WHAT IS FEAR FREE?
The Fear FreeSM initiative was created by Dr. Marty Becker, “America’s Veterinarian.” Its mission is to alleviate fear, anxiety, and stress (FAS) in pets and educate and inspire the people that care for them. With the guidance of a diverse advisory panel, it is a collaboration among specialists in multiple disciplines ranging from veterinary behavior, anesthesia, oncology, and internal medicine to animal welfare and training. What we all have in common is the desire to improve animal health and welfare.
Fear Free provides online and in-person continuing education programs and a certification program for veterinary professionals. The guiding principle of Fear Free is that pets need veterinary professionals to look after not only their physical well-being but also their emotional well-being. Fear Free provides tools, protocols, procedures, and guidelines on how to reduce FAS in patients and thus in clients and veterinary team members.
Currently, Fear Free certification is available only for individuals (BOX 1). However, starting in 2018, veterinary hospitals will be able to become Fear Free certified. The process will be similar to American Animal Hospital Association accreditation.
WHY BECOME INVOLVED?
- Better care. When we incorporate Fear Free techniques, our patients learn to trust us, and we are able to provide them with better medical care.
- Better medicine. Patients that are more relaxed and calm during diagnostic tests will have more accurate results. How many times have you had to disregard test results because of the stress level of your patient? Examples include hyperthermia, hyperglycemia, hypertension, tachycardia, leukophilia, and inability to evaluate orthopedic lameness because of stress-induced adrenaline release.
- Making our jobs easier. When our patients are eager to see us and are relaxed and calm, it is easier for us to provide needed veterinary care efficiently and effectively.
You might be thinking, “The way we do things here is fine. We use treats at times with our patients and provide excellent patient and client care.” You are right—you may already be using some Fear Free techniques and doing a great job of creating a relaxed and calm environment. However, with its diverse advisory panel of passionate and distinguished animal professionals, Fear Free offers a learning experience that can take your patient care to the next level.
Fear Free is about staying on the cutting edge. The Fear Free community, educational library, and toolbox routinely provide new information and resources to continue our learning and advance our skills. It is an exciting time to be involved in veterinary behavior science as new research is being published constantly.
MAIN FEAR FREE CONCEPTS
The focus of Fear Free is on preventing FAS in every patient. Young and inexperienced animals may show the best response. However, Fear Free techniques and concepts should be used with all patients, whether they are relaxed and happy to be in your care or afraid and displaying avoidance or aggression.
I wish there was a simple formula to make every visit for every patient Fear Free. However, there is no one way to make each visit a Fear Free experience. Individual animals and clients have individual preferences. The first step is noting these preferences in the pet’s emotional medical record (see Communication).
Some of the key concepts of implementing Fear Free while providing medical care include communication, considerate approach, gentle control, and touch gradient. Creating a plan of action for each patient can be a quick process that saves time and creates a more pleasant experience for the veterinary healthcare team, the patient, and the client.
Being able to recognize signs of a relaxed or stressed patient is critical to creating a Fear Free environment (BOX 2). Some signs can be subtle. We must constantly assess and reassess the patient throughout the veterinary hospital experience. When working with a patient, think of it as a 2-way conversation. Listen to what the patient’s body language is telling you and adjust the conversation accordingly to prevent the patient from escalating. It can be as simple as changing to a different treat or pausing for a second to let the patient acclimate to your touch before proceeding.
Keep an emotional record alongside the medical record for each patient. Document what worked for the patient so that during the next visit, the same techniques can be incorporated. Information that might be recorded includes the types of rewards that were effective, where the patient preferred to be examined, or the way a procedure was performed. For example, a note in the emotional medical record might read: “High-value reinforcers: canned cheese and canned dog food. Prefers to stand on a mat on the floor while having his nails trimmed. Works best to trim the rear feet first, then progress to the front feet.” During the patient’s next visit for a nail trim, the technician will have an initial plan for care and the client will be impressed with your thoughtfulness.
As defined by the Fear Free certification program, considerate approach encompasses the interaction between the veterinary team, the patient, and inputs from the environment while veterinary care is being administered. For example, when first interacting with a cat or dog, considerate approach would involve avoiding direct eye contact or leaning over the pet, turning sideways to appear less threatening, moving smoothly and calmly (fast motion can be unsettling for animals), allowing the pet to approach first, and tossing or handing treats to the pet (when medically appropriate to do so).
Creating a relaxing and pleasant experience also entails setting up the environment with the patient and client in mind. Consider the perception of the hospital from their points of view. Providing nonslip surfaces for pets to stand on, incorporating calming scents and/or pheromones, minimizing noises and using calming sounds, using LED lighting instead of fluorescent lighting, and using disinfectants with very little odor can help create a veterinary “spa” atmosphere to relax and calm not only dogs and cats, but also people.
As defined by the Fear Free certification program, gentle control is how the veterinary team comfortably and safely positions the patient to allow the administration of veterinary care with minimal restraint. It is often the restraint that the animal finds frightening, not the actual procedure. Incorporating distraction techniques (BOX 3) while providing gentle guidance and support to an animal allows many procedures to be performed safely with minimal restraint and fewer team members.
Touch gradient is a term used in the Fear Free certification program to describe how to touch canine and feline patients to minimize FAS during veterinary procedures. Touch gradient encompasses both gentle control and considerate approach. It has 2 components:
- Maintaining continuous hands-on contact with the patient through the entire procedure or examination, when possible
- Acclimating a patient to an increasing level of touch intensity while continuously measuring the patient’s acceptance and comfort
When working with large animals, such as horses, we are advised to keep our hands on them all the time so they know where we are and to avoid startling them. We can apply this same technique to our feline and canine patients to make for a more relaxed visit.
By gradually working through a procedure and responding appropriately to the animal’s response, we can minimize the amount of FAS the animal experiences, minimize the amount of restraint needed, and reduce the number of team members needed to perform a procedure. See the video below on use of touch gradient, gentle control, and considerate approach with a dog for an ear cleaning:
PLAN OF ACTION
Before starting a procedure, take a moment to create a plan of action. This will help make the experience more efficient and successful for everyone. Creating a plan of action for procedures includes the following:
1. Assess the patient
- Observe and note body language and behavioral indicators of FAS
- Continuously reassess throughout the procedure
2. Assess yourself
- Are you using considerate approach?
- Ask for help if you are feeling uncomfortable
3. Assess the environment
- Set up the environment to be patient friendly
- Remove stressors in the environment
4. Create a veterinary plan for care
- Identify reinforcers
- Rank most to least important procedures
- Plan least to most aversive procedures
- Identify stopping or pause points
- Consider the 3 Ws (where, who, what)
When creating the veterinary plan for care, first determine a reinforcement hierarchy for the patient. What does this patient enjoy that could be used as a possible distractor during a procedure or reinforcer after the procedure? Referring to the emotional medical record can help in planning, but reassess the patient’s response at every visit.
Next, rank procedures as most to least important. The veterinarian will be responsible for determining this hierarchy.
Then rank the most important procedures as least to most aversive. Determine whether there are stopping points for breaks in the procedure and what behavioral indicators for this patient will be considered stopping points. A general guideline is 3 seconds/3 tries for dogs and 2 seconds/2 tries for cats. The premise is that if a dog struggles or stops accepting a distraction for 3 seconds, then try something else. Three well-tolerated attempts/tries (or 2 tries for cats) is the general limit before you should consider rescheduling or sedation (see Prioritizing Procedures). Depending on the emotional medical record of the patient, these guidelines may be modified to fewer attempts or less time.
Once you have a high-level reinforcer for the patient, a plan for the order in which you will perform the procedures, and stopping or pause points, consider the 3 Ws.
- Where will you perform the procedure? The examination room, treatment area, or housing area? It is usually better for patients to remain where they are most comfortable. If the pet is there for a preventive care visit, can the procedure be performed in the examination room? If the pet is staying in the hospital, an examination room (if available) can provide a quiet and less active environment.
- Who will be present? If possible, it is usually best for the owner or familiar person to be present.
- What do you need to make the environment as pleasant as possible? What items do you need for the procedure? Get everything ready before the patient is brought to the area.
Always be willing to ask for assistance from other team members as needed for re-evaluation of the plan.
Procedures can be grouped into “wants” and “needs.”2
Wants are procedures that you would like to perform today. Needs are those that must be performed today because they are vital to the animal’s immediate health and waiting any length of time would be severely detrimental.
If wants are producing FAS in the patient, it does not mean the procedure will never be performed. Instead, other options should be considered, such as being willing to reschedule. Perhaps the patient has reached its tolerance for today. Another day may be better. In the meantime, schedule some fun visits so that the patient can have a pleasant experience at the hospital. The veterinarian should consider dispensing previsit pharmaceuticals.
If rescheduling is not an option—the procedure is a need—the veterinarian should consider sedation to minimize a potentially emotionally damaging experience.
WHAT CAN YOU DO?
- Become a Fear Free–certified professional by completing the online course.
- Make Fear Free part of how you interact with every patient, every client, every visit!
Through early recognition of behavioral signs of FAS and intervention, we can prevent the escalation of fear in our patients. Thus, we can facilitate pleasant associations with the veterinary hospital and the procedures we want to perform. Creating a veterinary plan for care for each patient will help facilitate a Fear Free experience for all team members. The veterinary technician plays a vital role in implementing Fear Free.
However, Fear Free is not just about the pet’s experience in the veterinary hospital. Pets actually spend a very small part of their lives in the veterinary hospital. To create pets that are Fear Free throughout their lifetime, we must offer preventive behavior care services for our clients and patients. These services will be the subject of an article in the next issue.