOCES) and continues her affiliation by lecturing and marking, as well as managing the online assignment system.
Loni is a freelance trainer focussing on training young horses, in addition to rehabilitation of more experienced horses. As she completed her degree, she developed a particular interest in equine injury, disease, training and rehabilitation and has based much of her project work, including a dissertation, in this field.
To cite this article use either
DOI; 10.1111/j.2045-0648.2012.00201.x or Veterinary Nursing Journal Vol 27 pp 294-297
References
1. WERTHEIMER, A. I. and SANTELLA. T. M [2003] Medication Compliance Research: Still So Far to Go. Journal of Applied Research in Clinical and Experimental Therapeutics. ISummer 20031 313).
2. DUNBAR-JACOB. J. and SCHLENK. E. [2001] Patient adherence to treatment regimens In: Baum. A., Revenson, T. and Singer, J. (eds): Handbook of health psychology [pp 571-580]. Mahwah, NJ: Erlbaum
3. CARTER. S. and TAYLOR. D. [2005] A question of choice – compliance in medicine taking – a preliminary review. 3rd Ed. Keele University Medicines Partnership Programme.
4. AMERICAN ANIMAL HOSPITAL ASSOCIATION [AAHA] [2009] Compliance: Taking quality care to the next level. Executive summary (online), available from http://www.aahanet.org/Protected/ Compliance ExecutiveSummary0309.pdf. accessed January 2012.
5. MADDISON, J. E. [2011] Medication compliance in small animal practice. Veterinary Ireland Journal, 64 [1].
6. LOFTUS. L [2011] Review of current wound-care protocol and dressing choice in equine veterinary practice, VNJ (Sept 2011) 26: 309-313.
7. CALDER. C. and VETERINARY WOUND LIBRARY (2012) Case study – Non-compliance in a canine case. Personal communication AND www.vetwoundlibrary.co.uk
8. POLLOCK, P, [2012] Case study – Increasing compliance in the developing world. Personal communication. European and RCVS Recognised Specialist in Equine Surgery. School of Veterinary Medicine, University of Glasgow
9. GARRETT. L. [2011] Master this veterinary procedure in DVM360 at http://bit.ly/Hlyznf. accessed 25/03/2012.
10. THOMPSON, B [2011] How to maximise compliance in a weak economy at http://www.vetermarybusinessbriefing.com/public M93.cfm?sd=21 accessed 25/03/2012,
Veterinary Nursing Journal • VOL 27 • August 2012 •