- Research article
- Open Access
Difficulties experienced by veterinarians when communicating about emerging zoonotic risks with animal owners: the case of Hendra virus
© The Author(s). 2017
Received: 21 November 2015
Accepted: 8 February 2017
Published: 18 February 2017
Communication skills are essential for veterinarians who need to discuss animal health related matters with their clients. When dealing with an emerging zoonosis, such as Hendra virus (HeV), veterinarians also have a legal responsibility to inform their clients about the associated risks to human health. Here we report on part of a mixed methods study that examined the preparedness of, and difficulties experienced by, veterinarians communicating about HeV-related risks with their clients.
Phase 1 was an exploratory, qualitative study that consisted of a series of face-to-face, semi-structured interviews with veterinary personnel from Queensland, Australia (2009–10) to identify the barriers to HeV management in equine practices. Phase 2a was a quantitative study that surveyed veterinarians from the same region (2011) and explored the veterinarians’ preparedness and willingness to communicate about HeV-related risks, and the reactions of their clients that they experienced. The second study included both multiple choice and open-ended questions.
The majority of the participants from Phase 2a (83.1%) declared they had access to a HeV management plan and over half (58.6%) had ready-to-use HeV information available for clients within their practice. Most (87%) reported “always or sometimes” informing clients about HeV-related risks when a horse appeared sick. When HeV was suspected, 58.1% of participants reported their clients were receptive to their safety directives and 24.9% of clients were either initially unreceptive, overwhelmed by fear, or in denial of the associated risks. The thematic analysis of the qualitative data from Phases 1 and 2a uncovered similar themes in relation to HeV-related communication issues experienced by veterinarians: “clients’ intent to adhere”; “adherence deemed redundant”; “misunderstanding or denial of risk”; “cost”; “rural culture”; “fear for reputation”. The theme of “emotional state of clients” was only identified during Phase 1.
Warning horse owners about health and safety issues that may affect them when present in a veterinary work environment is a legal requirement for veterinarians. However, emerging zoonoses are unpredictable events that may require a different communication approach. Future training programs addressing veterinary communication skills should take into account the particular issues inherent to managing an emerging zoonosis and emphasise the importance of maintaining human safety. Veterinary communication skills and approaches required when dealing with emerging zoonoses should be further investigated.
Veterinarians routinely communicate with their clients about a range of topics including animal health, wellbeing and lifestyle issues, animal-human interactions, animal behaviour, end-of-life decisions and cost for services provided . However, some veterinarians have reported feeling uncomfortable communicating about some of these topics: diagnosis, treatment options (including euthanasia) and cost. [2–5] For example, some veterinarians found the conversation about veterinary fees difficult due to apprehension about clients’ reactions, which may range from upfront acceptance; to suspicion; to disagreement or refusal to comply with a treatment plan; to a client not returning to the practice [6–8]. Communication between veterinarians and their clients can by affected by a number of factors: 1) communication skills of veterinarians; 2) misalignment between veterinarians’ and clients’ motivations 3) type of situation: “routine” vs “crisis” ; 4) perceptions of clients about the role of veterinarians; 4) veterinarian’s ability to communicate with the whole spectrum of clients, and 5) clients’ ability to understand the message [3–5, 8–26]. However, clients’ adherence with veterinary recommendations and directives has been shown to improve with a “client-centred” communication approach .
Breakdown in communication between veterinarians and their clients may affect animal health outcomes and the level of client satisfaction . Poor communication may also have serious occupational health and safety repercussions for both veterinary personnel and animal owners. In Australia, for example, veterinarians have a legal responsibility to prevent their staff and clients from becoming exposed to chemical, physical or infectious risks in the veterinary work environment . This is particularly relevant when managing zoonoses, infectious diseases transmissible from vertebrate animals to humans. Veterinary mitigation of known zoonoses has been reported as being less than adequate; leading to occupational infection of veterinary personnel, veterinary students and animal owners [29–34].
The relatively recent emergence of Hendra virus (HeV) in Australia has further highlighted these veterinary deficiencies and the challenges faced by veterinarians when managing a previously unknown zoonosis . Since 1994, HeV has spilled-over from flying foxes into horses on at least 52 occasions and in seven instances into humans: four veterinary personnel (two died, two survived); a horse trainer (died); a stable hand (survived) and a horse owner (died) [35, 36]. Transmission from horses to humans is via exposure to bodily fluids, including blood, from an infected horse which may have been shedding viral HeV particles 2 days prior to developing clinical signs [35–37]. Although infection is rare, the mortality rate is 57% in humans, hence its health and safety significance for veterinarians and horse owners [35, 36].
When a horse is suspected of HeV, veterinarians are mandated to notify the biosecurity authorities; and while awaiting field support from these authorities, they need to inform horse owners about the risks involved and, if necessary, instruct them about infection control (IC) strategies to mitigate these risks . Failing to do so would have legal repercussions for veterinarians and their practices [28, 39]. Hence, from a health and safety, legal and business perspective, it is important veterinarians are able to communicate with clients effectively about zoonotic risks.
A mixed methods exploratory sequential design was used (Fig. 1) . The aim of Phase 1, a qualitative exploratory study, was to identify the barriers to, and enablers of, HeV management in private veterinary practices in Queensland (Qld), Australia (Fig. 1) [40, 41]. Phase 2 of the study consisted of three cross-sectional studies (Phases 2a, 2b, 2c) (Fig. 1) which sought to further examine the barriers to HeV management and veterinary IC identified during Phase 1 . The design of the survey tools used in the second phase of the study was informed by the results obtained during Phase 1 of the study [40, 41]. The first cross-sectional study (Phase 2a) focused on the issues surrounding HeV management, including risk communication between veterinarians and horse owners . Only the part relevant to HeV-related risk communication with clients from Phase 2a is presented here. The research designs and protocols and some results from Phases 1 and 2 have been published elsewhere [40–42]. The qualitative components of the overall study complied with the qualitative research guidelines on relevance, appropriateness, transparency and soundness of research methodology (RATS) [44, 45].
Phase 1 consisted of a series of 21 semi-structured, face-to-face in-depth interviews with veterinary personnel from 14 private practices providing equine services along the eastern coast of Qld, Australia, between December 2009 and September 2010 [40, 41]. The purposively recruited participants included thirteen males and eight females between the ages of 28 and 63 years. Eight were veterinarian employees, ten were principal veterinarians who estimated spending between 2 and 100% of their time working with equine patients. Two veterinary nurses who worked regularly with equine patients and one practice manager were also interviewed. Participants were all recruited within the known distribution range of HeV [40, 41]. Nine worked in practices located in areas classified as metropolitan, nine in rural areas and three were remotely located [40, 41]. The questions included in the interview guide were developed after consultation with a reference group which included private veterinarians, biosecurity and health and safety government representatives, members of the Australian Veterinary Association and Equine Veterinarians Australia, and public health and veterinary academics (Additional file 1). The open-ended questions explored the participants’ experiences and views about the barriers to and enablers of HeV management and related IC practices. Participants were not asked specifically about possible communication issues, but most participants spontaneously broached the subject during the interviews.
During Phase 1, veterinarians reported having experienced various degrees of difficulty communicating HeV-related risk information and risk mitigation instructions to clients who, in some instances, were akin to lay assistants . Following these findings, communication issues between veterinarians and their clients were further investigated during Phase 2a, along with other issues identified during Phase 1 . Phase 2a consisted of a cross-sectional postal survey of all veterinarians working in private practice in Qld between June 2011 and September 2011 . However, only those who had provided veterinary services to a horse patient at least once in the 12 months prior to taking part in the survey were eligible to participate in the study. Aside from a number of socio-demographic, education and professional questions, participants were asked: 1) if they had access to a formally documented HeV management plan within their practice; 2) if the HeV management plan contained information for horse owners about HeV and flying foxes; 3) how often they provided HeV information and safety instructions according to the health status of a horse (healthy or sick); and 4) how often they instructed a lay assistant about the potential risk of exposure to HeV depending on the health status of the horse (Additional file 2). Frequency of HeV communication with clients was recorded as “always”, “sometimes”, “rarely”, “never”. Participants were also asked open-ended questions about the reactions of lay assistants/horse owners in regards to HeV risk communication and safety instructions when HeV was suspected. The survey was pilot-tested with three veterinarians from the target population who provided feedback on wording, format, and appropriateness of questions. Very few, and only minor, modifications were made.
Each participant was assigned an individual and a practice alphanumeric identifier (V* for veterinarians, VN* for veterinary nurses, PM* for practice manager, P* for practice). The iterative thematic analysis of the qualitative data collected during Phase 1 yielded six main themes, including “risk and risk mitigation communication” . The data coded to this particular theme were subsequently reanalysed thematically for further units of meaning in order to better conceptualise the communication issues between veterinarians and their clients. This process was repeated on several occasions by the first author (DM) and outcomes were reviewed by the last author (RS) for congruence and meaningfulness within the context of the management of HeV in private veterinary practices.
Access to HeV management plan and HeV-related risk and safety communication to horse owners and/or lay assistants and their reactions according to 200* participants during the winter of 2011. (Phase 2a)
Frequencies (relative frequencies)
HeV management plan in the practice (n = 195)
Are the following information documents available in the practice
Information sheet about HeV for horse owners (n = 191)
Information sheet about flying foxes for horse owners (n = 191)
Provision of HeV risk related education to horse owners if horse is healthy (n = 189)
Always or sometimes
Rarely or never
Provision of HeV risk related education to horse owners if horse is sick (n = 191)
Always or sometimes
Rarely or never
How often did veterinarians instruct lay assistants of potential risk of exposure to HeV if horse was healthy (n = 186)
Always or sometimes
Rarely or never
How often did veterinarians instruct lay assistant of potential risk of exposure to HeV if horse was sick (n = 189)
Always or sometimes
Rarely or never
Lay assistant’s reaction to risk communication about HeV (n = 133)
Unreceptive but comply
No lay assistant used
Lay assistant’s reaction to safety instructions when HeV suspected (n = 124)
Unreceptive but comply
Never had to or help not used
Both studies received approval from the James Cook University Human Ethics Committee (approvals no.H3513, no.H3687).
All of the veterinary personnel interviewed were aware of their legal responsibilities in regards to HeV-related risks to human health and had some level of HeV management plan in place. The analysis of the data coded to the theme “Risk and risk mitigation communication” yielded a further seven subthemes relating to the reported reactions of horse owners to veterinary advice and instructions about IC and HeV management: 1) “Clients’ intent to adhere”; 2)“Adherence deemed redundant”; 3) “Misunderstanding or denial of risk”; 4) “Cost”; 5) “Rural culture”; 6) “Fear for reputation”; and 7) “Emotional state of clients”.
A total of 1604 potentially eligible veterinarians were sent a survey; 200 veterinarians returned their questionnaire . Not all participants answered all questions. A response rate could not be calculated because the denominator (the total number of veterinarians who had treated a horse in the past 12 months) was unknown.
The socio-demographic, professional, educational and practice profile of participants have been presented elsewhere . The majority of respondents were female (52%), aged 40 years of age or older (58%), who had graduated from a Qld university (78%) and worked in a practice located in a highly to moderately accessible area (63%) as defined by the Accessibility/Remoteness Index of Australia . Over half of the participants were employees (51.8%), worked full-time (89.5%) in mixed practice (79.3%) and the majority had access to a formalised HeV management plan (83.1%) . Most of them reported providing veterinary services to equine patients at least weekly (77.4%) . Two thirds had dealt with at least one potential case of HeV (66%) and 61.5% had attended an IC-HeV management training workshop in the previous 12 months .
More than half the participants reported their HeV management plan included an information sheet about HeV for horse owners (58.6%) (Table 1). Less than half the participants (46.6%) “always or sometimes” provided HeV-related education to horse owners when a horse appeared healthy while most (87%) did so when a horse appeared sick (Table 1). The proportion of participants who reported “always or sometimes” instructing lay assistants about the potential risk of exposure to HeV according to apparent health status of horse were similar to those of participants providing HeV education to horse owners (Table 1).
Of the 48 participants who answered the open-ended questions, 41.4% reported lay assistants/horse owners usually were receptive to HeV-related information and willing to adhere with safety instructions, 19.5% reported lay people were often overcome by fear and 11.3% considered they were in denial about the information provided (Table 1). The number of participants (58.1%) reporting lay assistants being receptive and willing to adhere with the safety instructions increased when a horse was suspected of being infected with HeV (Table 1).
The thematic analysis from Phase 2a yielded similar themes to those relating to risk communication identified during Phase 1, with some variations within subthemes. One of the sub-themes identified during Phase 1, “emotional state of clients”, did not recur in Phase 2a.
Phases 1 and 2a: triangulation of qualitative data
Each of the themes below are illustrated by selected quotes from participants’ responses collected during Phases 1 and 2a.
Clients’ intent to adhere
“I find great difficulty in dealing with owners because it is a power play, and ultimately we are responsible of the safety of all involved. But some owners don’t believe that, which compromises the legal situation. We usually end up taking the risk out of concern for the welfare and wellbeing of the horse.”(V4/Pc)
“I have not had problems with owners complying … You just need to make them aware of the situation and the risks involved.” (V17/Pm)
“[Horse owners] comply as they have been informed and educated about the risks.” (P3553)
Adherence deemed redundant
“The owner had already spent half a day with the sick horse, so he declined the mask because [he] thought exposure had already happened.”(V7/Pa)
“Most clients refuse PPE as they have already been handling the horse, so they don’t feel it necessary to use PPE.”(P2444)
“[Horse owners] usually have been in very close contact with horse. So in theory, they have been exposed before vet has examined/tested the horse.”(P3221)
Misunderstanding or denial of risk
“You have to protect yourself first and foremost, but owners don’t see that way.”(V8/Pe)
“People don’t listen.”(V14/Pj)
“Usually [horse owners] make mistakes despite explicit instructions.”(P4002)
“They are in denial and think you are overreacting.”(P3472)
“Lay assistants are often reluctant to consider the disease. A lot of people don’t know anything about it.”(P2097)
“It is difficult to explain biosecurity to people with no prior [understanding of the] concept.”(P4002)
“I had one horse who came down with EI [Equine influenza] … and the next thing the others [horses] did too because the owners did not listen to what you said.”(V14/Pj)
“Sometimes owners put too much pressure … not to use infection control to lower cost, but it increases the risks.”(V1/Pa)
“Cost is an issue … What if the case turns out to be negative? How do you justify it [cost]?”(V10/Pg)
“Clients will not accept extra cost … for what they consider to be unnecessary PPE.”(P2925)
“[Some say] if you want to test the horse why don’t you pay for it! … There would be cases out there that have not been reported because of the cost.”(V14/Pj)
“We were following biosecurity measures … people were driving in out of properties with the attitude of: “She’ll be right [it’s alright], I won’t pet the horses.”(V7/Pa)
“My typical rural horse owner refuses to accept extra cost for exams and treatment of mildly ill horse.”(P2227)
“In more rural situations you tend to think you are being a bit of a Wally [silly] dressed up [in PPE] for minor issues.”(V10/Pg)
“[In rural settings] The cautious vet will often end up looking like it was a stupid fuss about nothing.”(P2227)
Fear for reputation
“Owners generally become nervous. They worry about gossip spreading about potential HeV cases and possible media involvement.”(P2717)
“I am worried owners might not notify of infectious diseases [including HeV] occurrences because don’t want to be in the public eye.”(V1/Pa)
“The racehorse trainers don’t like to see a vet in a suit [PPE]. They tend to panic. If a horse suddenly dies in a riding school, they are obviously very nervous. … [They] worry their horses may be put in quarantine. It’s a big threat to them.”(V18/Pn)
Emotional state of clients
“The owners … refused testing because if … positive for HeV they would have to euthanise the horse. They considered their horses like their children and said: “I wouldn’t euthanise my own child”.”(V9/Pf)
“There was a family … all sobbing and cradling the horse’s head. No matter what I said they weren’t listening. Their emotions overrode their ability to follow my instructions.”(V14/Pj)
“Clients sometimes think that vets and nurses don’t care. They don’t understand when you tell them they cannot comfort their horse, they cannot approach their horse or bury it where they want.”(VN2/Pe)
“The vet … was worried it may have been Hendra. [He] treated the horse for its clinical signs, sent the samples off and as usual you get into the frustration of waiting for results. … The clients were phoning us and we’d have to say no we really don’t want you to go near the horse. We told the client we can come out and give the horse more pain relief but that is it. They then phoned another practice. We sent the people a bill and they then wrote us a letter telling us how horrible we were and how distressed their daughter was.”(V12/Ph)
The aim of the overall mixed methods study was to identify and understand the factors affecting the management of an emerging zoonosis: HeV, and the related veterinary IC issues experienced by private veterinary practitioners. The results presented here focused on a subset of the study that examined the HeV-related risk communication challenges between veterinarians and their clients. Most participants from Phases 1 and 2a reported having had access to a HeV management plan and endeavouring to inform their clients about the health and safety risks involved when managing a suspected or confirmed case of HeV. Although, this information was conveyed to horse owners or lay assistants, participants from both phases of the study highlighted a number of communication issues that affected several aspects of HeV management. While some horse owners were receptive to information and safety directives regarding HeV-related risks to animal and human health, others were reportedly unreceptive to these recommendations. Reasons for lack of responsiveness from horse owners included: 1) exposure had already occurred; 2) risk was not properly understood or was denied; 3) scepticism about the risk within the rural culture; 4) cost of IC and/or testing for HeV; 5) fear of long-term detrimental effect to personal or business reputation; and 6) emotional state of clients. Participants in both studies reported that the lack of co-operation from some clients hampered their efforts to follow official guidelines when managing a potential HeV outbreak. Some participants went further by stating that these communication issues prevented them and/or their practice from fulfilling their workplace health and safety and biosecurity legal responsibilities.
Private veterinarians managing early HeV outbreaks were confronted with several challenges including: slow pattern of HeV emergence, overcoming work culture with poor IC standards and misconceptions about zoonotic risks; lack of experience managing emerging zoonoses; lack of professional and governmental leadership; dispatching samples for diagnosis; and managing a biosecurity, public health and occupational health and safety issue in the context of a private business [40, 41, 47–49]. Regardless of these difficulties, veterinarians are required to communicate effectively with their clients about the associated risks to human health and to encourage horse owners to adhere with veterinary risk mitigation advice. Clients’ adherence with veterinary recommendations has been shown to improve when a “client-centred care” approach is used in consultations and this approach is based upon a collaborative interaction between the veterinarian and the client which involves shared decision making to support adherence with veterinary recommendations . Hence, there is a growing impetus to design and provide adequate training for veterinary students and practising veterinarians to improve their communication and relationship building skills with their client [3, 4, 50]. Some of the veterinarians interviewed and surveyed for this study did not seem to experience any difficulty communicating with their clients about HeV risks or ensuring adherence with their IC directives; while others found it difficult. The communication skills of these participants may have been acquired through training and experience and/or been an innate personal quality. Since Phase 1 started before a State-wide government campaign of information about HeV management, some veterinarians may have found it difficult to communicate with their clients because they were insufficiently informed about the related risks or lacked confidence in their knowledge of the risks . Some early career veterinarians have also reported having been misinformed about the risks of HeV because of discrepancies in undergraduate curricula between Australian universities . So, unless veterinarians are adequately informed about a particular zoonotic risk it is likely they will experience some difficulties communicating with clients about the associated risks. Furthermore, it has been suggested that communication about risks related to animal diseases that could affect human health directly (zoonoses) or indirectly (affecting food safety) is not the sole responsibility of veterinarians and should be led by relevant government agencies . In the case of HeV, two independent reports and an Ombudsman’s report about the response of the Qld government to the early HeV outbreaks made similar recommendations [47–49].
When faced with a potential case of HeV, some clients were described as being fearful of the risks, or disbelieving the severity of the risks. This may have been due to a lack of knowledge and understanding about the risks associated with this emerging zoonosis. Kung and colleagues (2013) reported that horse owners in the geographic distribution range of HeV had inconsistent knowledge about the disease. In addition, although more than half recognised HeV was likely to occur in their area, only a third would think of HeV if their horse became ill . Moreover, they also reported inconsistent uptake of the recommendations provided to horse owners in terms of minimising the exposure of horses to HeV . Scheman and colleagues (2011) found that horse owners not directly involved in the horse industry had much lower perception of risk and lower adherence with biosecurity advice during an equine influenza outbreak than horse owners directly involved in the industry . Veterinarians may therefore need to assess a client’s level of prior knowledge about a particular risk, zoonotic or otherwise, in order to tailor the risk communication message.
Research suggests that generally clients perceive veterinarians as the animal health professional equivalent of their own physician . Yet, participants of both Phases 1 and 2a reported that the expert information, advice and assessment of the risk they provided was overlooked or ignored by clients. This seemed to occur more frequently in rural areas where local traditional beliefs prevailed over veterinary knowledge. Australian horse owners from rural areas have also previously been found to overlook preventive veterinary healthcare more often than those from urban areas . This is in contrast with other research which showed that animal producers recognised veterinarians as experts in animal biosecurity; while domestic animal owners did not value veterinary expertise other than when an animal appeared seriously ill [21, 24, 25]. The lack of trust in veterinary expertise may need to be further explored in order to understand its origin and its effect on the veterinary-client relationship. Veterinarians need to be aware of the way in which they and their expert opinion is perceived by clients. It has been suggested that veterinarian-client trust issues could be overcome by veterinarians establishing a relationship built on an inclusive collaboration with clients, which is more likely to yield client cooperation [17, 27]. However, in the case of the management of a lethal emerging disease such as HeV, biosecurity and occupational health and safety take precedent which may affect the dynamics of the client-centred care approach.
In Australia, HeV is a notifiable disease and veterinarians are legally responsible for warning their clients about risks and providing them with occupational health and safety procedures to avoid exposure [28, 35]. Despite holding this responsibility, veterinarians do not have the legal authority to enforce client’s adherence with veterinary health and safety directives . This can leave private veterinarians vulnerable to legal liability. A client experiencing a negative health outcome as a result of non-adherence with veterinary instructions could be interpreted as veterinary malpractice or negligence . However, veterinarians have the legal option to refuse services if they deem a work situation unsafe . The personal, professional and business interests of veterinarians which are vested in having clients adhere with occupational health and safety recommendations may differ from clients’ motivations when seeking veterinary advice. This misalignment of motivations may also be the source of miscommunication. In this study, the attitudes of some clients, as perceived by veterinarians, appeared to be based on: the misperception or misunderstanding of the risks involved; financial and reputation concerns; and/or emotional state of clients. This mismatch between veterinary and client views is not uncommon in veterinary practice [16–20]. For example, some clients tend to focus on the wellbeing of the animal, while veterinarians focus on delivering information about the health status of the animal from a clinical perspective [16–20]. Sayers and colleagues (2014) found that although some farmers viewed veterinarians as the experts, their motivations were very different from those of their veterinarians . While farmers were more motivated by the health of their animals, veterinarians were motivated by cost benefits and legal requirements . When a client did not expect or believe a HeV diagnosis, the cost incurred by the management of HeV was more likely to become an issue that was reported by several participants from Phase1 and 2a. Other cost issues associated with transport of biological samples and diagnostic testing for HeV have been previously reported . In some cases the level of legal responsibility combined with the difficulties in communicating with clients rendered the situation too burdensome for some veterinarians, who decided to cease equine practice . Veterinarians who continue to provide veterinary equine services, may need to recognise that clients have their own motivation and emotional drives. These considerations should be integrated into a client-centred approach to communicating with clients in order to improve the veterinary-client relationship and yield better outcomes, including health and safety, for all.
One underlining element that may have also hampered the communication between veterinarians and horse owners was the topic of conversation: risks surrounding an emerging zoonosis. Emerging zoonoses are unknown and unpredictable events. Prior to 2011, the epidemiology of HeV was not fully elucidated and outbreaks were rare . Suspecting a horse of being infected with HeV represented an unfamiliar scenario for most horse owners and veterinarians. For example, the case definition of HeV was non-specific [8, 41, 54]. It was also later found that infected animals could shed viral particles up to 2 days prior to developing clinical signs, which means the risk could be present but not apparent . The HeV-risks were therefore not easily identifiable. Furthermore, in order to efficiently manage a potential outbreak, a veterinarian would need to not only first suspect HeV, but also to promptly implement an appropriate management plan . Mitigating a severe but ambiguous occupational risk in a short amount of time would be akin to dealing with a crisis situation, which may have affected the interactions between veterinarians and their clients. Telg (2013) differentiates between “risk communication”, about the safety of certain known scenarios and “crisis communication”, which addresses unpredictable risks . The former proactively aims to prevent known unsafe events, while the latter tends to react to an unforeseen situation. The slow and erratic pattern of emergence of HeV was anything but predictable and has been reported to have hindered many aspects of HeV management . The attributes necessary to communicate effectively during a crisis situation may differ from those required during routine interactions; this requires further investigation within the veterinary context. This aspect of veterinary communication is likely to become more relevant as an increasing number of emerging infectious diseases are zoonotic in nature and veterinarians are more likely to be confronted with unpredictable zoonotic events in the future [55, 56]. Veterinarians have to be better prepared to manage low incidence, high-consequence pathogens such as HeV .
Since this study was undertaken, some of the issues have been addressed by government agencies through the Intergovernmental Task Force, professional peak bodies and the National Hendra Virus Research Program [58, 59]. For example the HeV management guidelines and recommendations to veterinarians have been widely distributed throughout Qld and the cost of PPE is now also subsidised by the government . Although this has helped improve the management of potential cases of HeV, some veterinarians still fail to comply with biosecurity directives as the recent prosecution of three veterinarians, who failed to protect themselves and/or inform and instruct their client about the risks of exposure to HeV, demonstrated . These prosecutions would have serious implications for the veterinary profession if the veterinarians concerned were to be charged in the absence of any adverse effect of the putative exposure to the virus. These prosecutions may also have implications for the medical and nursing professions because although breaches of IC occur very frequently in hospitals and clinics, they currently do not result in any legal workplace health and safety action, particularly when no harm arises from the lapse . In addition, communication about HeV has become more complicated and controversial as Qld veterinarians refuse to examine horses that have not been vaccinated against HeV .
There were several limitations to this study. The results presented here were part of a larger mixed methods study which focused on the perspectives of veterinarians only and not that of their clients. Phase 1 of the study did not specifically set out to examine communication issues, however, once this topic emerged as an important theme it was further explored during Phase 2a. Not all veterinarians who participated in Phase 2a answered the open-ended questions, and the research tool did not permit the clarification of responses of those who answered these questions. This may have introduced a bias towards those who experienced communication difficulties more frequently, and may also be the reason why one of the themes from Phase 1 did not recur during Phase 2a. However, this was not quantified during the survey. Nevertheless, the triangulation of qualitative data from both phases proved valuable in crystallising several factors affecting HeV-related risk communication between veterinarians and their clients. However, in order to fully understand the communication issues between veterinarians and horse owners it would be necessary to also explore the views of the latter.
Although, some of the communication issues experienced by veterinarians, and reported in these studies, were similar to those experienced during routine veterinary practice, other issues were associated more specifically to the emergence of HeV. When faced with an emerging zoonoses, veterinarians need to be promptly informed of the risks involved to give them the necessary knowledge to assess and explain the risks to their clients. In turn, veterinarians need to acknowledge that in such circumstances their clients are likely to lack the necessary information to appreciate the related risks and that a collaborative approach to communicating is likely to help get the message across. There needs to be further investigation of the particular skills or personal attributes that are necessary to communicate effectively in these kinds of crisis situations, emerging zoonotic outbreaks, within the veterinary context in order to better train existing and future veterinarians. Veterinarians also need to be aware of the ways in which their expertise is perceived and the motivation of their clients, in order to achieve better communication. This could be achieved by implementing a client-centred approach to veterinary communication with the aim of not only improving the veterinarian-client relationship but also achieving positive health and safety outcomes for both veterinary staff and their clients when dealing with zoonotic risks.
The authors would like to thank all private veterinary practices and their staff who participated, Dr Jenni Judd who provided initial methodology advice, Jennifer Cox who assisted with interviews, Kylie Halliday who assisted with interview transcription and Susan Reilly who assisted with survey data entry.
Funding for this project was provided initially by the Australian Biosecurity Cooperative Research Centre for Emerging Infectious Diseases and subsequently by the Anton Breinl Centre for Public Health and Tropical Medicine.
Availability of data material
Due to ethical considerations in regards to participants’ privacy, data is currently only available upon request from the first author (DM). However, data is in the process of being uploaded to the James Cook University Tropical Data Hub which is regularly harvested by the Australian National Data Services where the date will utlimataly be accessible (www.ands.org.au).
DM and RS conceived the study and RS provided support and advice to DM who conducted both phases of the study. DM and RS were involved in the drafting of both research tools and the piloting of Phase 1. DM recruited participants, conducted interviews, collated and analysed data from Phase 1. JK and MN assisted in the qualitative data analysis as well as the manuscript preparation. DM implemented the survey, collated the data and analysed the quantitative and qualitative data from Phase 2a. PB assisted with qualitative data analysis as well as the manuscript preparation. DM drafted the initial manuscript which was subsequently reviewed by RS, PB, MN and JK. All authors read and approved the final manuscript.
The authors declare that they do not have competing interests.
Consent for publication
Participants from both studies were provided with an information sheet outlining the use of the data they would provide, including publication for research reporting purposes. By consenting to participate in these studies they accepted that data would likely be published in a research journal.
Ethics approval and consent to participate
Both studies presented in this manuscript received approval from the James Cook University Human Ethics Committee (JCUHEC) (approvals no.H3513, no.H3687). All participants were provided with an information sheet detailing the conditions of participation in these studies. Participation in the interview phase of the study required participants to sign a consent form as per JCUHEC requirements and pro forma. Returning a completed survey to the research team was akin to consent to participate in the survey phase of the study.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Hamood W, Chur-Hansen A, McArthur M. A qualitative study to explore communication skills in veterinary medical education. Int J Med Educ. 2014;5:193–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Coe J, Adams C, Bonnett B. A focus group study of veterinarians’ and pet owners’ perceptions of veterinarian-client communication in companion animal practice. J Am Vet Med Assoc. 2008;233(7):1072–80.View ArticlePubMedGoogle Scholar
- Dickinson G, Roof P, Roof K. A survey of veterinarians in the US: euthanasia and other end-of-life issues. Anthrozoos. 2011;24(2):167–74.View ArticleGoogle Scholar
- Meehan M, Menniti M. Final-year veterinary students’ perceptions of their communication competencies and a communication skills training program delivered in a primary care setting and based on Kolb’s experiential learning theory. J Vet Med Educ. 2014;41(4):371–81.View ArticlePubMedGoogle Scholar
- Donnelly A. Talking to clients about treatment plans and fees. Proc North Am Veterinary Conference Orlando Florida USA. 2008;22:216–8.Google Scholar
- World Health Organization. The World Health report 2000 — Health systems: improving performance. http://www.who.int/whr/2000/en/. Accessed Feb 2017.
- Coe J, Adams C, Bonnett B. A focus group study of veterinarian’s and pet owners’ perceptions of the monetary aspects of veterinary care. J Am Vet Med Assoc. 2007;231(10):1510–8.View ArticlePubMedGoogle Scholar
- Mendez D, Judd J, Speare R. Testing for Hendra virus: difficulties experienced by veterinarians in Queensland prior to 2011. Aust Vet J. 2013;91(8):323–7.View ArticlePubMedGoogle Scholar
- Mills J, Baguley P, Meehan M, Austin H, Fitzpatrick L, Parry B. Development of veterinary communication skills at Murdoch university and in other Australian veterinary schools. J Vet Med Educ. 2006;33(1):93–9.View ArticlePubMedGoogle Scholar
- Kustritz M, Nault A. Professional development training through the veterinary curriculum at the university of Minnesota. J Vet Med Educ. 2010;37(3):233–7.View ArticlePubMedGoogle Scholar
- Adams C, Kurtz S. Building on existing models from human medical education to develop a communication curriculum in veterinary medicine. J Vet Med Educ. 2006;33(1):28–37.View ArticlePubMedGoogle Scholar
- McGowan T, Pinchbeck G, Phillips C, Perkins N, Hodgson D, McGowan C. A survey of aged horses in Queensland, Australia. Part 2: clinical signs and owners’ perceptions of health and welfare. Aust Vet J. 2010;88(12):465–71.View ArticlePubMedGoogle Scholar
- Zingg A, Siegrist M. Lay people’s and experts’ risk perception and acceptance of vaccination and culling strategies to fight animal epidemics. J Risk Res. 2012;15(1):53–66.View ArticleGoogle Scholar
- Schemann K, Taylor M, Toribio J, Dhand N. Horse owners’ biosecurity practices following the first equine influenza outbreak in Australia. Prev Vet Med. 2011;102(4):304–14.View ArticlePubMedGoogle Scholar
- Kung N, McLaughlin A, Taylor M, Moloney B, Wright T, Field H. Hendra virus and horse owners — risk perception and management. PLoS One. 2013;8(11):e80897.View ArticlePubMedPubMed CentralGoogle Scholar
- Shaw J, Bonnett B, Adams C, Roter D. Veterinarian-client-patient communication patterns used during clinical appointments in companion animal practice. J Am Vet Med Assoc. 2006;228(5):714–21.View ArticlePubMedGoogle Scholar
- Shaw J, Adams C, Bonnett B, Larson S, Roter D. Veterinarian-client-patient communication during wellness appointments versus appointments related to a health problem in companion animal practice. J Am Vet Med Assoc. 2008;233(10):1576–86.View ArticlePubMedGoogle Scholar
- McArthur M. Veterinarians’ communication skills and the impact of an educational intervention: a pilot study [professional doctoral thesis]. St Lucia, Qld: University of Queensland; 2010. http://espace.library.uq.edu.au/view/UQ:218217. Accessed Feb 2017.
- McArthur M, Fitzgerald J. Evaluation of a communication skills training program for companion-animal veterinarians: a pilot study using RIAS coding. JVME. 2016;43(3):111–25.PubMedGoogle Scholar
- McArthur M, Fitzgerald J. Companion animal and veterinarians’ use of clinical communication skills. Aust Vet J. 2013;91(9):374–80.View ArticlePubMedGoogle Scholar
- Sayers R, Good M, Sayers G. A survey of biosecurity-related practices, opinions and communications across dairy farm veterinarians and advisors. Vet J. 2014;200(2):261–9.View ArticlePubMedGoogle Scholar
- Bonvicini K, Cornell K. Are clients truly informed? communication tools and risk reduction. Compend Contin Educ Vet. 2008;30(11):572–6.PubMedGoogle Scholar
- Mellandy R, Rhind S, Bell C, Shaw D, Gifford J, Fennell D, Manser C, Spratt D, Wright M, Zago S, Hudson N. Perceptions of clients and veterinarians on what attitudes constitute “a good vet’. Vet Rec. 2011;168(23):616.View ArticleGoogle Scholar
- Brennan M, Christley R. Cattle producers’ perceptions of biosecurity. BMC Vet Res. 2013;9:71.View ArticlePubMedPubMed CentralGoogle Scholar
- Buckley P, Dunn T, More S. Owners’ perceptions of the health and performance of pony club horses in Australia. Prev Vet Med. 2004;63(1–2):121–33.View ArticlePubMedGoogle Scholar
- Telg R. Risk and crisis communication: when things go wrong. 2013. https://edis.ifas.ufl.edu/pdffiles/WC/WC09300.pdf. Accessed Feb 2017.Google Scholar
- Kanji N, Coe J, Adams C, Shaw J. Effect of veterinarian-client-patient interactions on client adherence to dentistry and surgery recommendations in companion-animal practice. J Am Vet Med Assoc. 2012;240(4):427–36.View ArticlePubMedGoogle Scholar
- Queensland Government. Work health and safety Act. 2011. https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/W/WorkHSA11.pdf. Accessed Feb 2017.Google Scholar
- Gait R, Soutar R, Hanson M, Fraser C, Chalmers R. Outbreak of cryptosporidiosis among veterinary students. Vet Rec. 2008;162:843–5.View ArticlePubMedGoogle Scholar
- Weese S, Caldwell F, Willey B, Kreiswirth B, McGeer A, Rousseau J, et al. An outbreak of methicillin-resistant Staphylococcus aureus skin infections resulting from horse to human transmission in a veterinary hospital. Vet Microbiol. 2006;114:160–4.View ArticlePubMedGoogle Scholar
- Myers K, Setterquist S, Capuano A, Gray G. Infection due to 3 avian influenza subtypes in United States veterinarians. Clin Infect Dis. 2007;45:4–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Reed K, Moore F, Geiger G, Stemper M. Zoonotic transmission of sporotrichosis: case report and review. Clin Infect Dis. 1993;16(3):384–7.View ArticlePubMedGoogle Scholar
- Pohojola S, Oksanen H, Jokipii L, Jokipii A. Outbreak of cryptosporidiosis among veterinary student. Scand J Infect Dis. 1986;18:173–8.View ArticleGoogle Scholar
- Van Droogenbroeck C, Beeckman D, Verminnen K, Marien M, Nauwynck H, de Thibault de Boesinghe L, et al. Simultaneous zoonotic transmission of Chlamydophila psittaci genotypes D, F and E/B to a veterinary scientist. Vet Microbiol. 2009;135:78–81.View ArticlePubMedGoogle Scholar
- Department of Agriculture and Fisheries, Queensland Government. What is Hendra virus? https://www.daf.qld.gov.au/animal-industries/animal-health-and-diseases/a-z-list/hendra-virus/general-information/what-is-hendra-virus. Accessed Feb 2017.
- Department of Health, Australian Government. Hendra virus National Guidelines for public health units. http://www.health.gov.au/internet/main/publishing.nsf/content/cdna-song-hendra.htm. Accessed Feb 2017.
- Marsh G, Haining J, Hancock T, Robison R, Foord A, Barr J, Riddell S, Heine H, White J, Crameri G, Field H, Wang L-F, Middleton D. Experimental infection of horses with Hendra virus/Australia/horse/2008/Redlands. Emerg Infect Dis. 2011;17(12):2232–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Biosecurity Queensland, Department of Agriculture and Fisheries, Queensland Government. Guidelines for veterinarians handling potential Hendra virus infection in horses. https://www.daf.qld.gov.au/__data/assets/pdf_file/0005/126770/2913_-Guidelines-for-veterinarians-handling-potential-Hendra-virus-infection-in-horses-V5.1.pdf. Accessed Feb 2017.
- Marsh A, Babcock S. Legal implications of zoonotic disease transmission for veterinary practices. Vet Clin North Am Small Anim Pract. 2015;45(2):393–408.View ArticlePubMedGoogle Scholar
- Mendez D, Judd J, Speare R. Unexpected result of Hendra virus outbreaks for veterinarians, Queensland, Australia. Emerg Infect Dis. 2012;18(1):83–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Mendez D, Kelly J, Büttner P, Nowak M, Speare R. Management of the slowly emerging zoonosis, Hendra virus, by private veterinarians in Queensland, Australia: a qualitative study. BMC Vet Res. 2014;10:215.View ArticlePubMedPubMed CentralGoogle Scholar
- Mendez D, Büttner P, Speare R. Hendra virus in Queensland, Australia, during the winter of 2011: veterinarians on the path to better management strategies. Prev Vet Med. 2014;117(1):40.51.View ArticlePubMedGoogle Scholar
- Creswell J, Plano CV. Designing and conducting mixed methods research. Thousand Oaks, California: SAGE Publications; 2007.Google Scholar
- Clark JP. How to peer review a qualitative manuscript. In: Godlee F, Jefferson T, editors. Peer review in health sciences. Secondth ed. London: BMJ Books; 2003.Google Scholar
- Biomedical Central: Qualitative Research Review Guidelines — RATS. http://old.biomedcentral.com/authors/rats. Accessed Feb 2017.
- Australian Institute of Health and Welfare. Rural, Regional and Remote Health: A Guide to Remoteness Classifications. AIHW 2014, Canberra (AIHW Catalogue No. PHE 53) http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442459567. Accessed Feb 2017.
- Perkins N. Independent review of Hendra virus cases at Redlands and Proserpine in July and August 2008. Toowoomba; 2008. http://www.tropicalhealthsolutions.com/sites/default/files//uploaded/Perkins-report-2008.pdf. Accessed Feb 2017.
- Perkins N. Progress audit of Biosecurity Queensland response activities at Cawarral in August 2009. Toowoomba; 2009. http://www.tropicalhealthsolutions.com/sites/default/files//uploaded/Perkins-Sep-2009.pdf. Accessed Feb 2017.
- Clarke P. The Hendra virus report. In: An investigation into agency responses to Hendra virus incidents between January 2006 and December 2009. Brisbane: Queensland Ombudsman; 2011. http://www.ombudsman.qld.gov.au/Portals/0/docs/Publications/Inv_reports/Hendra/Hendra_Virus_Report_web_V1.pdf. Accessed Feb 2017.Google Scholar
- Shaw J, Barley G, Broadfoot K, Hill A, Roter D. Outcomes assessment of on-site communication skills education in a companion animal practice. J Am Vet Med Assoc. 2016;249(4):419–32.View ArticlePubMedGoogle Scholar
- Queensland Government. Veterinarian guidelines and assistance for handling Hendra virus in horses. https://www.daf.qld.gov.au/animal-industries/animal-health-and-diseases/a-z-list/hendra-virus/for-veteriniarians/veterinary-practice-pack.
- Hueston W. The risk communication challenges of mass animal destruction. Vet Ital. 2007;43(2):303–15.PubMedGoogle Scholar
- ComLaw, Australian Government. Work Health and Safety Act 2011. Division 6 – Right to cease or direct cessation of unsafe work, section 84, p76. https://www.comlaw.gov.au/Details/C2011A00137/Download. Accessed Feb 2017.
- Field H, Schaaf K, Kung N, Simon C, Waltisbuhl D, Hobert H, Moore F, Middleton D, Crook A, Smith G, Daniels P, Glanville R, Lovell D. Hendra virus outbreak with novel clinical features, Australia. Emerg Infect Dis. 2010;16(2):338–40.View ArticlePubMedPubMed CentralGoogle Scholar
- Taylor L, Latham S, Woolhouse M. Risk factors for human disease emergence. Philos Trans R Soc B Biol Sci. 2001;356(1411):983–9.View ArticleGoogle Scholar
- Jones K, Patel N, Levy M, Storeygard A, Blak D, Gittleman J, Daszak P. Global trends in emerging infectious diseases. Nature. 2008;451:990–3.View ArticlePubMedGoogle Scholar
- Belay E, Monroe S. Low-incidence, high-consequence pathogens. Emerg Infect Dis. 2014;20(2):319–21.View ArticlePubMedPubMed CentralGoogle Scholar
- Department of Agriculture and Fisheries, Queensland Government. Intergovernmental Hendra virus taskforce. 2011. https://www.daf.qld.gov.au/animal-industries/animal-health-and-diseases/a-z-list/hendra-virus/intergovernmental-hendra-virus-taskforce. Accessed Feb 2017.Google Scholar
- Department of Agriculture and Fisheries, Queensland Government. National Hendra virus research program. 2011. https://www.daf.qld.gov.au/animal-industries/animal-health-and-diseases/a-z-list/hendra-virus/intergovernmental-hendra-virus-taskforce/national-hendra-virus-research-program. Accessed Feb 2017.Google Scholar
- Buchanan K, Australian Broadcasting Corporation. Three Queensland vets face prosecution over how they managed Hendra cases. September 25 2015. http://www.abc.net.au/news/2015-09-25/vets-prosecuted-over-hendra-cases/6801422. Accessed Feb 2017.
- Stock S, Tebest R, Westermann K, Samel C, Strohbücker B, Stosch C, Wenchel HM, Redaèlli M. Implementation of an innovative hands-on training to improve adherence to hygiene rules: a feasibility study. Nurse Educ Today. 2015;36:407–11.View ArticlePubMedGoogle Scholar
- McCarthy M, Sparkes D, Australian Broadcasting Corporation. Hendra vaccine critics gain powerful supporter who takes swipe at forced vaccination rules. November 18 2015. http://www.abc.net.au/news/2015-11-18/hendra-policy-opponents-gain-new-voice/6950790?section=qld. Accessed Feb 2017.