Modifying Your Environment and Handling Skills to Reduce Stress and Improve Patient Welfare
Assessing the Environment and Making It Comfortable for the Patient
When assessing the environment, one must consider how the animal perceives and interprets the associated stimuli. What an animal sees, smells, feels, tastes and hears can have dramatic effects on its well-being and emotional state. Animals with previous frightening or painful veterinary visits may be classically conditioned to associate any or all of the surrounding stimuli with a negative emotional response (fear).
Maximizing Environmental Comfort
Bright and/or constant light can be stressful for animals. The presence of a tapetum lucidum allows certain species to perceive light in higher abundance than humans, making what people consider soft lighting seem brighter and aversive. Consider 60-watt bulbs in exam rooms and treatment areas to provide softer lighting.
Keep quick and sudden movements to a minimum, as animals may startle or suddenly feel threatened. If animals are not tolerating subtle movement, it may help to restrict their visual intake through the use of towels or other visual blocking aids, such as a ThunderCap (ThunderWorks, Durham, NC). Towels can be used to cover a cat’s head during all parts of the exam and procedures that do not involve the head.
Cover cat carriers in the clinic with a towel until you are ready to work with the cat. If housing cats in a cage, provide a hiding option, such as a box or a partially covered cage front so that they can remove themselves from visual stimuli and have the perception of being concealed.5 The sight of dogs or other cats in the lobby or treatment area is highly likely to be stressful.
Admit fearful or fractious dogs and cats through a side or back entrance to reduce visual contact with other animals and strangers.
Take off your white coat. Animals may make visual associations with stimuli in the veterinary clinic, including the attire of the veterinary clinicians and staff, with a frightening experience (i.e., the “white coat effect”). These animals may respond better without exposure to this fear-eliciting stimulus.
Speak softly and sparingly around animals to help them stay calm. As animals begin to exhibit symptoms correlated with elevated stress when ambient sounds approach 85dB6, keeping noise levels at or below 60dB is preferable.
Avoid reprimands or using harsh or punitive tones of voice, regardless of the animal’s behavior, as this is likely to increase stress and may exacerbate aggression. Classical music has been shown to increase behaviors associated with relaxation in animals.
Utilize sources of noise cancellation, such as white noise, to mask extraneous and potentially stressful sounds, such as barking dogs and people talking or moving in the adjacent hallway or rooms.
Allow time for the chemical smell of cleaning agent to dissipate after disinfecting an exam room between patients. This is also important for cage cleaning as placing an animal in a cage that has not fully dried after cleaning will expose them to harsh chemical scents. Use alcohol sparingly during procedures as the strong scent is potentially aversive to animals.
Wipe down exposed surfaces, such as the floors, walls and cabinets, after stressed animals as they have likely deposited scents and pheromones associated with fear and alarm which may indicate the environment is dangerous.
Minimize exposing cats to canine odors by having designated cat exam rooms and/or wiping down and airing out rooms between canine and feline patient as the smell of a potential predator may induce a stress response.
Utilize calming pheromones [Feliway; Adaptil (Ceva Animal Health, Lenexa, KS)] in exam rooms and treatment wards, on towels, tables, and your own clothing to provide a signal of safety for the animal and to reduce stress.
Utilize calming scents, such as lavender and chamomile when handling animals. Essential oils can be dabbed on bedding and handlers can use mildly scented lotions on their hands prior to handling.
Avoid placing animals on cold, slippery surfaces. Cover metal exam tables with towels no-slip mats or soft foam covering. Use a padded mat when placing animals into recumbency on the floor. Place soft bedding inside the cage or kennel to promote rest, to provide warmth, and to prevent cats from resting in their litter box.
Avoid over-stimulating touch with animals. While some pets enjoy petting, others may find it frightening or uncomfortable.
Many animals are less anxious and tolerate veterinary handling better with a familiar person present, likely because animals feel safer in proximity to familiar members of their social group. It is also import to be sensitive to owner requests about not being present. A fearful, agitated, or punishing owner may escalate the animal’s fear and aggression.
Making a Handling Plan
Once an assessment of the environment, patient and handler comfort levels is complete, a careful handling plan can be designed and implemented.
Guidelines for organizing a patient handling plan: Critically consider what needs/must be done.
Critically consider what needs to be performed—must the procedure be done today, or at all?
Determine if and what the patient can eat so that a plan for counter-conditioning that is appropriate and safe for the animal can be made.
Select the appropriate level of restraint for the individual patient and the procedure.
Select any handling tools that will increase safety and decrease your patients fear and arousal.
Place the required procedures in order of most important to least important in the event the patient is unable to tolerate some of the procedures.
Place those procedures in order of least offensive to most offensive so that early difficult procedures do not inhibit your ability to complete later ones.
Consider the level of pain, invasiveness, number of procedures, and how the patient is coping with minimal handling and consider chemical restraint when it is unlikely the patient will be able to tolerate all the procedures.
If there is a possibility that chemical restraint will be necessary, have it ready and waiting so that it can be implemented before the animal becomes too aroused.
To combat the development of this fear or to alter an already established fear of the veterinary clinic settling, animal handlers can rely on counter-conditioning. To create this positive emotional response, we pair veterinary experiences with something that naturally elicits a positive emotional response in the animal—food.
Palatable food is the easiest and most powerful means of establishing this association as it is a natural and automatic elicitor of a positive emotional response. This natural emotional wiring is what motivates animals to eat and to survive. Keep in mind the palatability of the food needs to be high to maximize the animal’s interest in eating and increase the power of the positive emotional response.
Procedures where counter-conditioning should be utilized:
- Injections toenail trims
- Otoscopic exams restraint by a stranger
- Rectal temperature/palpation microchip placement
- Placement onto a cold table
Examples of palatable foods for dogs:
- Chicken or turkey baby food
- Peanut butter
- Squeeze cheese
- Kong Paste (The Kong Company, Golden, CO) Braunschweiger (liverwurst)
- Canned dog food
- Pill Pockets (Greenies, Franklin, TN) Examples of palatable food for cats:
- Chicken or turkey baby food Canned tuna or chicken Squeeze cheese
- Canned cat food
- Pill pockets (Greenies, Franklin, TN) Soft cat treats
- Whipped cream
Safe and Effective Restraint
Once the itinerary of procedures has been organized, a restraint plan should be coordinated for each procedure. Less invasive procedures tend to require less restraint, whereas more invasive and aversive procedures may require heavier restraint for safety purposes and so that the animal feels secure.
Guidelines for Restraint
Use the least restraint that is necessary to safely perform the procedure. Venipuncture from a lateral saphenous vein in a standing dog is typically better tolerated than is placing a dog into lateral recumbency. Furthermore, many cats will tolerate gently being turned into lateral recumbency for a medial saphenous venipuncture without being scruffed. When greater restraint is needed, support the animal well by providing firm, balanced restraint with global support around the patient. Prevent flailing by keeping control of head and rear end at all times.
If the pet struggles in response to restraint for longer than 3 seconds, stop, reposition, and try again. Wait until the pet has relaxed and, preferably starts eating, before beginning the procedure. If after 2–3 attempts the patient does not relax and/or starts to getting fractious, stop altogether and consider whether or not the procedure is essential. If it is essential, make a plan for chemical restraint. If it is non-essential, send the animal home and create a plan for a more successful visit the following day.