Over the past decade, a growing body of literature has highlighted the important role that communication with clients can have on the outcomes of veterinary care. Observational research conducted in veterinary practice settings has found associations between the nature of veterinarians' communication with their clients and important outcomes including appointment efficiency,1 client recall of information,2 veterinarian satisfaction,3 client satisfaction,4,5 and client adherence to recommendations.6 As a result of the increasingly recognized importance of communication in veterinary practice, formal communication skills training has been built into many veterinary education curricula7–19 and is increasingly being offered through continuing education conferences and workshops for veterinarians and their employees. A range of approaches has been used to teach communication skills to health-care professionals. Whereas traditional continuing education interventions have largely relied on lecture-type formats, more effective models for teaching communication skills emphasize experiential learning and use of multiple teaching formats including individual or small-group workshops; discussions; case presentations; lectures; role playing; video recording and review of interactions; use of simulated or standardized clients, patients, or both; and in-practice coaching.20–24 Research suggests that interventions that are interactive and include small-group feedback lead to greater effectiveness25,26 and other benefits, including acquisition and transfer of communication skills to practice27 and behavioral change.28
The purpose of the study reported here was to assess the feasibility and outcomes of a practice-level communication skills training intervention that included an intensive 2-day CSTP and a follow-up CIPP that included performance of mini-communication modules every other week over a 3-month period in everyday companion animal veterinary practice settings. The main objective was to determine whether the CSTP and CIPP had detectable impacts on measures of health-care team members' communication confidence, client satisfaction with the experience at these practices, and practice-level financial metrics.
Materials and Methods
Participating practices
A convenience sample of 5 companion animal veterinary practices in the United States (1 used for the pilot test and to refine the training program [pilot practice] and 4 used in the main study [practices 1 through 4]) was selected for participation in the program, which took place between September 21, 2013, and February 1, 2015. Only data from practices 1 through 4 were included in analyses. Practices were selected by representatives from Bayer Animal Health on the basis of whether the practice had a current collegial working relationship with a Bayer Animal Health technical services veterinarian, the desire to have representation of practices across the United States, a location that ensured the assigned technical services veterinarian could readily provide the CIPP, and study enrollment criteria. Practices were contacted by the assigned technical services veterinarian and provided with the study inclusion requirements.
To be included in the study, practices were required to have a veterinary health-care team of 15 to 35 full-time employees (eg, veterinarians, veterinary technicians [formally or on-the-job trained], veterinary assistants, practice managers or administrators, receptionists or client service personnel, kennel attendants, and groomers). The practice leadership had to agree to provide access to practice financial records for 15 months prior to the training period and for the duration of the approximately 3.5-month-long training period, to allow all team members to participate in all components of the program, and to assign an invested point person (eg, a practice administrator or manager) to support the clinic's participation in the study and the delivery of all program components. Community population data were gathered from United States Census Bureau dataa for the city where the practice was located.
Training program overview
Data were collected from each practice for predetermined periods before the intensive 2-day CSTP and during the 3 months that followed this training (which was also the time of the follow-up CIPP training period). Practice financial metric data were collected for 15 months before and 3 months after the CSTP, and client satisfaction surveys were collected for 2 months before and 3 months after the CSTP. Surveys that were focused on veterinary health-care team members' client communication skills were collected immediately before and after the CSTP and at the end of the CIPP. In accordance with US Health and Human Services Policy for Protection of Human Research Subjects (45 CFR 46), the research was considered exempt from requirements for institutional review board approval.
Training was performed in large and small group settings. The pilot practice was used to evaluate feasibility of overall program implementation and evaluation, including the delivery and content of client and team member surveys, implementation of the 2-day CSTP, and delivery of the on-site 3-month CIPP. Changes were made to the training content and program evaluation methods as deemed necessary according to information gained during testing at the pilot practice, which included 35 participating veterinary health-care team members. The modifications included revision of the CSTP content to facilitate more direct application of communication skills in specific clinical contexts, such as additional information to support the delivery of client education related to heartworm disease and dental disease, the importance of a physical examination, and environmental considerations or procedural steps used to reduce stress for cats and cat owners during veterinary visits. Video content that demonstrated context-specific application of communication skills was added to the 2-day program, and a Likert-type response scale used in the team member survey was expanded from a range of 1 to 5 to a range of 1 to 10 to allow more discrimination by the respondent when assessing his or her client communication skills.
Client surveys
Each client who completed a patient visit to a participating veterinary practice for any reason was invited by veterinary health-care team members to complete an anonymous, English-language paper survey developed by the authors immediately after the appointment. Each survey was deposited in a central collection site at the practice by the client. The central collection site was emptied periodically, ensuring that batches of surveys were retrieved, precluding recognition of any individual client's survey. Immediately prior to the CSTP, the collection site was emptied completely, ensuring that pre- and post-CSTP surveys could be identified. Clients were asked to complete 1 survey/visit, not per pet, for each visit during the pre- and post-CSTP study period. The client survey used for practice 1 contained 9 items focused on interactions with team members and on client service during that day's visit. Clients were asked to rate each of these items on a scale from 1 (poor) to 5 (excellent) or 6 (not applicable). Items included how well team members communicated health issues and procedures, benefits of the recommended care, and related costs; the amount of attention the pet had received from the team; how well the team appeared to understand the reason for the visit; the physical examination performed; how well the team involved the client in decision-making related to the care options that were offered and addressed all of the client's concerns; and the team's expression of interest in the client's opinion. This survey also contained 4 questions (with binary responses) that asked whether the client had been asked to start giving a new medication or diet or schedule a dental procedure for the pet; whether the client had been asked to schedule a recheck or follow-up appointment for the pet; whether the client did schedule a recheck, follow-up, or dental procedure appointment for the pet; and whether a product or medication had been purchased as a result of that day's appointment.
The client survey used for practices 2, 3, and 4 contained the same 9 items focused on veterinary health-care team–client interactions and client service that were previously described, but after preliminary evaluation of practice 1 data, these were rated on an expanded scale from 1 (poor) to 10 (excellent) or 0 (not applicable) to allow additional discrimination (Supplementary Appendix S1, available at avmajournals.avma.org/doi/suppl/10.2460/javma.255.12.1377). Responses to these 9 questions were considered to reflect client satisfaction. This survey included the same 4 binary response questions about changes to diet or medication and scheduling of additional appointments as in the survey for practice 1, as well as 3 additional items. The first of these was a multipart question related to prophylaxis against flea and tick infestations or heartworm infection (ie, preventives); the 2 product types were listed (with an option of none), and clients were asked to indicate whether these products were used and whether they were purchased from the practice. They were also asked to indicate whether team members had talked to them about the benefits and cost of the product and whether they had purchased the product at the time of the visit as a result of recommendations from team members. The next item asked the client to select all applicable responses from a list of reasons for not purchasing these 2 product types from the practice on the day of the visit (if this was the case). For the final item, clients were asked to select all that applied from various service options (cleaning and polishing of teeth, testing for heartworm infection, physical examination, or none) in response to statements that team members had discussed with them regarding the benefits and cost of the service and that they had scheduled the service at that practice as a result of the recommendation from team members.
Veterinary health-care team surveys
The veterinary health-care team survey, adapted from the work of Levoy29 and Norgaard,30 was administered at 3 time points: immediately prior to the 2-day CSTP, at the time of CSTP completion, and at the end of the 3-month CIPP. The surveys were conducted anonymously, with each team member completing the paper survey and submitting it as part of a batch at the described time points. Forms were coded to identify the practice and time point when they were collected and provided to one of the authors (KEF) for data entry and analysis. The survey used at practice 1 consisted of 22 items, including 20 statements rated on a Likert-type scale from 1 (strongly disagree) to 10 (strongly agree), 1 case scenario item that asked the respondent to identify specific communication skills needed in a routine wellness examination appointment for a puppy, and 1 optional item in which further background information regarding any of the 20 items with Likert-type responses could be provided. Eight of the 20 items in that category were used to measure self-assessment of client communication skills, 8 were used to measure the team member's assessment of communication with clients by the veterinary health-care team as a whole, 3 were used to measure the team member's perception of importance given to client communication by the practice, and 1 was used to measure the value the team member placed on nonverbal communication. After preliminary evaluation of data from practice 1, 6 additional items with Likert-type responses were added to the surveys distributed at practices 2, 3, and 4; these included 2 items regarding the team member's understanding of the importance of educating clients about products or services, 2 items related to the initiation of conversations with clients about the value of goods and services, and 2 items related to the discussion of the cost of preventive care products and services. These additional questions were placed after the original 20 items rated by use of the same scale on the survey. The survey used in practices 2, 3, and 4, which included all questions in the survey used for practice 1, is provided (Supplementary Appendix S2, available at avmajournals.avma.org/doi/suppl/10.2460/javma.255.12.1377).
Statistical modeling was used to assess the association between team member communication confidence and practice financial metrics by calculating a composite self-reported personal communication skills confidence score for each team member in each practice (practices 1 through 4) at each of the 3 survey times. This value was determined as the sum of the confidence scores for the 8 survey items that provided a self-assessment of the team member's client communication skills.
Financial metrics
Financial metrics provided by the management of each practice for the 15 months preceding the start date of the 2-day CSTP (to establish baseline values) and for the 3-month CIPP period that followed the CSTP were reviewed (KEF). Data collected for these 2 periods included the overall practice revenue, number of invoices generated, and mean transaction charge; invoices were further assessed to determine the number for canine patients, number for feline patients, and revenue and mean transaction charge for each of these species.
The number of examinations (canine or feline; for any reason excluding a recheck examination), recheck examinations, and dental procedures and the revenue related to each type of visit; the number of tests performed for heartworm infection (as individual procedures or as part of comprehensive hematologic analysis) or fecal examinations and the revenue related to each test type; and the number of doses of heartworm preventives and flea and tick preventives sold (including topical, oral, and injectable treatments), number of vaccinations performed, and revenue related to each were recorded. A subset of these data, specifically addressed in the communication skills training, was used to assess the total number of services (examinations, dental procedures, heartworm tests, fecal examinations, and vaccinations) performed and the total revenue for those services. Finally, the total number of new clients was recorded for each of the 2 periods of interest.
CSTP
Targeted educational needs (content related to specific veterinary information and skills involved in veterinary communication) and professional practice gaps were drawn from communication skills research conducted in human and veterinary medicine.6,31–43 The program was led by facilitators from the Institute for Healthcare Communication with a ratio of no more than 5 participants to 1 facilitator in the small-group sessions.
Each CSTPb was held over a weekend (Saturday and Sunday) and included curriculum content designed to accommodate various levels of communication competence among participants, with a variety of teaching methodologies that accommodated different learning styles and reinforced and refined skills through practice.44,45 The sessions at each practice took place at different times of the year (September, October, December, and June). On the basis of adult learning theory principles,46 the CSTP program was purposefully designed to use interactive methods including small-group learning activities, case-based training specific to areas of preventive veterinary care, and scenarios with simulated client interactions that allowed for immediate practice application. Learning goals for this intensive program included the acquisition of evidence-based communication concepts40 and skills (process) and relevant clinical subject matter (content) to effect changes in learner performance. Specifically, the integration of content related to clinical practice (eg, history taking for pets and discussion of the importance of dental cleaning and rationale for administration of heartworm preventives) with the application of communication process skills (eg, the use of open-ended inquiries, active listening and additional information gathering, and summary feedback statements [termed funneling]; the practice of asking what the client knows or wants to know before providing information and following up with a question to ensure the client's understanding or need for additional information [termed ask-tell-ask]; and expressions of empathy and nonverbal cues) was emphasized throughout the training program. The teaching format included the use of video recordings to demonstrate various verbal and nonverbal communications.
The learning format consisted of large group sessions in the morning of both days. During this time, short didactic presentations were interchanged with exercises for small groups and for pairs of participants and review and discussion of vignette-based video recordings (professionally produced recordings with actors portraying veterinarians and clients) depicting communications between veterinary health-care team members and clients. The purpose of this mixed learning method was to enhance participants' understanding of client communication from an evidence-based perspective and to introduce core communication skills with direct applications to a variety of clinical contexts (eg, talking with clients about monetary issues related to treatment or making a medical recommendation). The afternoon portion of the training was devoted to facilitated communication skills practice (with simulated client-and-team member discussions) for all participants in small groups. Each participant had 2 opportunities to participate in interactions with simulated clients.
A skilled Institute for Healthcare Communication facilitator with knowledge of communication models, evidence, and skills, as well as prior experience conducting veterinary train-the-trainer programs, guided each group. Sessions used simulated clients who were trained actors recruited from a standardized patient program at a local medical school in the geographic region of the practice. A Bayer Animal Health senior technical services veterinarian with prior training from the Institute for Healthcare Communication assisted each facilitator and small group during the CSTP. Scenarios for the simulation sessions were developed to be relevant to each team member's role and to reflect common communication and preventive care practice situations. Examples of case scenarios included history taking, recommendations, and cost discussions associated with heartworm prevention and testing, dental health and dental cleaning, and treatment and prevention of flea infestations as well as difficult conversations regarding money and unmet client expectations. Facilitators were responsible for creating group norms and guidelines for giving and receiving feedback from peers. Following each simulation session, facilitators conducted structured debriefings using a balanced feedback model that involved feedback sharing from all group members. At the end of the CSTP, a follow-up action plan (CIPP) and commitment to practicing communications skills were discussed, and course assessment and self-assessment forms were completed by participants.
CIPP
The goal of the 3-month CIPPb was to reinforce and build upon each veterinary health-care team member's development of personal communication skills following the 2-day CSTP. The same senior technical services veterinarian who participated in the delivery of the CSTP to the practice was responsible for leading the in-practice education sessions and served as the point of contact for the practice during the 3-month follow-up. The 3-month education program included in-practice visits every other week as well as telephone contact with the practice communications team leader (selected from among the participants) once weekly during the alternate weeks and electronic correspondence to reinforce specific skills and concepts introduced during the CSTP as needed throughout the program. Each in-practice visit ranged in duration from 1.5 to 2 hours, with the first weekly visit devoted to meeting with the communications team leaders at the practice to discuss the goals and tasks of the CIPP, to gain their perspectives and experiences regarding team members' use of the skills from the CSTP, and to encourage communication skills goal setting for individual team members. In addition, visual job aids were developed and circulated to help remind participants of key training points from the CSTP and to reinforce the development of their client communication skills. Examples of job aids included visual reminders placed in the clinic for team members to use the learned communication skills with clients, such as using open-ended questions to gather information and checking the client's understanding of the provided information. A box was also placed in the practice so that participants could document observations of other team members applying 1 or more of the skills from the CSTP.
From weeks 3 (the second on-site CIPP meeting) through 11, the meetings included a mini-communication module presentation of 30 to 60 minutes' duration with follow-up discussions and interactive skill activities. The 5 mini-module topics reinforced and expanded on the communication skills identified during the CSTP by means of a variety of teaching and coaching techniques. Topics covered included empathy, making a clear recommendation, communicating the value of a physical examination, delivery of consistent messages to the client by different team members, managing difficult client interactions, and talking with clients about money. Each mini-module consisted of a brief presentation including short video recordings with demonstrations of core communication skills and ≥ 1 experiential exercise. Telephone communications during weeks between the in-practice visits were scheduled for approximately 0.5 hours; these were used to review the use of job aids, observation notes placed in the communications box, and progress related to key points from the previous week's training session.
The final in-practice visit was used to acknowledge completion of the CIPP and allow participants to share their experiences regarding the use of communications skills. Plans for sustaining and reinforcing the skills learned and used during the CSTP and CIPP were also discussed at this meeting.
Statistical analysis
Mean response scores were determined for all questions scored with a Likert-type scale on the client surveys. Following consultation with 2 independent statisticians, the practice 1 response scores that were rated on a 1 to 5 scale were translated to a 1 to 10 scale by doubling. Mean responses for each question across all 4 practices were compared between the 2-month period before the CSTP and the 3-month period after the CSTP (corresponding to the CIPP period) by use of paired Student t tests (for normally distributed data) or Wilcoxon signed rank tests (for nonnormally distributed data). Analysis of the veterinary health-care team member surveys to compare the mean responses for each question across all 4 practices for the 3 time points of interest (before the CSTP, after the CSTP, and at the end of the CIPP) was conducted with ANOVA F tests to assess whether an overall difference existed among time points. Likert scale data were treated as interval data, which assumes that the differences in levels of responses are equidistant. If significant differences were identified with the F test, Bonferroni post hoc tests were used to test for significant differences between each pair of time points.
A mixed-model analysis with random effects to account for variation among clinics was used to test for an impact of communication skills training on 12 of the described financial metrics (mean practice transaction charge; number of examinations, recheck examinations, dental procedures, heartworm tests, vaccinations, and fecal examinations performed; combined number of doses of heartworm preventives and flea and tick preventives sold; mean transaction charge for canine patients; mean transaction charge for feline patients; total number of new clients; and total number of services performed). Potential predictor variables including a training indicator variable (before vs after the CSTP) and a time indicator (month 1, month 2, or month 3 after the CSTP or the same time in the previous year) were retained in all models. An effect of interaction between training and time was also tested for all response variables. Each of the financial metrics used as response variables during modeling was also investigated for a correlation with team members' self-reported communication skills confidence scores after the CIPP. Pearson correlations were calculated for each comparison across all practices. Statistical analysis was performed with commercially available software.c Values of P < 0.05 were considered significant unless otherwise indicated. Bonferroni post hoc tests were performed with an α of 0.0167.
Financial metrics were also evaluated for each practice by determining the percentage change for a given variable between the 3-month period after the CSTP and the same 3-month period 1 year earlier (ie, the percentage change with the CSTP). To control for year-to-year variability in practice performance, the percentage change in the same variable between the 3 months immediately prior to the CSTP and the same 3 months 1 year earlier was also determined for each practice (ie, the percentage change without the CSTP). The percentage change with and without the CSTP were then compared graphically for each variable; the percentage change without the CSTP was used as an internal control to aid in determining whether any apparent change after the CSTP was part of a preexisting pattern for the practice or an effect attributable to the CSTP.
Selected financial metrics (data reflecting the subject matter focus for communication skills relevant to the clinical setting, including the number of heartworm tests performed, number of doses of heartworm preventives sold, number of doses of flea and tick preventives sold, and number of dental procedures performed) with and without the CSTP were depicted graphically.
Results
Practice characteristics
The study sample comprised companion animal practices from suburban communities in the Midwest (n = 2), west coast (1), and east coast (1) regions of the United States; practice and staff characteristics were summarized (Supplementary Table S1, available at avmajournals.avma.org/doi/suppl/10.2460/javma.255.12.1377). Community population estimates for each practice ranged from 10,000 to 59,000. The number of veterinary health-care team members (employees) ranged from 12 to 39. Greater than 85% of team members for each practice (15/17, 12/14, 39/42, and 18/19 in practices 1, 2, 3, and 4, respectively; 84/92 [91%] overall) participated in the 2-day CSTP. The number of CIPP participants was not recorded.
Client surveys
A total of 259 surveys (57, 40, 62, and 100 at practices 1, 2, 3, and 4, respectively) were completed before the CSTP, and 312 surveys (21, 64, 120, and 107 at practices 1, 2, 3, and 4, respectively) were completed after the CSTP. Survey responses revealed a high degree of client satisfaction both before and after the CSTP; the mean scores on all survey questions ranged from 9 to 9.9 on the 10-point scale for both time periods. No significant differences were found in client responses before versus after the CSTP to any of the 9 items focused on veterinary health-care team–client interactions and client service or the 4 binary response questions regarding changes to diet or medication and scheduling of additional appointments. The remaining client survey items were qualitative data and were not evaluated.
Veterinary health-care team surveys
Scores for 19 of the 20 items that were included on all veterinary health-care team surveys differed significantly among the survey time points (Table 1). The remaining item (indicating that good client communication by all team members was valued) had an apparent increase in scores for each time point after the CSTP, but the difference was nonsignificant by ANOVA. No significant differences were found in scores for any survey items immediately after the CSTP, compared with those before the CSTP; however, scores for 16 of these 19 items were significantly greater on surveys completed after the CIPP than scores for the same items on surveys completed before the CSTP. Significant increases were also identified in scores for 16 of these 19 items after the CIPP, compared with scores immediately after the CSTP, including all 8 items used to measure the team members' confidence in their own client communication skills.
Veterinary health-care team member communication survey results prior to training, immediately after completion of an intensive practice-level 2-day CSTP, and at the end of a 3-month follow-up CIPP in a study to evaluate potential impacts of a communications training intervention on veterinary health-care team member's communication confidence, client satisfaction, and practice financial metrics.
| Survey responses | Before CSTP | After CSTP | After CIPP | ANOVA | Post hoc pairwise comparison | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| No. of responses | Mean ± SD | No. of responses | Mean ± SD | No. of responses | Mean ± SD | Before CSTP vs after CSTP | Before CSTP vs after CIPP | After CSTP vs after CIPP | ||
| A. Good client communication by all practice members is valued.* | 85 | 8.84 ± 1.81 | 84 | 9.1 ± 1.23 | 74 | 9.38 ± 1 | 0.054 | — | — | — |
| B. I have the skills to communicate effectively with clients.† | 85 | 7.89 ± 1.57 | 84 | 8.26 ± 1.25 | 74 | 9.05 ± 0.87 | < 0.001 | 0.1496 | < 0.0001 | 0.0004 |
| C. I encourage clients to ask questions.† | 86 | 8.03 ± 1.80 | 84 | 7.76 ± 2.06 | 74 | 8.88 ± 1.08 | < 0.001 | 0.5563 | 0.0063 | 0.0002 |
| D. I listen carefully to clients.† | 86 | 8.47 ± 1.53 | 84 | 8 ± 1.62 | 74 | 9.09 ± 0.94 | < 0.001 | 0.0832 | 0.0149 | < 0.0001 |
| E. I believe that we acknowledge our clients' perspectives at our practice.‡ | 86 | 7.99 ± 1.64 | 83 | 7.63 ± 1.59 | 74 | 8.66 ± 1.23 | < 0.001 | 0.2661 | 0.0146 | < 0.0001 |
| F. I am confident that clients feel comfortable talking with me.† | 85 | 8.11 ± 1.72 | 84 | 8.06 ± 1.52 | 74 | 8.81 ± 1.12 | 0.002 | 0.9777 | 0.009 | 0.005 |
| G. I initiate discussions with clients about their concerns.† | 86 | 7.92 ± 1.67 | 83 | 7.41 ± 1.96 | 74 | 8.78 ± 1.06 | < 0.001 | 0.1065 | 0.0027 | < 0.0001 |
| H. I can tell when a client does not understand a term I have used and am able to reword the phrase in more understandable terms.† | 86 | 8.09 ± 1.69 | 84 | 7.70 ± 1.56 | 74 | 8.80 ± 0.99 | < 0.001 | 0.1929 | 0.0075 | < 0.0001 |
| I. I am confident in making recommendations to clients that are clear and specific.† | 86 | 7.76 ± 1.74 | 84 | 7.60 ± 1.67 | 74 | 8.70 ± 1.14 | < 0.001 | 0.7796 | 0.0005 | < 0.0001 |
| J. I explain the value of recommendations to clients.† | 85 | 7.56 ± 1.76 | 84 | 7.29 ± 2.02 | 74 | 8.47 ± 1.11 | < 0.001 | 0.5322 | 0.0024 | < 0.0001 |
| K. My nonverbal communication with clients is as important as the words I use.§ | 85 | 8.82 ± 1.47 | 84 | 9.23 ± 1.32 | 73 | 9.56 ± 0.69 | 0.001 | 0.0861 | 0.0006 | 0.2051 |
| L. I feel efforts to improve communication are valued by the leadership at our practice.* | 86 | 8.40 ± 2.03 | 83 | 8.81 ± 1.69 | 74 | 9.09 ± 1.4 | 0.039 | 0.2745 | 0.0317 | 0.5564 |
| M. We do a good job of explaining health issues and/or procedures to our pet owners.‡ | 86 | 8.16 ± 1.57 | 84 | 7.98 ± 1.38 | 74 | 8.96 ± 0.91 | < 0.001 | 0.6331 | 0.0006 | < 0.0001 |
| N. We do a good job of explaining the cost of veterinary care to pet owners.‡ | 84 | 7.74 ± 1.8 | 82 | 7.66 ± 1.47 | 74 | 8.42 ± 1.16 | 0.003 | 0.9388 | 0.0143 | 0.0055 |
| O. We do a good job of involving pet owners in decisions about care for their pet.‡ | 85 | 8.44 ± 1.45 | 82 | 8.1 ± 1.29 | 74 | 9 ± 0.94 | < 0.001 | 0.1941 | 0.0141 | < 0.0001 |
| P. We do a good job of discussing pet care options with our clients.‡ | 85 | 8.39 ± 1.46 | 81 | 8.2 ± 1.26 | 74 | 8.92 ± 0.99 | 0.001 | 0.5938 | 0.0234 | 0.0013 |
| Q. We are interested in our clients' opinions regarding the care of pets.* | 85 | 8.13 ± 1.65 | 81 | 8.47 ± 1.25 | 73 | 9.01 ± 1.01 | < 0.001 | 0.2347 | 0.0001 | 0.0335 |
| R. We do a good job of addressing all of our clients' concerns.‡ | 84 | 7.94 ± 1.52 | 84 | 7.68 ± 1.41 | 73 | 8.78 ± 1.04 | < 0.001 | 0.4223 | 0.0004 | < 0.0001 |
| S. We effectively communicate the need for follow-up appointments and preventative pet care.‡ | 85 | 8.07 ± 1.6 | 83 | 7.81 ± 1.43 | 74 | 8.82 ± 0.96 | < 0.001 | 0.428 | 0.0019 | < 0.0001 |
| T. We effectively communicate the need for | ||||||||||
| preventative pet care products to pet owners.‡ | 85 | 8.33 ± 1.48 | 84 | 8.01 ± 1.52 | 74 | 8.86 ± 1.01 | 0.001 | 0.2897 | 0.0388 | 0.0004 |
| U. I understand the importance of educating clients about the products that would be good for their pets.‖ | 69 | 8.88 ± 1.4 | 67 | 9.18 ± 1.04 | 60 | 9.13 ± 0.87 | 0.271 | — | — | — |
| V. I understand the importance of educating clients about the services that would be good for their pets.‖ | 69 | 8.93 ± 1.46 | 67 | 9.16 ± 1.27 | 60 | 9.28 ± 0.78 | 0.240 | — | — | — |
| W. I initiate conversations with clients about the value of products that would be good for their pets.¶ | 69 | 7.84 ± 1.77 | 68 | 7.62 ± 1.8 | 60 | 8.65 ± 1.04 | 0.001 | 0.6921 | 0.0124 | 0.0010 |
| X. I initiate conversations with clients about the value of services that would be good for their pets.¶ | 69 | 7.87 ± 1.66 | 68 | 7.54 ± 1.97 | 60 | 8.75 ± 1.02 | < 0.001 | 0.4697 | 0.0067 | 0.0001 |
| Y. When discussing the importance of preventative care products, I discuss the cost of the products with the client.# | 69 | 8.16 ± 1.99 | 68 | 7.66 ± 2.37 | 59 | 8.47 ± 1.95 | 0.093 | — | — | — |
| Z. When discussing the importance of preventative care services, I discuss the cost of the services with the client.# | 69 | 8.07 ± 1.97 | 68 | 7.69 ± 2.14 | 60 | 8.47 ± 2.11 | 0.110 | — | — | — |
Four companion animal practices with 86 employees participated in the main study. Items are shown as worded in the survey; items A through T were included in the survey used for all 4 practices. Items U through Z were added to the survey used for practices 2, 3, and 4. Items shown were scored on a Likert-type scale from 1 (strongly disagree) to 10 (strongly agree). When significant (P < 0.05) differences were identified with ANOVA, pairwise comparisons were performed with Bonferroni post hoc tests; for these comparisons, values of P < 0.0167 were considered significant.
Used to measure the respondent's perception of importance given to client communication by veterinary health-care team members at the practice.
Used to measure the respondent's confidence in his or her client communication skills.
Used to measure the respondent's assessment of communication with clients by the health-care team as a whole
Used to measure the value the respondent placed on nonverbal communication
Used to measure the respondent's assessment of his or her understanding of the importance of educating clients about products or services.
Used to measure the respondent's assessment of his or her initiation of conversations with clients about the value of goods and services.
Used to measure the respondent's assessment of his or her discussion of the cost of preventive care products and services with clients.
— = Not applicable.
Survey questions were adapted from 2 sources. Nørgaard B. Communication with patients and colleagues. Dan Med Bull 2011;58:B4359, copyright © 2011 Birgitte Nørgaard. Lovoy B. Quick survey: what do you think about your veterinary job? DVM360 2011. Reprinted with permission.
For data collected with surveys for practices 2, 3, and 4 only, scores for items that addressed the team member's understanding of the importance of educating clients about products or services that would benefit the pet and scores for items used to measure the team member's assessment of his or her discussion of the cost of preventive care products and services with clients were slightly higher after the CIPP than at preceding survey times, but the differences were nonsignificant (Table 1). Scores for items used to measure the team member's assessment of his or her initiation of conversations with clients regarding the value of goods and services were significantly greater on surveys completed after the CIPP than scores for the same items on surveys completed before or after the CSTP.
Financial metrics
Subjective evaluation of financial metric data reflecting the subject matter focus for communication skills relevant to the clinical setting indicated a positive percentage change in the 3 months after the CSTP at 3 of 4 practices for the number of dental procedures performed, at 2 of 4 practices for the number of heartworm infection tests performed, and at 1 of 4 practices for the combined number of doses of heartworm and flea and tick preventives sold, compared with results for the same 3 months in the previous year (Figure 1). However, there was no significant change in any of the 12 selected financial metrics (mean practice transaction charge; number of examinations, recheck examinations, dental procedures, heartworm tests, vaccinations, and fecal examinations performed; combined number of doses of heartworm preventives and flea and tick preventives sold; mean transaction charge for canine patients; mean transaction charge for feline patients; total number of new clients; and total number of services performed) when data for the 3 months after the CSTP were compared with data for the same 3 months 1 year earlier by mixed-model analysis. Considerable variability in financial metric data was observed within and between practices over time; for example, the number of dental procedures performed, number of heartworm tests performed, and combined number of doses of heartworm and flea and tick preventives sold were summarized for practice 1 (Figure 2). Notable variability was evident in these measures for practice 1, particularly in the number of doses of heartworm and flea and tick preventives sold.
Comparison of percentage change in selected financial metrics of 4 companion animal veterinary practices between the 3-month period after a 2-day CSTP and the same 3-month period 1 year earlier (ie, percentage change with the CSTP; dark gray bars) and percentage change in the same variables between the 3 months immediately prior to the CSTP and the same 3 months 1 year earlier (ie, the percentage change without the 2-day CSTP; light gray bars) in a study to assess the potential impacts of a 2-day CSTP and 3-month CIPP on outcomes related to veterinary health-care team members' communication confidence, client satisfaction, and practice financial metrics. A—Percentage change with and without the CSTP for the number of dental procedures performed. B—Percentage change with and without the CSTP for the number of tests for heartworm infection performed. C—Percentage change with and without the CSTP for the combined number of doses of heartworm and flea and tick preventives sold.
Citation: Journal of the American Veterinary Medical Association 255, 12; 10.2460/javma.255.12.1377
The number of dental procedures performed (black bars), heartworm tests performed (light gray bars), and partial number of doses of heartworm and flea and tick preventives sold (dark gray bars) in practice 1 prior to and during the program evaluation period. Values shown for heartworm and flea and tick preventives represent one-tenth of the actual results for each month (calculated to simplify graphic illustration). The CSTP took place at this practice in late December 2013. Brackets with straddle lines indicate the 3-month periods for which the percentage change with (black lines) and without (gray lines) the CSTP was calculated. There is substantial variability over time for each of the variables of interest.
Citation: Journal of the American Veterinary Medical Association 255, 12; 10.2460/javma.255.12.1377
A significant (P = 0.017) positive correlation was detected at the end of the CIPP between veterinary health-care team members' composite self-reported communication skills confidence score and the mean practice transaction charge (r = 0.604). The percentage change in the number of heartworm tests performed in the 3 months after the CSTP, compared with results for the same 3-month period in the previous year, also had significant positive correlation with this score (r = 0.594; P = 0.042).
Discussion
Results of the study reported here revealed that intentional employee communications training offered in the complex and dynamic environment of everyday veterinary practices improved veterinary health-care team members' confidence in communications skills. Self-assessed scores for communication skills on the veterinary health-care team survey improved significantly by the end of the CIPP, compared with scores for the same items on surveys completed before and after the CSTP. Interestingly, scores for all except 1 of the 8 items used to measure this perception (a statement indicating the respondent had the skills to communicate effectively with clients) were lower (albeit nonsignificantly) on the survey taken immediately after the CSTP than on the survey taken before the training. We speculated that many participants may have had an increased awareness of specific client communication skills learned or identified during the CSTP and therefore a greater awareness of previous gaps in their own client communication skills at the time of the second survey. An increase in self-knowledge and awareness is an important critical step in facilitating behavioral change as identified in the transtheoretical model of change.47 This model of behavioral change, which has been the basis for developing effective interventions to promote health behavior change and organizational change, identifies raised consciousness and increased awareness as critical components in changing behavior.48,49 The significant improvements in scores for all survey items related to self-assessed communication skills after the CIPP, compared with the 2 earlier time points, suggested that the overall training program (the CSTP and the CIPP) contributed to improvement in team members' communication confidence.
Interestingly, among the survey items used for veterinary health-care team member self-assessment of communication skills, the 2 items with the lowest mean scores prior to the CSTP were both related to making recommendations to clients. Scores for these 2 items, which comprised statements indicating the respondent was confident in making recommendations to clients that were clear and specific and that the respondent explained the value of recommendations to clients, had the second and third greatest gains in mean score, respectively, after the CIPP. Although significant improvement in self-reported communication skills confidence does not necessarily equate directly to improved application of communication skills, other research has shown an empirical association between improved self-efficacy scores and improvement in demonstrated communication skills.50–52 It is possible that the increased employee confidence in communication skills in the study reported here, including initiating discussions with clients about their concerns, making clear and specific recommendations, and explaining the value of such recommendations, may translate into improved patient outcomes. Confidence among clinicians in clinical communication skills that focus on patient-centered care has been reported to have positive outcomes specific to clients' treatment plan adherence as well as pain control.53 In veterinary medicine, research has shown that effective communication has a positive impact on client adherence to dentistry and surgery recommendations for companion animals.6 Research results also suggest that individual engagement of veterinary health-care team members, including the opportunity to expand knowledge and enhance the individual's role in a veterinary practice, is positively associated with job satisfaction and professional efficacy.54
In the CSTP portion of the training assessed in the present study, each member of the veterinary health-care team received 2 opportunities to interact with a simulated client and gain feedback from peers and from trained and experienced facilitators. Additional opportunities to practice client communication skills during the CSTP and CIPP might have further supported and impacted team members' confidence in, and use of, the communication training they received. Research has shown that differences in the duration and format of CSTPs are associated with variations in training effectiveness. For example, a physician communication training program of short duration (4.5 hours) was found to have no significant effect on communication with patients.55 Results of a meta-analysis22 suggested that increased duration of the intervention and continued contact are associated with more effective outcomes for continuing medical education. In the present study, the CSTP included experiential activities devoted to individual role-specific communication practice, whereas the CIPP sessions were mainly devoted to training of the entire team, with less direct emphasis on specific practice roles. In future studies of communication skills training, investigators should consider focusing more on the use of booster or consolidation sessions including one-on-one role-specific coaching, shadowing of client interactions, and feedback sessions to sustain long-term beneficial effects.
Research in human and veterinary medicine indicates that video recording of learner interactions along with learner review of the recording and feedback from an experienced facilitator may further enhance the effectiveness of communication skills training.2,24,27 In the program evaluation reported here, recording and review of veterinary health-care team members' interactions were not performed because of time and resource restrictions. Inclusion of these methods in future communication training studies would provide participants with an additional opportunity to self-assess and potentially enhance their communication skills.
No significant difference was detected in the measures of client satisfaction during the 3 months after the CSTP in the present study, compared with the same values in surveys completed before the CSTP. This was not surprising, given the high degree of client satisfaction identified at all 4 practices prior to the CSTP. The high degree of client satisfaction regardless of the intervention was consistent with results of other studies5,39,56 that assessed client satisfaction in small animal veterinary practices. In general, measures of client satisfaction are known for being positively skewed,56 which makes detecting changes in this variable difficult. The high degree of client satisfaction at all 4 clinics in the present study also suggested a possible selection bias for the veterinary practices invited to participate. The high degree of client satisfaction measured suggested a possibility that the 4 practices were already attuned to client interactions and focused on delivering a positive client experience. This was supported by the fact that the owners and team members of each practice made the commitment and investment to participate in the 2-day CSTP, 3-month CIPP, and associated evaluation components of the program. Client satisfaction has been suggested to be an important means for evaluating the quality of veterinary health care in other studies.5,56 Observational research in companion animal practice has shown that appointment-specific client satisfaction is associated with client adherence to veterinarians' recommendations.6 Thus, it would benefit practitioners, veterinary practices, and practice consultants to continue to track this important source of feedback, giving careful consideration to the interpretation of results in light of the positively skewed distribution often obtained when measuring client satisfaction.
Veterinary practices are complex and dynamic environments. The training program in the present study was conducted with veterinary health-care teams working in varied practice settings with competing demands and was attended by individuals with various degrees of commitment and communication competence; however, it was still possible to achieve an overall increase in measures of team members' communication confidence. All participants in the training were assessed in the same manner; therefore, the effect on the outcomes of this intervention at role-specific levels was unknown. For example, although the entire veterinary health-care team (comprising all employees) at each practice was invited to participate in the training program, 91% of these individuals overall participated in the CSTP, and the biweekly training sessions (CIPP) were scheduled so that most employees could participate, but attendance at each session at each clinic was not reported to the investigators. It was unknown whether or how the absence of specific team members may have impacted the motivation levels of participants or the in-practice application of learned communication skills.
Although communication among veterinary health-care team members of the participating practices was not assessed, health-care team training and research with a focus on team communication has increasingly become more widespread.57 The authors of a 2010 study23 involving intensive on-site training and coaching in a veterinary practice indicated that team members anecdotally reported the greatest outcomes of the study were “enhanced teamwork, professional satisfaction, positive work environment, and long and lasting relationships with clients.” Future communication research should also consider the role of team dynamics on practice-level interventions.
In the present study, descriptive comparison of selected financial metrics (percentage change with the CSTP for the number of dental procedures performed, number of tests performed for heartworm infection, and combined number of doses of heartworm and flea and tick preventives sold in a 3-month period, compared with results for the same 3-month period 1 year earlier) suggested that the training may potentially have positive effects on some financial variables; for example, the number of dental procedures (a content area that received considerable attention during the CSTP with context and content specific training) performed appeared to have increased notably in 3 of the 4 practices after the CSTP. However, changes in financial metrics were highly variable within and between practices, and there was no significant change in any of the 12 financial metrics after the CSTP on evaluation with mixed-model analysis.
Kurtz et al36 discussed the importance of integrating content and process in health-care communication and formulated a revised communication skills guide that incorporated a content-related approach to communication during health-care visits. Combining content and process during communication training facilitates incorporation of learned communication skills into practice and helps to prevent these from being viewed as a stand-alone group of skills. Veterinary practices and practice consultants implementing communication training programs in the future should carefully consider the importance of integrating communication content and process skills to maximize communication-related behavioral outcomes.
Unlike a randomized controlled trial, the training program of this report was performed in working veterinary practice environments. Because of this, there were likely several factors that led to variability in the financial metric data. The time of year when the CSTP was performed varied among practices (September, October, December, and June), and this exposed the financial evaluations to potential seasonal variation in the demand for products and services (eg, the number of heartworm tests performed and the number of heartworm and flea and tick preventives sold). In addition, geographic variation likely influenced practice recommendation priorities, particularly those related to prophylaxis against heartworm, fleas, and ticks. As a result, the ability to detect a change in financial metrics associated with certain services may have been limited by the low frequency of recommendations made overall by veterinary health-care team members in a given practice. In addition, financial data were collected for a total of 15 months, and during this long period of time, other factors could have contributed to variability in financial metrics. These included the occurrence and timing of promotional activities for products and services, changes in practice policies, changes in product and service pricing, and changes in the types of products and services provided. Further, the measurement of financial metrics after the CSTP was completed during the 3-month follow-up CIPP, a time when participants were attempting to apply and build on their communication skills training. Subsequently, potential changes in some metrics, for example the number of annual wellness examinations performed, would not have been captured during the 3-month CIPP. In addition, the failure to detect significant effects of the training on various financial metrics could have been attributable to the short follow-up time, small study sample, or both. Other factors that could have affected variability in these metrics included turnover among team members and differences in practice culture (especially as it relates to the norms around outspoken and consistent promotion of products and services), ability of in-practice leadership to support and prioritize communication skills acquisition by team members, and regional economic differences in the demand for veterinary services. Future communication training programs may benefit from completing the full training program (CSTP and CIPP) prior to measuring the outcomes of interest, tracking financial metrics for a longer period, and accounting for more sources of variation when assessing the potential impact of communication training on practice-level financial metrics.
Each CIPP was led by a communications-trained veterinarian facilitator from an agency outside of the practice. The CIPP extended the contact time to help reinforce learning, but the program had limitations including the inherent complexity of training in a work environment and practice-to-practice variability in the social and physical settings of each practice. Further, each practice was assigned a regionally based facilitator who conducted the CIPP during different times of year, which may have influenced standardization of the educational protocol. For instance, 1 practice participated in the CSTP during the winter holiday season, which may have interfered with full veterinary health-care team participation in the subsequent CIPP. Variations in the CIPP protocol may have resulted from limitations with regard to timing, seasonal disruptions, competing practice demands, variation in the degree of support for the program among practices, and time devoted to in-practice visits by the assigned facilitator.
Overall, the present study highlighted opportunities to increase veterinary health-care team members' communication confidence by implementing an intensive 2-day CSTP followed by a 3-month CIPP. Evaluation of this program also exposed some of the challenges and factors for veterinary practices and practice consultants to consider when developing, implementing, and evaluating communication skills training in the veterinary workplace.
Acknowledgments
Funding for the study was provided by Bayer Animal Health.
All of the authors are full-time employees (KAB) or paid consultants (KKC, JBC, and DHS) for the Institute for Healthcare Communication or Bayer Animal Health (KEF).
The authors thank Sherri Rigby, Andy Plum, Brian Patrick, Michael LaRosh, Jennifer Sheehy, and Monie Yee for their assistance in facilitation and commitment to this project.
ABBREVIATIONS
| CIPP | Communication in practice program |
| CSTP | Communication skills training program |
Footnotes
American FactFinder [database online]. Washington, DC: US Census Bureau. Available at: factfinder.census.gov/faces/nav/jsf/pages/index.xhtml. Accessed May 26, 2019.
Outlines of the 2-day CSTP and 3-month CIPP are available upon request from the corresponding author.
SAS, version 9.4, SAS Institute Inc, Cary, NC.
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