An Interprofessional Approach to Veterinary Nutrition

By Rachel Lumbis and Tierney Kinnison

In veterinary practice, the interface between veterinarians, veterinary nurses or technicians, and paraprofessional team members is crucial. It influences patient care, incidence of medical errors, client satisfaction, success of the veterinary practice and revenue generation. Ensuring a coherent approach to the maintenance of animal health and wellbeing is of paramount importance, yet challenges such as interprofessional prejudice, misunderstanding of motivations, and a lack of recognition, respect, empowerment or trust, can prevent best practice.

Nutrition is one of the most important considerations in the maintenance of health, and plays a critical role in disease management, patient recovery and hospital outcome; a reflection of its recognition as the fifth vital assessment. Owners are increasingly aware of the role of nutrition in optimising pet health, yet considerable misinformation can make this one of the most difficult aspects of pet ownership. Playing a central role as a source of expert information, veterinary healthcare teams must rise to the challenge of optimising pet nutrition.

Effective interprofessional communication and collaboration is considered a key factor in the successful implementation of nutritional assessment, and a positive team environment founded on respect, trust and mutual support helps overcome challenges and provide the best outcome for both pets and their owners. This book provides evidence-based theory in an accessible and practical way to help veterinary healthcare teams implement interprofessional approaches to nutritional care and support.

• Language: English
• Publisher: CAB International
• Release date: May 31, 2023
• ISBN: 9781800621107

Rachel Lumbis

Rachel is a Registered Veterinary Nurse whose research interests include small animal nutrition and interprofessional education and practice. She completed the City and Guild's Certificate in Small Animal Nutrition in 2006 and helps to raise awareness of the importance of correct nutrition through veterinary and veterinary nurse education in the UK and, internationally, as a member of the WSAVA Global Nutrition Committee and past member of the European Veterinary Nutrition Educators Group. She is a former Lecturer in Veterinary Nursing and Course Director for the VN BSc and FdSc programmes at the Royal Veterinary College and one of the founding members of the RVC's interprofessional education team. She is an external examiner for veterinary nursing undergraduate programmes at two universities, an examiner for City and Guilds and Lantra, and an editorial board member for international peer reviewed journal, The Veterinary Nurse. Rachel is currently studying for a PhD in Veterinary Companion Animal Sciences on the topic of small animal nutrition.

Book preview

1 Introduction

Tierney Kinnison

Abstract

This short introduction outlines the aims of this book and provides a definition of ‘interprofessional’. A brief explanation of why it is important to consider interprofessional practice is included alongside clarification of the sources from which the evidence base for this book is derived.

We are delighted that you are reading this book on an interprofessional approach to nutrition. The overall aim of this book is to provide evidence-based theory in an accessible and practical way. We hope this will enable veterinary healthcare teams to implement optimal interprofessional approaches to nutritional care and support for their individual situations. With its emphasis on collaborative working, this resource aims to be useful for all members of the veterinary healthcare team, including the clinical professions (veterinarians and veterinary nurses/technicians/assistants), other members of the practice team such as practice managers, those who work alongside practice teams (including animal industry representatives, such as nutritionists and dieticians), individuals interested in interprofessional education within undergraduate or postgraduate settings, and anyone studying veterinary medicine, veterinary nursing and animal care, and embarking on their future as a veterinary team member. Though written by professionals in the UK, we hope that the core messages from the book will also be relevant to veterinarians, vet techs and other allied professions and groups worldwide.

Before we begin, it is important to provide a definition of the term ‘interprofessional’ so that we can set expectations for readers of this book. Strictly speaking, this means ‘between professionals’. The term ‘professionals’, of course, relates to members of a profession. But what is a profession? There are many ways to view the answer to this question, one being to consider a list of elements which makes a profession. A notable author in the area is Eliot Freidson, whose list of elements includes: a specific body of knowledge and skills, which leads to individuals with recognised credentials; division of labour being controlled by a working group, within a protected marketplace; in addition to an ideology of help over personal gain (Freidson, 2001). Veterinarians in the UK have long met this list of requirements, and more recently Registered Veterinary Nurses (RVNs) have done so as well, supported by the creation of a Register of RVNs and the proposal to protect the title. However, while much of this book will relate to these important veterinary professions, other groups and occupations which may not fit these strict criteria for a profession are no less important to our consideration of the veterinary team and will therefore be included. We believe that this focus on the interprofessional team is vital for providing the best possible care to our patients and clients, and is also of benefit to the teams themselves.

Several terms used within this book also require brief mention: veterinarian, veterinary nurse (VN), veterinary healthcare team (VHCT) and caretakers. These terms have been chosen to aid inclusivity and to reiterate the fact that the messages in this book are associated with more than simply ‘veterinary surgeons’ in the UK, ‘veterinary techs’ from the US, or individual pet caretakers and clients of a practice. The lessons we will explore for veterinary interprofessional teams can be developed from both human healthcare and aviation, where research into teamwork and the implications of different groups working together have been studied for many years. The similarities in the non-technical skills between aviation, human healthcare and veterinary care enable us to explore themes that have already been the subject of systematic study without reinventing the wheel. However, we must remember our own context, and that though similar, there are notable differences between working in an aeroplane cockpit, a rural (human medical) GP practice and an emergency room in a veterinary surgery! For example, Reeves et al. (2013) urged caution with simply using crew resource management (CRM) in other situations, and more recently Malcom et al. (2020) have reiterated the need for further research in human medicine, while also identifying transferable and useful aspects of CRM, such as a change in the way errors are managed, not avoided. Thus, while authors from human healthcare have looked to CRM for ideas, and while we will look to human medicine, it is also an aim of this book to share lessons learned from veterinary research into this complex topic as well as highlight the need for further context-based research.

This book aims to share, in an accessible way, some of the findings from interprofessional working, learning and education research, as well as experiences from professionals in the area of veterinary nutrition.

References

Freidson, E. (2001) Professionalism: The Third Logic. Polity Press, Cambridge, UK.

Malcom, D.R., Pate, A.N. and Rowe, A.S. (2020) Applying safety lessons from aviation to pre-licensure health professions education: A narrative critical review. Currents in Pharmacy Teaching and Learning, 12(8), 1028–1035.

Reeves, S., Kitto, S. and Masiello, I. (2013) Crew resource management: How well does it translate to an interprofessional healthcare context? Journal of Interprofessional Care, 27(3), 207–209.

2 Interprofessional working in veterinary practice

Tierney Kinnison

Abstract

There are many types of veterinary healthcare team (VHCT). VHCTs have developed over time, and now frequently include veterinarians and registered veterinary nurses, as well as other groups. The histories of these groups are vastly different; in the UK, veterinary nurses have been recognised, formally, as a profession since 2015, in stark contrast to the historic veterinary profession, whose professionalisation dates back to at least 1844. These historical differences lead to challenges in creating mutual understanding. Additional challenges to good working between these interprofessional groups include practicalities, attitudes and understanding of roles. However, when done well, there are many benefits to interprofessional working for patients, caretakers, the VHCT and veterinary practices. In this chapter, it is proposed that an awareness of regulatory body requirements and international developments in interprofessional competencies can help to guide understanding of necessary developments for creating optimal VHCTs which can work together on nutritional cases.

What is a veterinary healthcare team?

There is not a single correct answer to this question. It is likely that each reader of this chapter would answer the question in a different way, unique to their current situation and past experiences. It is also likely that the range of possible answers has changed over time.

Today, the composition of a veterinary healthcare team (VHCT) is rarely uni-professional, i.e. consisting of just one profession or occupation. However, historically, it may have been, or at least may have appeared so. A team can be multiprofessional, consisting of different professions or specialities, but working largely separately, for example within a referral hospital. Or it can be interprofessional, where the different professions and groups are working together for a common goal.

The goals of a VHCT may differ too, and may be focused on directly working with patients, developing education or practising research. Even if we consider just veterinary practices, the types of patients cared for, the caretakers seen, and the nature of the practice, be it corporate or independent, owned by a veterinarian or not, demonstrate a multivariable concept of veterinary healthcare goals.

Practically speaking, where the teams are located may differ; from large single-site practices to branch locations, to hub-and-satellite structures, and even extending to a partial or a purely online presence. In addition, personal aspects of the team may differ – a young team or older team, one which hosts students on placements or one that does not, and perhaps in the current era, an all-female team.

The literature has focused on several of these aspects which represent historic changes. For example, there has been a rise in the number of corporate practices, which has been a focus of research; a search of The Veterinary Record in PubMed shows the first mention of ‘corporate’ in 1985, followed by a gap of 11 years until a steady increase in publications from 1996 (one) to 2018 (five) with a drop in recent years. The feminisation of the veterinary profession is another area which has commanded much empirical research, as well as opinion pieces from the UK (Allen, 2016), the Netherlands (Koolmees, 2000) and the US (Smith, 2006), for example. There has, however, been relatively little research and conscious consideration of the changing interprofessional nature of the teams in which veterinary professions and occupations work, which has led to our current varied situation.

Throughout this book it is argued that this is an important research activity to conduct. It is suggested that understanding where we have come from and the experiences of our predecessors will assist with our interpretation of current interprofessional relationships, and potential ways forward, to implement optimal interprofessional approaches to care.

The development of the veterinary professions

At the start of my PhD, entitled ‘Insights from Veterinary Interprofessional Interactions: Implications for Interprofessional Education (IPE) in the Veterinary Curricula’ I wrote a paper with my supervisors on the rise of interprofessional practice within the veterinary field (Kinnison et al., 2014). In this article we explored how researchers who have considered the development of veterinarians have typically done so in isolation from the other groups with which they have worked. In the article, we argued that it is important to consider the changing face of any single profession alongside those groups with which that profession works closely. After all, as one profession chooses to expand or contract its role (such as veterinarians moving from primarily working with equines and food animals towards primarily working with dogs and cats, and all the complexities this has brought about), other groups and professions fill in the gaps, or may potentially be required to give up their own roles.

The paper focuses on the professionalisation of the veterinary nurse (VN) in the UK. Consideration of the early stages of the veterinary nursing timeline has been collated by the Royal College of Veterinary Surgeons (RCVS) Knowledge Charitable Trust, and starts with the first RCVS approved Animal Nursing Auxiliary (ANA) training scheme in 1961 (RCVS Knowledge, n.d.). Since then, there have been a range of steps contributing to an overarching ability to recognise VNs as a profession at the time of publication of this book, including:

inclusion of a list of VNs (2007) (now the Register)

inclusion of disciplinary procedures (2011)

a declaration of professional responsibilities (2012)

requirement for continuing professional development for registered VNs (RVNs) (Kinnison et al., 2014).

In 2015, a new supplemental Royal Charter was introduced, which confirmed the RCVS as the regulator of VNs, strengthened the Register of RVNs, and thus enhanced the accountability of RVNs for their own actions (RCVS, n.d.). These elements relate to Freidson’s (2001) elements of a profession, as explored in the Introduction, and this Royal Charter demonstrates the continued commitment of the RCVS to veterinary nursing as a profession.

A further step for the development of this newer veterinary profession has been underway in bids to protect the title of ‘veterinary nurse’, so that only RVNs may use the term, and unqualified and unregistered laypeople may not refer to themselves by this name. In 2015, a petition was launched by the RCVS to the government to protect the title, and it received significant support from VNs alongside their colleagues from practice. However, the Department for Environment, Food & Rural Affairs (Defra) did not protect the title, claiming that the criminalisation for improper use of the title was unduly harsh (Woodmansey, 2016).

Since that time, the RCVS has set up another Legislation Working Party (LWP) (2017) to make recommendations for future veterinary legislation which have been reported and subjected to public consultation. The ‘Recommendations for future veterinary legislation’ (RCVS, 2021) calls for a new veterinary surgeons/services Act to replace the current 1966 Act, and incorporates veterinary professions and paraprofessions with the core focus on animal welfare and public protection. Notably, for VNs, the executive summary includes the following statements:

‘By increasing opportunities for veterinary nurses and other allied professionals, the vision set out will create a more robust and flexible workforce and at the same time, increase efficiency within clinical practice.’

‘Legislation should not be unduly burdensome or complicated; it should provide clarity to the public and enhance public confidence in the professions, e.g. protection of veterinary titles, statutory underpinning for continuing professional development (CPD).’

The recommendations also describe ‘The vet-led team’ (RCVS, 2021). This is a term which has been used to advocate for interprofessional working between veterinarians and other allied professions, and promotes a ‘hub and spoke model with the vet at the centre’ (BVA, n.d.). However, the term and the model have not been received without confusion, for example regarding the regulation of the paraprofessions (Brizuela, 2019) and disappointment in relation to a lack of explicit inclusion of farriers (Dyer, 2019). In addition, it may be claimed that the portrayal of the veterinarian at the centre of the hub promotes the continuation of the hierarchical nature of veterinary practice, whereby the veterinarian maintains control of all the team’s actions, potentially inhibiting the expertise of other groups, limiting their willingness to speak up and reducing efficiency in tasks where a veterinarian does not need to be directly involved. These aspects of interprofessional working are explored further in this book.

The existence of a veterinary hierarchy is not surprising when the differences in the history of the veterinarians and RVNs is examined. The history of RVNs as portrayed in this chapter is in stark contrast to that of veterinarians in the UK in terms of its timeframe, with veterinarians being recognised as a profession since the Royal Charter in 1844, compared to the date of 2015 cited above for RVNs. Being recognised as a profession was an early step in the development of veterinarians as we know them today, with further stages including the introduction of the first Veterinary Surgeons Act in 1881 and the updates in later years including in 1966, which together prevented unqualified practice and allowed only veterinarians to undertake and charge for acts of veterinary surgery (RCVS Knowledge, 2010).

The working relationship between veterinarians and RVNs is complex, not least of all because of the changes which the veterinary nursing profession is undergoing, which in turn have ramifications for the accountability of a VN. Although the RCVS legislation review (RCVS, 2021) considers removing the requirement for a VN to be employed by the veterinarian with whom they are working, ‘under direction’, it still mandates that VNs are working under the direction of veterinarians, who would usually be a part of the practice team in which they are employed, including their direct employers. Consequently, there is a complexity in the choices of VNs if presented with the requirement to undertake, or not undertake, action with which they disagree, potentially resulting in moral distress (Morley et al., 2019), and even disciplinary procedures for the RVN. Further exploration of hierarchy and hierarchical interactions is found in Chapter 5.

Benefits of interprofessional teamworking

So why have RVNs risen as a profession, alongside other paraprofessional groups, including equine dentists, physiotherapists and animal behaviourists, to name but a few?

This chapter argues that the benefits of interprofessional working and a good team are obvious, with potential benefits for all stakeholders: the patients, the caretakers, the team and the practice.

A clear advantage for a team that integrates multiple professions, each with its own expertise, is that the team can benefit from the knowledge, skills and experience of all individuals, without requiring any one profession to know everything. This has been described as ‘distributed’ or ‘team’ cognition and is especially important for solving the complex problems (Hutchins, 1995; Salas et al., 2007) that are common in medicine today, as our patients live longer and our understanding of diseases develops, and the demands of caretakers/our clients grows. For this to come to fruition, it can be seen that all professionals are required to recontextualise their knowledge (Guile, 2012). In essence, in order to share knowledge learned in their ‘professional silos’, in a way that is of use for the whole team and its members, within their new working environment, individuals adapt their understanding and see others’ points of view in a way which is relevant to them. In a nice metaphor, this behaviour can be thought of as leading to a ‘pool of shared meaning’ (Patterson et al., 2001) which is required in order for conversations to be effective and collective decisions to be able to be made. Ultimately, this can lead to ‘collective competence’, a useful term which reminds us that competence in a complex setting such as a veterinary practice is not only an individual trait, and that it is possible to have an incompetent team made up of competent individuals (Lingard, 2009).

At this point, to provide an overview of the research undertaken on the benefits of effective interprofessional teamworking, from micro to macro levels, the following are just a few examples from the literature on human and veterinary medicine outlining specific benefits of ‘good’ interprofessional working, i.e. collective competence, for the different stakeholder groups.

Benefits to:

Patients: health

a holistic view towards care with a focus on the patient (Walton et al., 2019)

reduction in medical error, contributed to by poor interprofessional behaviour including poor communication (Alvarez and Coiera, 2006; Kinnison et al.,2015a, b).

Patients: satisfaction (human healthcare, suggested as comparable to caretaker satisfaction in the veterinary field)

increased patient satisfaction with collaborative care (Archer et al., 2012).

VHCT

good collaboration and support (Horder, 2004).

Practice

economic advantages of using the correct profession for the appropriate roles (Getz, 2012).

In a case study of interprofessional working in the veterinary field, the following facilitators to interprofessional working which may lead to the aforementioned anticipated benefits were observed, and are considered further in this book (Kinnison et al., 2016):

different perspectives providing more holistic understanding of issues

professionalisation and accountability of different groups involved

hierarchy (appropriate)

trust and value between all team members

formal infrastructure that reinforces desired behaviours.

Challenges of interprofessional teamworking

It must be acknowledged that, like most examples of teamworking, there are many challenges to interprofessional working. A small selection of these, from the veterinary and human healthcare professions, are outlined below.

Challenges:

time constraints (Walton et al., 2019; Luebbers et al., 2021)

coordination of teams (Walton et al., 2019) including distributed teams due to physical location (Kinnison et al.,2015a, b).

Attitudes:

prejudice and lack of recognition, which can contribute to decisions to leave the profession (Robinson et al., 2019)

inappropriate hierarchical behaviour when seeking advice and other resources (Kinnison et al., 2016).

Understanding:

lack of understanding of roles (Baxter and Brumfitt, 2008).

Direction for VHCT interprofessional working

The importance of overcoming these challenges and contributing to good interprofessional working has not been neglected within the global veterinary field and is highlighted within regulatory body requirements, for example, the RCVS’s Code of Professional Conduct for Veterinary Surgeons includes the following professional responsibilities (RCVS, 2022b) which are mirrored in the Code of Conduct for Veterinary Nurses (RCVS, 2022a):

4. Veterinary surgeons and the veterinary team

4.1 Veterinary surgeons must work together and with others in the veterinary team and business, to co-ordinate the care of animals and the delivery of services.

4.2 Veterinary surgeons must ensure that tasks are delegated only to those who have the appropriate competence and registration.

4.3 Veterinary surgeons must maintain minimum practice standards equivalent to the Core Standards of the RCVS Practice Standards Scheme.

4.4 Veterinary surgeons must not impede professional colleagues seeking to comply with legislation and the RCVS Code of Professional Conduct.

4.5 Veterinary surgeons must communicate effectively, including in written and spoken English, with the veterinary team and other veterinary professionals in the UK.

In addition, within the veterinary code, there is advice and guidance relating how to work specifically with RVNs, in the section ‘Delegation to veterinary nurses’, which outlines the current Schedule 3 exemption (which allows nurses to legally practice), maintenance and monitoring of anaesthesia, vaccination of companion animals and dentistry.

The Interprofessional Education Collaborative has demonstrated four core competencies for interprofessional collaborative practice. While some edits are required for use in the veterinary field, these competencies are suggested to provide a useful starting point for consideration of improvements to interprofessional working.

Competency 1: Work with individuals of other professions to maintain a climate of mutual respect and shared values. (Values/Ethics for Interprofessional Practice)

Competency 2: Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of