Introduction

The word 'compliance' is defined as the act of complying with a wish, request or demand. In medical dictionaries, it is defined as the willingness to follow a prescribed course of treatment. For us in the veterinary field, compliance means that clients are following and accepting our recommendations for diagnostic tests and treatment for their animals.

Clients have stated five main reasons for not complying with recommendations made to them during visits to the practice:

1.  The practice never recommended a certain treatment or test.

2.  They didn't understand the recommendation.

3.  They didn't understand the importance of the recommendation.

4.  The clients felt complying with the recommendation was too difficult.

5.  The client forgot what was recommended.

Client adherence is directly related to our communication skills. The Four Habit Communication Model used by our medical counterparts forms a helpful backbone on how we can improve communication with our clients and, in return, create better compliance.

The Four Habits are:

1.  Invest in the beginning

2.  Elicit the client's perspective

3.  Demonstrate empathy

4.  Invest in the end

Veterinary nurses and technicians form a vital part of the healthcare team and are often the first and last encounter a client has with a veterinary practice. Clients' impressions are influenced by their entire visit to the practice and all the members of the team they interact with. And this lasting impression relates directly to their inclination to comply with our recommendations. You are more inclined to follow recommendations made by someone you respect and that you know cares for your wellbeing and that of your pet.

Clients often see nurses and technicians as less threatening and are more likely to communicate openly and truthfully with you. It is difficult to change an impression, once formed (not impossible, but difficult). Think of your own likes and dislikes in all aspects of your life and when that dislike or like was created - often at first interaction.

The presentation will focus on the Four Habits of Communication and how we, as veterinarians, nurses and technicians can incorporate them into our daily interaction with our clients. The desired result being to create greater all-around compliance from our clients.

Habit 1: Invest in the Beginning

First impressions are lasting. The first few moments of an encounter with clients are often overlooked by us as a pleasantry, but they are important for establishing a trusting relationship and often will affect the outcome of the entire visit as well as the future relationship with the client.

It is important, in the first few seconds, to establish a welcoming atmosphere. If it is a new client you are meeting for the first time, then a handshake during introduction indicates an equal stance and initiates touch. Ask the names of all parties present and their relationship to the pet as this creates a personal connection. Thus you can give vital information in advance to the veterinarian before he or she meets the clients. Also, if possible, try to be on the same eye level as the clients. (I will often kneel to be at eye level with a client sitting on a chair if one is not available for me to sit on.)

Before talking to the clients, make sure you are familiar with their pet's history or condition if available. We all get confused with whether or not a patient is male or female, but this can be a crucial break in trust/communication with clients if we get it wrong. Make sure you know the pet's detail prior to chatting to the client. If you are not sure how to pronounce a pet's name, you can ask a simple question: "Wow, that is an interesting name - how do you pronounce it? Does it have any special meaning?" This again provides a personal touch and conveys that you care about the connection of the owner with the pet.

I stated earlier that first impressions are lasting.... Get into the habit of not judging your clients on how they present themselves physically; for example, how they are dressed, or their mental attitude. Remember that a lot of times the clients are stressed and emotional when they arrive at the practice and this may not be a true reflection of them. Do not judge a person by his or her clothing. The old idiomatic expression "Clothes make the man" does not hold water in this day and age. It also helps to embrace the owner's idiosyncrasies - what makes us all unique and create a different experience with every consultation or the interaction we have with clients. Even the most intelligent/intellectual people can forget sense and appear irrational where their beloved pets are concerned.

The second part of initial contact should be eliciting the full spectrum of concerns the clients may have whether they are having a consultation with the veterinarian or visiting their pets in hospital. It is important to actively listen to the clients - make notes of their concerns and use vocalisations such as "I see," "Go on," or "I'll make a note of that for the vet," as well as nonverbal communications such as head nodding, etc. These small gestures will make clients feel at ease and they are more likely to elaborate on their concerns. By fully understanding what is on clients' minds and how they value their pet will help later in the visit with the compliance of all recommendations made. The key ingredient is to be sincere.

Habit 2: Elicit the Client's Perspective

This habit is important in creating trust and showing respect to the clients and animals. By eliciting the clients' perspectives, it helps to assess their requests for care, what impact the animal's illness has on the clients, as well as the value of the pet to the clients.

For example: Sometimes by asking the client: "What do you think is the problem or what may have caused it?" - may give some insight on whether they feel responsible/guilty. "What are you worried about most?" Many of us forget why the client initially brought the pet to us, especially if we find a more serious problem during consultation or discussion. It is of course important to address the new, more serious issue, but it is equally important to address the original presenting complaint even if it involves telling the client "Mrs. Jones, I know Fluffy was brought in for his itchy ears, but you mention that he is drinking a lot more than usual, and this may be indicative of a more serious condition. Once we have found the cause of his abnormal drinking behaviour we will then sort out the ears for you as well."

Unmet expectations occurred in about 18% of visits in one veterinary study conducted. Most of the dissatisfaction was due to the presenting complaint not being addressed. This "habit" is more the veterinarian's responsibility, but sometimes we all need reminding why a pet presented to us in the first place. You can assist the veterinarian by eliciting the clients' perceptions of what the perceived problems are. Again people are often more open and honest with veterinary nurses and technicians than with the veterinarians. This also gives you a chance to evaluate the clients' understanding and knowledge of the presented condition and also enables the veterinarian to judge how much information they need to give to the clients at the end of the visit. Clients are more likely to adhere to what the veterinarian or nurse recommends if they understand the condition their pet has, the way to diagnose and manage it, and what can be done to prevent or stop it from progressing. A good example is heart failure due to mitral valve regurgitation. If a client understands the physiology behind the formation of lung oedema and that we are not fixing the leaky valve, they are more likely not to just stop the medication because their pet is looking and feeling better.

Habit 3: Demonstrate Empathy

"... to know and understand, obviously is a dimension of being scientific; ... to feel known and understood, is a dimension of caring and being cared for." (Engel 1988)

Stewart et al. showed that medical physicians who are sensitive to and explore patients' emotional concerns take a mean of only one minute longer to complete visits when compared to physicians who do not do so. In other words, empathy does take time, but the rewards far outweigh that extra minute it takes. Put yourself in the clients' shoes. If it was your pet or family member that was ill, I am sure you would like that same empathy from the nurse, veterinarian or physician. Be sincere - clients know when we are faking it, in the same way you know when someone is not being honest with you. It is often the so-called 'gut' feeling.

It is important to create a safe environment for clients during this time. If a client is upset, it may be worth taking them to a more private area (consult room). Let them talk and ask them if there is anything you or the veterinarian can do to help. Give them reassurance that it is ok and normal to be emotional or upset and that it is nothing to be embarrassed about. Allow them the space to interact as a family, or with their pet - be it singing to it, reciting poems or just the time to cuddle and reassure the animal.

Habit 4: Invest in the End

Habit 4 is the direct link to better compliance. At the conclusion of the visit, it is crucial to make sure the clients understand what has transpired.

Make sure that they have the necessary information and knowledge of the diagnosis and plan before they leave. A good place to start is by involving the clients in the decisionmaking. Part of this should be done in conjunction with the veterinarian. A number of studies have shown that increasing patient participation in the decisionmaking leads to better compliance. The importance of checking client comprehension cannot be overemphasised. One of the biggest barriers to client compliance is our assumption that they understand what we are talking about. Client communication is incomplete without comprehension. It helps to give clients written information as they often retain very little of what is said in a stressful situation, especially what is discussed after the diagnosis is given. An American Animal Hospital Association survey suggests only 10% is recalled, of which only half is recalled accurately. As many as 80% of clients indicate they wanted information in both verbal and written forms. The written information should briefly summarise the diagnosis, treatment plan or diagnostic recommendations, and the rationale behind them as well as prognosis and follow-up plan. It also helps to put in writing what signs will show either progression or improvement of the condition. Client information sheets for most of the common conditions/procedures are available on the Internet and can be easily adapted to suite the practice you are working in. It is a good idea to get some preapproved by your veterinarians for the most common conditions. They can be kept in a folder and handed out at the end of the visit to the clients. It helps if you had time to discuss the case with the veterinarian before speaking with the clients - to make sure everyone is on the same page and to avoid confusion.

Another part of compliance is that clients often perceive that nothing is working and they feel out of control, as pets cannot communicate if they are alright, or not. Another way to involve clients and give clients some control and commitment is for them to keep a diary. For itchy pets, a diary may provide some clues on potential triggers; for a cancer patient, it may indicate a decline in quality of life and that euthanasia should be considered. If clients can see the difference medications or diet recommendations are making, then they are more inclined to persevere and comply with future recommendations.

Do not discourage the use of the Internet - as the saying goes: "If you can't beat them join them." The Internet is an integral part of our community and rather create an environment where the client will trust you and bring the information they have found on the Internet to your or the veterinarian's attention for evaluation.

At the end of the visit, ask clients if they foresee any potential problems with regards to complying with the recommendations or treatment plan given. Reasons often provided for noncompliance include concerns about costs, time management, or even the fear or lack of skills (e.g., insulin injections). By knowing this prior to the client leaving, we can try and address the issues. Provide support and do not judge the clients. Acknowledge the difficulty in following the plan and try to provide a plan or resolution to the concern. This might entail having the client return to do the procedure, or give the injection in your presence. We will recommend that the first couple of days they can return and do it in front of a nurse if they are unsure they are doing it correctly - free of charge. Encourage the client to telephone or e-mail if they are uncertain or just in need of support. Clients are more at ease phoning a nurse or technician without feeling that they are "bothering" the veterinarian with nonessential questions. These are often very essential questions for all parties concerned.

Book a follow-up visit or make a time for telephonic update prior to the clients leaving. It is useful to encourage clients to write down any questions or concerns they may have prior to the follow-up visit if they had not already called or e-mailed. Personal contact is and will always remain the best form of communication.

When the visit has been completed, it is important to walk the client back to reception or the front door if possible and even to open it for them. It may take an extra minute, but it shows a caring attitude that is not time driven.

Summary

It is our responsibility (veterinarians, nurses and technicians) to educate our clients. At the end of a visit, make sure they understand what disease their pet has or are at risk for; how the diseases are diagnosed; how they are treated and if they can be prevented. The more clients understand why we recommend certain things, the more they will be inclined to comply. This will lead to a much happier and healthier relationship between clients and your practice, and it creates greater job satisfaction for you.

References

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2.  Glass RM. The patient-physician relationship. J Am Med Assoc. 1996;275:147–148.

3.  Keller VF, Carroll JG. A new model for physician-patient communication. Patient Educ Couns. 1994;23:131–140.

4.  Cohen-Cole SA, Bird J. Building rapport and responding to patient's emotions. In: The Medical Interview: The 3-Function Approach. St. Louis, MO: Mosby; 1991:21–27.

5.  Richard M. AAHA Compliance Study. 2002.

6.  Wayner CJ, Heinke ML. Compliance: crafting quality care. Vet Clin North Am Small Anim Pract. 2006;36(2):419–436.

7.  Abood SK. Increasing adherence in practice: making your clients partners in care. Vet Clin North Am Small Anim Pract. 2007;1:151–164.

8.  Feldman BM. Increasing client compliance to benefit animals. J Am Vet Med Assoc. 2007;231(4):521.

9.  Downing R. Cornerstones of Compliance. Lakewood, CO: AAHA Press; 2006.