Emotional responses of clients to veterinarian communication style during a vaccination visit in companion animal practice

Outi A. Tuisku Research Group for Emotions, Sociality, and Computing, Faculty of Communication Sciences, University of Tampere, Kanslerinrinne 1, 33014 Tampere, Finland.

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Mirja K. Ilves Research Group for Emotions, Sociality, and Computing, Faculty of Communication Sciences, University of Tampere, Kanslerinrinne 1, 33014 Tampere, Finland.

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Jani K. Lylykangas Research Group for Emotions, Sociality, and Computing, Faculty of Communication Sciences, University of Tampere, Kanslerinrinne 1, 33014 Tampere, Finland.

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Veikko V. Surakka Research Group for Emotions, Sociality, and Computing, Faculty of Communication Sciences, University of Tampere, Kanslerinrinne 1, 33014 Tampere, Finland.

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Mari Ainasoja Research on Information, Customer and Innovation Management, Faculty of Natural Sciences, University of Tampere, Kanslerinrinne 1, 33014 Tampere, Finland.

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Sanna E. Rytövuori Research on Information, Customer and Innovation Management, Faculty of Natural Sciences, University of Tampere, Kanslerinrinne 1, 33014 Tampere, Finland.

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Mikko J. Ruohonen Research on Information, Customer and Innovation Management, Faculty of Natural Sciences, University of Tampere, Kanslerinrinne 1, 33014 Tampere, Finland.

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Abstract

OBJECTIVE To study the effects of veterinarian communication (ie, the information provided and gaze and body direction) and vaccination style on the emotions and physiologic reactions experienced by clients and on clients' evaluation of the expertise and trustworthiness of the veterinarian.

DESIGN Simulation study.

PARTICIPANTS 20 small animal clients.

PROCEDURES Participants were shown 12 videos of a female veterinarian in which she first provided information about puppy vaccination and then performed the procedure. The veterinarian's behavior varied regarding the information provided about the vaccination (ie, scarce, factual, or emotional), her gaze and body direction (ie, direct or 30° averted), and her vaccination style (ie, routine or emotional). While the participants watched the videos, their corrugator supercilii muscle activity (corrugator supercilii muscles are activated when frowning) and skin conductance activity were measured. Participants also rated the emotions they experienced (ie, valence and arousal) and assessed the veterinarian's behavior (ie, expertise and trustworthiness).

RESULTS Overall, emotional information, a direct gaze and body direction, and an emotional vaccination style were associated with more pleasant emotions and higher ratings of the expertise and trustworthiness of the veterinarian's behavior by clients.

CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that through certain behavioral actions, veterinarians may positively affect the emotions and feelings experienced by clients during veterinary clinic visits, even in the case of vaccination visits, which can be considered routine visits from the viewpoint of the veterinarian.

Abstract

OBJECTIVE To study the effects of veterinarian communication (ie, the information provided and gaze and body direction) and vaccination style on the emotions and physiologic reactions experienced by clients and on clients' evaluation of the expertise and trustworthiness of the veterinarian.

DESIGN Simulation study.

PARTICIPANTS 20 small animal clients.

PROCEDURES Participants were shown 12 videos of a female veterinarian in which she first provided information about puppy vaccination and then performed the procedure. The veterinarian's behavior varied regarding the information provided about the vaccination (ie, scarce, factual, or emotional), her gaze and body direction (ie, direct or 30° averted), and her vaccination style (ie, routine or emotional). While the participants watched the videos, their corrugator supercilii muscle activity (corrugator supercilii muscles are activated when frowning) and skin conductance activity were measured. Participants also rated the emotions they experienced (ie, valence and arousal) and assessed the veterinarian's behavior (ie, expertise and trustworthiness).

RESULTS Overall, emotional information, a direct gaze and body direction, and an emotional vaccination style were associated with more pleasant emotions and higher ratings of the expertise and trustworthiness of the veterinarian's behavior by clients.

CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that through certain behavioral actions, veterinarians may positively affect the emotions and feelings experienced by clients during veterinary clinic visits, even in the case of vaccination visits, which can be considered routine visits from the viewpoint of the veterinarian.

Communication skills are recognized as of critical importance in the training of physicians. Thus, training methods for interpersonal and communication skills in human medicine have become well established.1 Although veterinarians are also service providers and health-care professionals, the importance of communication skills for veterinarians has only been realized recently, and therefore relevant research is limited.1,2 Veterinary schools are beginning to include communication training in their teaching curricula.3 In the United States and Canada, veterinary communication skills are a requirement in colleges of veterinary medicine. However, that is not the case in all countries. Communication and interactions in the veterinary clinic are 3-fold, involving a veterinarian, a client (ie, the owner of an animal), and a patient (ie, the animal). A visit to a veterinary clinic often evokes emotions. For example, clients might be nervous for their pet or, alternatively, feel stress related to how their pet behaves in the veterinary clinic. The recent evidence of cross-species empathy (ie, canine emotional contagion due to human distress) reported by Young and Ruffman4 further suggests that the veterinarian should take into account not only the emotions and feelings of the pet but also that of the pet owner; that is, if the client is calm, it is likely that the patient will be calm as well.

Emotion is a multifaceted phenomenon of human behavior that includes changes in subjective experience, physiologic function, and expressive behavior. Theories on emotion can be divided into approximately 2 categories. The discrete theory of emotions defines emotions as separate, distinguishable categories. For example, Ekman's5 basic theory of emotions proposes that there are 6 basic emotions (joy, fear, anger, disgust, sadness, and surprise), which all have a specific neurophysiologic basis and an associated facial expression. Alternatively, the dimensional theory of emotions states that a set of dimensions can capture the full range of emotions.6,7 The most frequently studied dimensions are valence and arousal. The valence dimension is related to the pleasantness of an experience, ranging from unpleasant to pleasant. The arousal dimension is related to the level of activation and ranges from relaxed to high arousal. These dimensions together form a 2-D affective space where each emotion can be placed.

There is evidence of a relationship between the valence and arousal dimensions and physiologic changes. For example, changes in facial muscle activity are related to the valence of an experienced emotion. The corrugator supercilii muscles knit the eyebrows together and downwards, generating the facial expression of frowning. The activity of the corrugator supercilii muscles increases during negative emotions, whereas the muscles relax during emotions with a positive valence.8,9 In addition to emotional valence, activity of the corrugator supercilii muscles may also be influenced by cognitive factors, such as concentration.10 Changes in the electrical conductivity of the skin reflect the activity of the sweat glands controlled by sympathetic branches of the autonomic nervous system. Skin conductance is known to be sensitive to changes in emotional arousal, such that responses are greater for arousing stimuli than for neutral stimuli.11

Human emotions are significantly affected by the behavior and emotions of another person.9 Furthermore, emotions arising during human-to-human communication have a significant influence on the quality of the interaction and the individuals' willingness to continue the interaction.12 Spoken language is probably the most important means for people to communicate with and to influence others.13 In speech, emotional information can be delivered through the lexical meaning of the speech or through nonverbal aspects of speech, such as loudness, speech rate, or pitch.14 There is evidence that differences in both types of characteristics (while keeping the other aspects as neutral as possible) can convey information about emotions and activate the listener's emotional system.9,15–17 It is known from studies18 on physician-patient interactions that physician empathy correlates positively with patient satisfaction and decreased anxiety. A recent study by Cousin et al19 showed that even the communication style of a virtual, artificial physician can influence human affective responses. A highly caring communication style of the virtual physician (containing the expressions of concern, empathy, and reassurance) led to higher patient satisfaction than a style showing little caring.

In addition to spoken communication, nonverbal behavior plays a central role in human-to-human communication. For example, emotions can be communicated nonverbally by means of facial expressions, touch, and body position.20 Furthermore, eye contact is known to play an important role in interpersonal communication. In social interactions, people naturally look at the person with whom they are interacting.21 However, previous studies22,23 have shown that veterinarians tend to look at and talk to their patient rather than to the client. Additionally, the use of electronic medical records is now common, and although it seems to positively affect the exchange of medical information, according to physician-patient studies, the use of electronic medical records can have a negative impact on patient-centeredness because of the need for the physician to gaze at a screen while communicating with the patient.24 Researchers have shown that nonverbal aspects of the physician-patient interaction, such as the physician's eye contact with the patient, are significantly related to patient satisfaction.25 There is evidence from psychological studies that another individual's direct gaze elicits brain activation that indicates a tendency to approach, whereas an averted gaze activates brain activation that indicates avoidance.26 Furthermore, the level of arousal (for both subjective ratings and psychophysiologic responses) tends to increase for a direct gaze compared with an averted gaze or an averted gaze and body direction.26–29 There is also evidence that under mutual gaze conditions (ie, direct gaze and body direction), emotional facial expressions result in more pronounced subjective experiences and physiologic responses than under averted gaze and body conditions.29

Some qualitative studies (eg, interviews and focus groups) have investigated the communication skills of veterinarians and how their clients experience the communication. According to a descriptive study by Shaw et al,30 veterinarians lack important skills related to expressing empathy, compassion, and courtesy to clients. A study by Hamood et al2 suggested that the veterinarian can affect how the client feels about the visit even through small variations in communication style. The researchers2 found that it is essential that the veterinarian takes into consideration both the patient and the client. The clients also suggested that the veterinarians should use understandable language rather than medical jargon that the clients cannot follow. Coe et al31 found that clients seemed to have many expectations about the communication they received from a veterinarian. For example, clients wished that the veterinarian would consider the patient as an individual, similar to how they wish to be treated themselves.31 Thus, it seems important that veterinarians acknowledge the client as well as the patient to make the visit a satisfactory experience for the client.

The communication styles used by veterinarians have also been investigated by videotaping actual veterinary clinic visits. For example, Shaw et al32 classified the communication patterns employed by 50 veterinarians during clinical appointments. Their results showed that 46% of the veterinarians provided mostly biomedical communication content (ie, related to the medical condition, diagnosis, treatment, or prognosis), whereas 16% provided mostly bio-lifestyle-social communication content (ie, medical dialog involving a balance between biomedical and lifestyle-social aspects, such as the pet's daily living activities and social interactions), and 38% used a mostly mixed communication pattern.32 A bio-lifestyle-social communication content received the highest scores. There is further interesting evidence that communication that builds the relationship between the veterinarian and the client is also related to the veterinarian's satisfaction.33

However, there appears to be a lack of controlled studies investigating the effects of the behavior of the veterinarian on the pet owner. Experimental research methods allow researchers to investigate the impact that 1 or more variables has on another, as measured by observable outcomes in a controlled laboratory context.34 Thus, in controlled experiments, it is possible to minimize the effects of uncontrollable variables, such as the environment.35

For many pet owners, the first visit to a veterinary clinic is for vaccination. It is recommended that the first vaccination is administered when the companion animal (generally a puppy or kitten) is 8 to 9 weeks old.36 From the veterinarian's point of view, vaccination is a routine procedure, but for the client, the situation might be new and even evoke anxiety. For this reason, it is important to investigate the factors that affect the client's experience, such as the style of providing information about the procedure, paying attention to the client in terms of the gaze and body direction, and the way in which the patient is treated.

The objective of the study reported here was to determine whether small differences in veterinarian communication and vaccination style have an effect on how the client feels, physically reacts, and evaluates the behavior of the veterinarian. More specifically, we varied the veterinarian communication (information provided and gaze and body direction) and vaccination style (routine or emotional) and studied the effects of these changes on clients' emotions (subjective experiences and psycho-physiologic reactions) and on clients' evaluation of the expertise and trustworthiness of the veterinarian.

Materials and Methods

Participants

The study was performed in May 2014 at the University of Tampere, Finland. Twenty (16 female, 4 male) voluntary participants took part in the experiment. They were recruited from a puppy romp at a local pet shop. Mean age of the participants was 35 years (range, 18 to 70 years; median, 29 years). They all self-reported as having normal hearing and vision. They were all dog owners and had either the main responsibility (n = 12) or shared responsibility for the dog (ie, main responsibility together with a spouse). Mean age of their dogs was 15 months (range, 2.5 months to 9 years; median, 7 months). Prior to the experiment, all participants reported being able to watch a vaccination procedure (eg, were not uncomfortable because of a needle phobia). The study followed the principles outlined in the Declaration of Helsinki of 1975, as revised in 2000 and 2008. All study participants signed an informed consent form. The participants were compensated for their participation at the completion of the study with a 20 Euro pet shop gift card.

Equipment and physiologic measurements

The video stimuli were recorded with 2 web camerasa and presented to the participants with computer software.b,c Study participants watched the videos on a 55-inch television screen at a distance of approximately 3 feet (1 m).

Facial EMG and skin conductance activity were measured with a physiologic monitoring device.d The sampling rates were 2,048 Hz for EMG and 32 Hz for skin conductance. Facial EMG activity was measured on the left side of the face from above the corrugator supercilii muscle with bipolar pre-gelled Ag-AgCl sintered electrodes. The ground electrode was placed over the left mastoid bone. For EMG measurements, the guidelines of Fridlund and Cacioppo37 were followed. An analog high-pass filter of 0.5 Hz was used, and EMG activity was further digitally passband filtered (fourth order Butterworth) from 20 to 500 Hz. Skin conductance was measured with Ag-AgCl electrodes coated with electrode paste. The electrodes were attached to the medial phalanges of the index and middle fingers on the nondominant hand. Prior to attachment of the electrodes, the participants washed their hands with mild soap and water and dried them carefully.

Stimuli

The stimuli consisted of videos in which a male puppy received its first vaccination. At the beginning of each video, a female veterinarian provided information about the vaccination procedure, after which she administered a vaccine to the puppy. The veterinarian provided information about the vaccination with 3 different communication styles: scarce, factual, and emotional. The information was provided according to the vaccination recommendations of the Finnish Food Safety Authoritye (Appendix 1).

A licensed veterinarian was filmed in an actual consulting room with 2 video cameras simultaneously recording at a resolution of 640 × 480 pixels and a frame rate of 30 frames/s. One of the cameras was placed directly in front of the veterinarian, creating an illusion that the veterinarian was facing and looking straight at the client (ie, direct gaze and body direction). The other camera was placed at a 30° angle away from the veterinarian, creating the illusion that the veterinarian was looking away from the client (ie, averted gaze and body direction). The distance between the veterinarian and the 2 cameras was identical, so that the size of her visual image would appear to be similar in the videos (Figure 1).

Figure 1—
Figure 1—

Screenshots of videos used in a study of the effects of veterinarian communication (ie, information provided [scarce, factual, or emotional] and gaze and body direction [direct or averted]) and vaccination style (routine or emotional) on the emotions and physiologic reactions experienced by clients and on clients' evaluation of veterinarian expertise and trustworthiness during vaccination of a puppy. Figures show a direct gaze and body direction (left) and a 30° averted gaze and body direction (right). Figures were cropped from the videos, and the contrast was enhanced for clarity.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

Vaccination was performed by the same veterinarian with 2 different styles: routine and emotional (Appendix 2). In the routine vaccination, the veterinarian only administered the vaccination, whereas in the emotional vaccination, the veterinarian paid more attention to the patient by first giving the puppy tidbits and petting and complimenting it after the vaccination. In total, each study participant watched 12 (3 information × 2 gaze and body direction × 2 vaccination style) videos.

Procedure

When each participant arrived in the study laboratory, he or she was introduced to the laboratory space. Then, the participant was seated in a chair, and the purpose of the experiment was explained. At this point, it was confirmed whether the participant was able to watch a vaccination procedure without the likelihood of any discomfort caused, for example, by needle phobia. The investigator explained that the purpose of the study was to determine the participant's reactions and feelings related to situations in a veterinary clinic. The investigator explained that the sensors attached to the participant's hand and face measured physiologic responses, without mentioning the facial muscle activity measurements, because of the objective of measuring spontaneous facial reaction and to avoid either intentional or unintentional exaggeration or inhibition of the participant's facial expressions. The participant then signed the informed consent form.

The study consisted of 2 sessions. In the first session, each participant was asked to try to imagine themselves as a client while watching the videos. The videos were presented once in a software-generated,b fully randomized order, while corrugator supercilii EMG activity and skin conductance activity were measured. There was a pause of 30 seconds between each video to measure the baseline and poststimulus activity required for analysis of physiologic signals. During the pause, the television screen was black.

In the second session, the participant watched the videos again in a randomized order and rated their experiences with 4 different scales. First, the participant evaluated valence and arousal with 9-point bipolar scales that varied from 1 (unpleasant; relaxed) to 9 (pleasant; aroused). On both scales, 5 represented a neutral feeling (ie, neither unpleasant nor pleasant; neither relaxed nor aroused). Then, the participant rated the expertise of the veterinarian (ie, “In this video, the behavior of the veterinarian was professional”) and the trustworthiness of the veterinarian (ie, “In this video, the behavior of the veterinarian was confidence inspiring”) with a 9-point Likert scale. The scale varied from 1 (ie, totally disagree) to 9 (ie, totally agree).

After both sessions, the participant was debriefed about the purpose of the study and about the use of the physiologic measurements and received a gift card as compensation for taking part in the study. The total duration of study sessions for each participant was approximately 1 hour.

Statistical analysis

Electromyographic responses were extracted by averaging rectified sample values. A 1,000-millisecond prestimulus baseline correction was performed. Mean EMG responses during the videos and for 1,000 milliseconds after the stimulus offset were analyzed to measure the reactions during the videos and the initial reaction after the videos. The same procedure was used for analyzing the extent of skin conductance.

Data were analyzed with a 3 × 2 × 2 (information × gaze and body direction × vaccination style) 3-way repeated measures ANOVA (reported as the F statistic with df). Greenhouse-Geisser adjusted df were used when violations of sphericity occurred. Bonferroni-corrected pairwise t tests (reported as the t statistic with df) were used for post hoc comparisons. Statistical significance was set at a value of P < 0.05. All statistical analyses were performed with standard software.f

Results

Subjective ratings

Valence—Mean ± SEM ratings for valence were summarized (Figure 2). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA indicated significant main effects of information (F = 36.59; df = 2, 38; P < 0.001), gaze and body direction (F = 5.04; df = 1, 19; P < 0.05), and vaccination style (F = 37.95; df = 1, 19; P < 0.001). There was also a significant 2-way interaction of information with gaze and body direction (F = 5.53; df = 2, 38; P < 0.05) and a significant 3-way interaction of information, gaze and body direction, and vaccination style (F = 4.14; df = 2, 38; P < 0.05).

Figure 2—
Figure 2—

Mean ± SEM ratings of valence (1 = unpleasant; 9 = pleasant) assigned by dog owners (ie, simulated clients; n = 20) who viewed the 12 videos used in the study described in Figure 1.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

Because of the significant 3-way interaction of information, gaze and body direction, and vaccination style, separate 2-way 3 × 2 (information × gaze and body direction) ANOVAs were performed for the 2 vaccination styles.

For the routine vaccination style, the 2-way 3 × 2 ANOVA showed a significant main effect of information (F = 24.83; df = 2, 38; P < 0.001). The main effect of gaze and body direction and the interaction of gaze and body direction with information were not significant. Post hoc pairwise comparisons showed that the ratings of valence were significantly higher for the videos involving emotional information (MD = 1.70; P < 0.001) and factual information (MD = 1.37; P < 0.001) than for the videos involving scarce information.

For the emotional vaccination style, the 2-way 3 × 2 ANOVA showed a significant main effect of information (F = 24.87; df = 2, 38; P < 0.001) and a significant interaction of information with gaze and body direction (F = 6.01; df = 2, 38; P < 0.01). Because of the significant interaction, separate 1-way ANOVAs with information as a factor were conducted for the 2 gaze and body directions. The effect of information was significant for both direct (F = 21.30; df = 2, 38; P < 0.001) and averted (F = 7.50; df = 2, 38; P < 0.01) gaze and body direction. The pairwise comparisons showed that the content of the information had an effect on the ratings of valence (Table 1).

Table 1—

Effects of information content on the ratings of valence (1 = unpleasant; 9 = pleasant) assigned by dog owners (ie, simulated clients; n = 20) when an emotional vaccination style was used by the veterinarian in a study of the effects of veterinarian communication (ie, information provided [scarce, factual, or emotional] and gaze and body direction [direct or averted]) and vaccination style (routine or emotional) on the emotions and physiologic reactions experienced by clients and on clients' evaluation of veterinarian expertise and trustworthiness during vaccination of a puppy.

Gaze and body directionPairwise comparisonsMDP value
DirectEmotional information vs factual information1.20< 0.05
 Emotional information vs scarce information3.05< 0.001
 Factual information vs scarce information1.85< 0.01
AvertedEmotional information vs factual informationNCNS
 Emotional information vs scarce information1.20< 0.01
 Factual information vs scarce information0.95< 0.05

NC = Not calculated. NS = Not significant.

In addition, because the interaction of vaccination information with gaze and body direction was significant, the effect of gaze and body direction under different vaccination information styles was tested through pairwise comparisons. The analysis showed that the ratings of valence were significantly higher for the videos in which the veterinarian provided emotional information with a direct, rather than an averted gaze and body direction (t = 3.56; df = 19; P < 0.01). The other pairwise comparisons were not significant.

ArousalMean ± SEM ratings for arousal were summarized (Figure 3). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA indicated a significant main effect of information (F = 3.43; df = 2, 38; P < 0.05) and a significant interaction of gaze and body direction with vaccination style (F = 5.77; df = 1, 19; P < 0.05). To further analyze the significant interaction of gaze and body direction with vaccination style, the 2 vaccination styles were compared separately for the 2 gaze and body directions. The pairwise comparisons were not significant.

Figure 3—
Figure 3—

Mean ± SEM ratings of arousal (1 = relaxed; 9 = aroused) assigned by study participants.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

Expertise of the veterinarianMean ± SEM ratings of veterinarian expertise were summarized (Figure 4). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA showed significant main effects of information (F = 37.67; df = 2, 38; P < 0.001) and vaccination style (F = 25.07; df = 1, 19; P < 0.001). A significant 2-way interaction of information with gaze and body direction (F = 3.36; df = 2, 38; P < 0.05) and a significant 3-way interaction of information, gaze and body direction, and vaccination style (F = 4.65; df = 2, 38; P < 0.05) were found.

Figure 4—
Figure 4—

Mean ± SEM ratings of veterinarian expertise (1 = totally disagree; 9 = totally agree with the statement “In this video, the behavior of the veterinarian was professional”) assigned by study participants.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

Because of the significant 3-way interaction of information, gaze and body direction, and vaccination style, separate 2-way (information × gaze and body direction) ANOVAs were performed for the 2 vaccination styles.

For the routine vaccination style, the 2-way 3 × 2 ANOVA indicated a significant main effect of information (F = 26.76; df = 2, 38; P < 0.001). The main effect of gaze and body direction and the interaction of information with gaze and body direction were not significant. The post hoc pairwise comparisons for the 3 information styles showed that the behavior of the veterinarian was rated as significantly more professional in videos involving emotional information (MD = 2.25; P < 0.001) and factual information (MD = 2.23; P < 0.001) than in videos involving scarce information. The other pairwise comparisons were not significant.

For the emotional vaccination style, the 2-way 3 × 2 ANOVA indicated a significant main effect of information (F = 24.02; df = 2, 38; P < 0.001) and a significant interaction of information with gaze and body direction (F = 4.59; df = 2, 38; P < 0.05). Because of the significant interaction, separate 1-way ANOVAs with information as a factor were conducted for the 2 gaze and body directions. The effect of information was significant for both a direct (F = 22.22; df = 2, 38; P < 0.001) and an averted (F = 11.25; df = 2, 38; P < 0.001) gaze and body direction. The pairwise comparisons showed that the content of the information had a significant effect on the ratings of the expertise of the veterinarian (Table 2).

Table 2—

Effects of information content on ratings of veterinarian expertise (1 = totally disagree; 9 = totally agree with the statement “In this video, the behavior of the veterinarian was professional) assigned by study participants when an emotional vaccination style was used by the veterinarian.

Gaze and body directionPairwise comparisonsMDP value
DirectEmotional information vs factual informationNCNS
 Emotional information vs scarce information3.05< 0.001
 Factual information vs scarce information2.85< 0.001
AvertedEmotional information vs factual informationNCNS
 Emotional information vs scarce information1.55< 0.001
 Factual information vs scarce information1.75< 0.01

See Table 1 for key.

Because the interaction of information with gaze and body direction was significant, the effect of gaze and body direction under different information styles was analyzed in more detail through pairwise comparisons. This analysis indicated that the ratings of the veterinarian's expertise were higher for videos in which the veterinarian provided emotional information with a direct gaze and body direction, compared with an averted gaze and body direction (t = 2.13; df = 19; P < 0.05). The other pairwise comparisons were not significant.

Trustworthiness of the veterinarian—Mean ± SEM ratings of veterinarian trustworthiness were summarized (Figure 5). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA indicated significant main effects of information (F = 28.69; df = 2, 38; P < 0.001) and vaccination style (F = 29.88; df = 1, 19; P < 0.001) and a significant 3-way interaction of information, gaze and body direction, and vaccination style (F = 5.63; df = 2, 38; P < 0.01). Because of the significant 3-way interaction of information, gaze and body direction, and vaccination style, separate 2-way (information × gaze and body direction) ANOVAs were performed for the 2 vaccination styles.

Figure 5—
Figure 5—

Mean ± SEM ratings of veterinarian trustworthiness (1 = totally disagree; 9 = totally agree with the statement “In this video, the behavior of the veterinarian was confidence inspiring”) assigned by study participants.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

For the routine vaccination style, the 2-way 3 × 2 ANOVA indicated a significant main effect of information (F = 20.18; df = 2, 38; P < 0.001) and a significant interaction of gaze and body direction with information (F = 4.06; df = 2, 38; P < 0.05). The main effect of gaze and body direction was not significant. Because of the significant interaction, separate 1-way ANOVAs with information as a factor were conducted for the 2 gaze and body directions. The effect of information was significant for both a direct (F = 16.46; df = 2, 38; P < 0.001) and an averted (F = 18.80; df = 2, 38; P < 0.001) gaze and body direction. The pairwise comparisons showed that the content of the information had an effect on ratings of veterinarian trustworthiness (Table 3).

Table 3—

Effects of information content on ratings of veterinarian trustworthiness (1 = totally disagree; 9 = totally agree with the statement “In this video, the behavior of the veterinarian was confidence inspiring”) assigned by study participants when a routine vaccination style was used by the veterinarian.

Gaze and body directionPairwise comparisonsMDP value
DirectEmotional information vs factual informationNCNS
 Emotional information vs scarce information1.80< 0.01
 Factual information vs scarce information2.15< 0.001
AvertedEmotional information vs factual informationNCNS
 Emotional information vs scarce information2.25< 0.001
 Factual information vs scarce information1.70< 0.001

See Table 1 for key.

Because the interaction of information with gaze and body direction was significant, the effect of gaze and body direction under different information styles was evaluated further through pairwise comparisons. The analysis showed that the ratings of trustworthiness were higher for the videos in which the veterinarian provided emotional information with an averted gaze and body direction, compared with a direct gaze and body direction (t = 2.52; df = 19; P < 0.05). The other pairwise comparisons were not significant.

For the emotional vaccination style, the 2-way 3 × 2 ANOVA indicated a significant main effect of information (F = 19.21; df = 2, 38; P < 0.001) and a significant interaction of gaze and body direction with information (F = 4.55; df = 2, 38; P < 0.05). The main effect of gaze and body direction was not significant. Because of the significant interaction, separate 1-way ANOVAs with information as a factor were conducted for the 2 gaze and body directions. The effect of information was significant for both the direct (F = 19.93; df = 2, 38; P < 0.001) and averted (F = 8.02; df = 2, 38; P < 0.01) gaze and body directions. Pairwise comparisons showed that the content of the information had an effect on ratings of veterinarian trustworthiness (Table 4).

Table 4—

Effects of information content on ratings of veterinarian trustworthiness assigned by study participants when an emotional vaccination style was used by the veterinarian.

DirectEmotional information vs factual informationNCNS
 Emotional information vs scarce information2.75< 0.001
 Factual information vs scarce information2.30< 0.01
AvertedEmotional information vs factual informationNCNS
 Emotional information vs scarce information1.25< 0.05
 Factual information vs scarce information1.60< 0.01

See Table 1 for key.

Again, because the interaction of information with gaze and body direction was significant, the effect of gaze and body direction under different information styles was tested through pairwise comparisons. The analysis showed that the ratings of trustworthiness were higher for videos in which the veterinarian provided emotional information with a direct gaze and body direction than for videos in which the veterinarian provided emotional information with an averted gaze and body direction (t = 2.66; df = 19; P < 0.05). The other pairwise comparisons were not significant.

Physiologic reactions

Corrugator supercilii muscle activity—Changes in corrugator supercilii muscle activity were summarized (Figure 6). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA showed a significant main effect of information (F = 3.87; df = 2, 38; P < 0.05). Other main effects and all interactions were not significant. Post hoc pairwise comparisons showed that during videos involving factual information, the corrugator supercilii muscle was significantly more activated than during videos involving scarce information (MD = 0.202; P < 0.05). Other pairwise comparisons were not significant.

Figure 6—
Figure 6—

Mean ± SEM change in corrugator supercilii muscle activity as study participants viewed the 12 videos.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

To determine the reaction to the videos in more detail, the change in activity of the corrugator supercilii muscle during each video was compared individually with the prestimulus baseline value (ie, with the starting point of the EMG activity). One-sample t tests showed that the videos in which the veterinarian provided factual information (t = 3.48; df = 19; P < 0.01) or emotional information (t = 2.54; df = 19; P < 0.05) with a direct gaze and body direction and administered a routine vaccination resulted in significantly higher corrugator supercilii muscle activity, compared with the baseline values. Increases or decreases in the activity of this muscle during the other videos were not significant.

To follow EMG responses from the stimulus offset, corrugator supercilii muscle activity 1 second after the video offsets was analyzed (Figure 7). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA showed a significant main effect of vaccination style (F = 4.78; df = 1, 19; P < 0.05). Other main effects and all interactions were not significant. Pairwise comparisons showed that activity of the corrugator supercilii muscle was significantly lower after watching videos involving an emotional vaccination style than after watching videos involving a routine vaccination style (MD = 0.774; P < 0.05). Other pairwise comparisons were not significant.

Figure 7—
Figure 7—

Mean ± SEM change in corrugator supercilii muscle activity 1 second after video offsets for study participants.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

Again, 1-sample t tests were used to compare the extent of activation after watching the videos with prestimulus baseline activity separately for each video. The analysis showed a significant increase from the prestimulus baseline value for videos in which the veterinarian provided factual information with either a direct gaze and body direction (t = 2.59; df = 19; P < 0.05) or an averted gaze and body direction (t = 2.49; df = 19; P < 0.05) and used a routine vaccination style. The increase or decrease in activity of the corrugator supercilii muscle after the other videos was not significant.

Skin conductance activity—Extent of change in skin conductance activity during the videos was summarized (Figure 8). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA for the data obtained during the videos did not reveal any significant effects.

Figure 8—
Figure 8—

Mean ± SEM change in skin conductance activity as study participants viewed the 12 videos.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

The extent of change in skin conductance activity 1 second after the stimulus offset was also summarized (Figure 9). Three-way 3 × 2 × 2 (information × gaze and body direction × vaccination style) ANOVA for the data obtained after the video presentation did not reveal any significant effects.

Figure 9—
Figure 9—

Mean ± SEM change in skin conductance activity 1 second after video offsets for study participants.

Citation: Journal of the American Veterinary Medical Association 252, 9; 10.2460/javma.252.9.1120

Discussion

Results of the present experimental study indicated that veterinarian behavior had significant effects on participants' emotional responses and their ratings of the expertise and trustworthiness of the veterinarian. Overall, the provision of emotional information, an emotional vaccination style, and a direct gaze and body direction evoked significantly more pleasant emotions and resulted in significantly higher ratings of the expertise and trustworthiness of the veterinarian's behavior than provision of scarce information, a routine vaccination style, and an averted gaze and body direction. Furthermore, the consistency of communication style appeared to be an important factor in our results. That is, if the veterinarian first communicated with an emotional style and a direct gaze and body direction and then administered the vaccine in a routine style, the inconsistency of the behavior appeared to evoke distrust in participants.

More specifically, in the present study, both the emotional and factual information styles combined with both vaccination styles resulted in higher ratings of valence and veterinarian expertise and trustworthiness than the brief, condensed, scarce information style. This finding indicated that it is important that veterinarians thoroughly explain an upcoming procedure. In terms of the ratings of veterinarian expertise or trustworthiness, it did not seem to matter whether the veterinarian provided information about the vaccination with an emotional or factual style. However, for the videos in which the veterinarian used the emotional vaccination style and provided information with a direct gaze and body direction, the ratings of pleasantness were even higher when emotional information was provided, compared with factual information.

Thus, on the basis of results of the present study, it appeared that the client's experience is enhanced when the veterinarian takes the client into consideration and provides information about a procedure. It is noteworthy that conveying emotional or factual information resulted in lower ratings in this study when the veterinarian did not consider the patient while performing the procedure (ie, routine vaccination style). The ratings of valence and veterinarian expertise and trustworthiness were approximately the same when emotional and factual information were combined with a routine vaccination style as when scarce information was combined with an emotional vaccination style. The importance of the vaccination style was also reflected in the activation of the corrugator supercilii muscle. Our results showed that the activity of this muscle was significantly lower after participants viewed videos involving the emotional vaccination style, compared with after viewing videos involving the routine vaccination style. More specifically, the corrugator supercilii muscle relaxed from baseline activity after an emotional vaccination style, whereas it was activated after a routine vaccination style. Earlier studies8,9 have indicated that relaxation of the corrugator supercilii muscle is associated with pleasant emotional experiences, whereas its activation is related to negative emotional experiences. During the videos used in the present study in which the veterinarian provided emotional or factual information with a direct gaze and body direction and then vaccinated the puppy by means of a routine vaccination style, the corrugator supercilii muscle was significantly activated, compared with the prestimulus baseline value. This probably reflected the negative emotion or confusion resulting from the inconsistency between the prevaccination information and the actual behavior of the veterinarian during the vaccination procedure.

Overall, the activity of the corrugator supercilii muscle was higher during the videos involving factual information, compared with activity during those involving scarce information. This does not necessarily mean that factual information evoked greater negative emotions than scarce information. It is known that, in addition to emotion, the activity of the corrugator supercilii muscle is related to cognitive processing, such as concentration or mental effort.10,38 It is possible that comprehension of factual information in the present study required more mental effort because it contained more medical terminology, compared with the scarce and emotional information.

Ratings of arousal in the present study were quite neutral. A main effect of vaccination style was found, although the difference between routine and emotional vaccination style was not significant. However, there was a slight indication that the participants rated the routine vaccination style as more arousing than the emotional vaccination style. The quite neutral evaluations of arousal were in line with the skin conductance measurements. Skin conductance recorded during the videos was quite close to the prestimulus baseline values, and there were also no significant differences in skin conductance between videos.

Results of previous research have been somewhat contradictory regarding whether a direct gaze results in a heightened level of arousal.27 Hietanen et al26 suggested that the discrepancy between findings could be because gaze direction has an effect on physiologic arousal only in live conditions versus when the human stimulus is presented on a television monitor or a computer screen. In the present study, the stimuli were videos, and the results showed that the gaze and body direction did not have an effect on the extent of arousal experienced or the skin conductance. Furthermore, the social situation in the present study was different from that in previous studies26,27 of gaze and body direction, because our study involved verbal communication by the veterinarian whose gaze and body direction were varied, whereas earlier studies26–28 have used silent individuals (in person or in pictures). On the basis of results of the present study, the participants' level of arousal appeared to be more strongly affected by the information the veterinarian was providing than by the gaze and body direction of the veterinarian.

However, in the present study, gaze and body direction had a significant effect on the pleasantness experienced by the participants, in that the participants rated the direct gaze and body direction as more pleasant than the averted gaze and body direction. This result is in agreement with results of previous results26,28 regarding gaze and body direction, showing that a direct gaze is experienced as more pleasant than an averted gaze and body direction. The videos in which the veterinarian performed the vaccination with the emotional style and also provided emotional information with a direct gaze and body direction evoked higher ratings of pleasantness and higher ratings of veterinarian expertise and trustworthiness than the videos in which emotional information was provided with an averted gaze and body direction. In contrast, the videos in which the veterinarian performed the vaccination with the routine style and provided emotional information with an averted gaze and body direction induced higher ratings of trust in the veterinarian's behavior than videos involving a direct gaze and body direction. Again, this probably reflected the inconsistency between the veterinarian's behavior before and during vaccination. If the veterinarian first communicated with an emotional style and direct gaze and body direction and then performed the vaccination with a routine style, the inconsistency appeared to evoke distrust in clients.

Overall, results of the present study suggested that veterinarians can affect the experience of the clients through quite small behavioral actions. Participants in the present study felt more pleasant and evaluated the veterinarian's behavior as more expert and trustworthy when she took the client into account by looking at the client, explaining what she was about to do, and expressing empathy. This was in line with results of a case study by Hamood et al2 in which the participants wished for a clear explanation of what the veterinarian was doing. Communication skills are an important part of medical competency, and these skills can be taught and learned. With training, it is possible to improve veterinarians' communication skills. For example, Shaw et al39 found that after training, veterinarians asked more questions about the pet. Furthermore, a study by Ishikawa et al40 showed that even a short training session for communication skills can be effective in increasing medical students' awareness of nonverbal communication skills in a medical interview. A certain level of awareness of both the problem and the solution is important before an actual change in behavior may occur.41 It is also important to be aware of the fact that the nervousness or anxiety of the client might be transferred to the patient, and as a result, the patient may see the veterinarian as a threat. Additionally, it seems on the basis of our results that participants found it important that the veterinarian considered the needs of the pet by handling the pet kindly and as an individual.

Our results further suggested that the veterinarian's behavior during an actual procedure was at least as important as their behavior before the procedure. Whereas brief, condensed information delivery may be best to meet the veterinarian's need to perform vaccination efficiently, the results of the present study suggested that increased communication and consideration are necessary if the client's feelings and assessment of the veterinarian are to be taken into account as well as the potential impact on future visits to the same veterinary clinic and the client's adherence and loyalty. There is also evidence that a more client-centered approach does not necessarily increase the duration of the visit. Roter et al42 showed that communication-trained physicians used significantly more problem-defining and emotion-handling skills than untrained physicians, without an increase in the duration of the visit.

The present study represented a preliminary investigation, conducted in a controlled manner, that addressed the communication style of veterinarians and included some limitations. For example, we varied only 1 aspect of nonverbal communication, (ie, gaze and body direction); however, nonverbal communication includes other behavioral elements. Thus, it would be interesting to investigate aspects such as how the distance between the veterinarian and client and the facial expressions of the veterinarian affect the client evaluation of the visit. In addition, in the present study, the videos showed the vaccination of a dog, and the participants were dog owners. In the future, owners of other types of companion animals may also be studied.

Although a visit to a veterinary clinic for vaccination was chosen as the study scenario in the present investigation, it is possible to extend these results to other types of veterinary clinic visits. For example, the veterinarian might pay attention to direct eye contact with the client and adopt an emotional information delivery style for any appointment. Complimenting the pet can also affect the client. That is, if the client seems nervous about the visit, inviting positive feedback by the veterinarian might assuage the client's nervousness, thus relaxing the patient. It is likely that when veterinarians exhibit empathetic behavior throughout an appointment, increased client satisfaction will result.

Acknowledgments

Supported by the Finnish Funding Agency for Innovation (TEKES), project Nos. 2502302611 and 2502302612, and LUT Research Platform on Smart Services for Digitalisation.

The authors declare that there were no conflicts of interest.

The authors thank Dr. Jouni Niemi and Dr. Pirkko Hämeenoja from the Eläinklinikka Ehyt Oy (Veterinary Clinic Ehyt Inc) for their assistance with study design, and also thank Pirkko Hämeenoja for appearing in the stimulus videos.

ABBREVIATIONS

df

Degrees of freedom

EMG

Electromyography

MD

Mean difference or difference in means

Footnotes

a.

Creative Live! Cam Sync, Creative Labs Ltd, Dublin, Ireland.

b.

E-Prime, version 2.0, Psychology Software Tools, Pittsburgh, Pa.

c.

Microsoft Windows 7 operating system, Microsoft Corp, Redmond, Wash.

d.

NeXus-10, Mind Media B.V., Herten, The Netherlands.

e.

Evira, Finnish Food Safety Authority, Helsinki, Finland. Available at www.evira.fi/en/.

f.

IBM SPSS Statistics for Windows, version 22, IBM Corp, Armonk, NY.

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Appendix 1

Relevant portions of video scripts illustrating the 3 information styles used in a study of the effects of veterinarian communication (ie, information provided [scarce, factual, or emotional] and gaze and body direction [direct or averted]) and vaccination style (routine or emotional) on the emotions and physiologic reactions experienced by clients and on clients' evaluation of veterinarian expertise and trustworthiness during vaccination of a puppy.

Scarce information
“You are receiving a puppy vaccination. This vaccination needs to be renewed in a month. You can now place the puppy on the table.”
Factual information
“Kelmi is coming for a puppy vaccination. The puppy vaccination provides protection against distemper, contagious hepatitis, and parvovirus. The vaccine will not be injected in a muscle as in human vaccinations, but under the skin of the neck. Because of this, it is barely noticeable. This first vaccination does not yet provide full protection, and thus after a month, an additional vaccination needs to be administered.”
Emotional information
“Okay, Kelmi is coming for a puppy vaccination. He is such an active puppy that the vaccination will surely go fine. Many owners may be a bit nervous about the vaccination, but there is no need to be worried; he will hardly notice the vaccination. I will administer the vaccination under the skin of the neck so it is nearly imperceptible. After a month, we will meet again, when I will administer an additional vaccine to Kelmi. Do you have any questions?”
This information has been translated from Finnish to English

Appendix 2

Relevant portions of video scripts illustrating the 2 vaccination styles used in the study described in Appendix 1.

Routine vaccination

“Now you can hold the puppy as I give the vaccination” (vaccination occurs*).

The owner holds the puppy still while the veterinarian administers the vaccination.

Emotional vaccination

“Let's give a few tidbits to Kelmi so he won't even notice the vaccination” (tidbits placed on the table; vaccination occurs*). “That's right, fine boy!” (puppy is petted).

Tidbits are on the table so the puppy is still and the owner does not need to hold the puppy.

*The puppy was not actually vaccinated. Care was taken to not injure the puppy.

Text translated from Finnish to English. Figure contrast was enhanced for clarity.

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