Evaluating veterinary practitioner perceptions of communication skills and training

A survey was conducted among veterinary practitioners in the UK and the USA in 2012/2013. Thematic analysis was used to identify underlying reasons behind answers to questions about the importance of communication skills and the desire to participate in postgraduate communication skills training. Lack of training among more experienced veterinary surgeons, incomplete preparation of younger practitioners and differences in ability to communicate all contribute to gaps in communication competency. Barriers to participating in further communication training include time, cost and doubts in the ability of training to provide value. To help enhance communication ability, communication skills should be assessed in veterinary school applicants, and communication skills training should be more thoroughly integrated into veterinary curricula. Continuing education/professional development in communication should be part of all postgraduate education and should be targeted to learning style preferences and communication needs and challenges through an entire career in practice.

included a sample of veterinary practitioners in the UK and the USA, allowing for comparison between the two groups. The study gathered information on communication training during and after veterinary school, the degree to which training helped practitioners communicate with clients, the need for additional training, the importance of communication skills relative to clinical knowledge and in specific practice scenarios, and the challenges encountered by veterinary surgeons regarding communication with clients. A combination of closed, open and Likert scale-type questions were used. Further details on the survey and previous data are reported elsewhere (McDermott and others 2015).

Data analysis
Thematic analysis was used to analyse the responses to the open questions in the survey that related to veterinary communication gaps and needs as well as the motivation (or lack thereof ) for participating in postgraduate communication skills training. Qualitative methods are particularly well suited to analysing open questions in surveys, facilitating the exploration of perceptions and experiences, and understanding a wide range of topics Clarke 2006, 2013). Thematic analysis is one of the most commonly employed qualitative methods as it is useful for exploring and identifying patterns and themes across a data set. It can also be used to develop descriptions of phenomena explored in the research Clarke 2006, 2013).
Data were collected from the survey responses and imported into a spreadsheet and reviewed by the authors. The data were transferred to nVivo 10.0 and organised for thematic analysis. To help ensure reliability of the data (Barbour 2001), the responses were co-coded by two authors (MPMcD and IJR) using an iterative process to generate themes (broad patterns that capture important elements of the data) and subthemes (specific aspects of the themes) (Braun and Clarke 2006). Collaboration in the coding process has been cited as a means to promote clarity, transparency and integrity of the data interpretation others 2005, Cornish andothers 2013).

Response rates and demographics
A total of 1190/3000 responses were received from the UK (39.7 per cent response rate) and 584/3000 responses were received from the USA (19.5 per cent response rate). The overall response rate was 29.6 per cent (1774/6000). Mix of respondents was 57.3 per cent female (1013/1768) and 42.7 per cent male (755/1768), with similar gender mix in the UK and the USA. Range in age was 23-79 years (median age 41 years), with a higher median age in the USA (47 years) than in the UK (37 years).

Themes and subthemes
The themes identified from the free-text responses and reported in this study were (1) room for improvement, (2) why the lack of interest in further training? and (3) implications for communication training. These and emergent subthemes are presented in Fig 1, and details are presented below. Two additional themes were identified around the importance of communication skills and the hallmarks of effective communication but they were not included in this study. They concurred with a wealth of previous research but they did not add any significant new insights. Nevertheless, the fact that the respondents in this study supported the importance and elements of effective communication adds value to the learnings from the other three themes.
Theme 1: room for improvement As mentioned in the previous study (McDermott and others 2015), only 35 per cent of respondents felt the communication training they received in veterinary school prepared them 'well' or 'very well' for communicating with clients. Results from the current study suggest this is may be due to a combination of the amount and type of training received, experience in practice (which can be summarised by the comment 'it's difficult to know what one needs to do until one has had to do it') and individual ability. The majority of respondents indicated a preference for a combination of communication formats, as one noted: [You] need a combination of theory of how to deal with clients and practical to see how you perform. (Male practitioner, age 35, UK)

Discussion
In pursuing the study aims of investigating communication training gaps and challenges, motivations for further training and barriers to further training, the authors were able to identify a need for improvement in communication ability among practitioners at all levels of experience. This room for improvement has been referenced by others (Severidt 2010, Bachynsky and others 2013, McArthur and Fitzgerald 2013) and this is despite the increased emphasis on communication training in veterinary medicine. In this study, likely reasons for this result include the lack of formal training in senior practitioners, the relative inexperience in practice for more junior veterinary surgeons and individual ability in communicating.
The training gap for senior practitioners could be addressed in part by making CPD/CE more relevant to veterinary surgeons of all levels of experience.
The results of this study demonstrate how the perceived value of communication skills training, and participation in this training, could be improved by developing and promoting programme content that addresses 'real-world' communication challenges, such as cost discussions, dealing with distractions in the exam room and responding to difficult clients. The skills gap for junior practitioners could be addressed through a combination of increased emphasis on communication during veterinary school and increasing the appeal of, and support for, CPD/CE for younger practitioners. Each of these is covered in further detail in the discussion of Theme 3.
The authors' findings indicate that the lack of interest in further training (Theme 2) was due in part to lack of time and money. Since some practitioners would apparently welcome further communication training but feel their employers do not support it, we need to find ways to demonstrate and convince practice owners that time and money invested in building this crucial skill are well spent. One way to do this would be conducting studies to demonstrate the financial benefits of effective communication to a practice (eg, in client retention and improved compliance). Encouraging practices to include communication in client satisfaction surveys and promoting the benefits of effective communication to client relationships as well as to personal and job satisfaction for veterinary team members are additional ways to illuminate the value of communication training.
Bringing the training to the practice is an alternative to off-site courses that might facilitate the provision of communication skills for practice owners. After 12 months of one day per month training sessions onsite in one practice, client-centredness of consultations improved significantly for veterinary surgeons who went through the training (Shaw and others 2010).
Another barrier to participation in training was the feeling that experience was a better teacher. Though it is likely that the best communication training cannot prepare a practitioner for every communication experience she or he will encounter, it is also likely that learning by experience alone will not support the most complete development of communication competence (Kurtz 2006). An improved approach would be to combine experience with training during and after veterinary school that encompasses as many of the communication situations encountered in practice as possible (Hamood and others 2014); this also addresses another source of reluctance; a feeling that training does not adequately prepare one for the 'real world' of client communication.
Communication in veterinary practice is closely intertwined with clinical activities such as diagnostic procedures, physical examinations and treatments (Everitt and others 2013). Conversations also include topics that are unique to veterinary medicine with different topics (eg, euthanasia and cost) presenting particular challenges Lagoni 2007, Hamood andothers 2014). Communicating with a dog or cat owner is also different from communicating with a horse owner or dairy farmer (Kleen andothers 2011, Moreau 2012). Educators should ensure that training considers the various topics and audiences likely to be encountered by practitioners and the variety of challenges they represent.
The third theme identified was 'Implications for communication training'. The results of this study suggest that communication skills development be addressed in a comprehensive manner. This should begin with the selection of students for veterinary school and the prioritisation of communication throughout the undergraduate curriculum. It should continue with accessible and relevant CPD/CE offerings, so that every practitioner, regardless of personality, learning preference, level of experience or specific communication need, is equipped to communicate with clients through a career in practice (see Fig 2). This could also be achieved by incorporating communication skills content into traditional CPD/CE courses, for example, a course on heart failure, to make sure the veterinary surgeon is properly equipped to deliver important messages the owner needs to hear.
During the veterinary school recruitment process, interviews could include questions designed to gauge the communication ability of the applicant. Role-plays or other exploration of communication skills in the interview might be employed. This is Paper already done in some veterinary and medical schools (Hecker and others 2009, Hudson and others 2009, Conlon and others 2012. Once accepted into veterinary school, students should receive early reinforcement of the importance of communication skills (Chun andothers 2009, Burns andothers 2015). This emphasis should be maintained throughout the undergraduate curriculum, and this study suggests some specific ways in which this could be done.
Communication training should be interwoven with the teaching of clinical skills in the veterinary curriculum. This was done recently at Texas A&M University by combining physiological concepts, clinical application and communication with clients about the concepts in a physiology course assignment (Washburn and others 2016). Communication skills assessment might also be incorporated more completely with Objective Structured Clinical Examination stations (Bark andShahar 2006, Davis andothers 2006), including stations designed to test clinical skills. An online module about conducting a surgical procedure could include instruction on how to communicate with the client about the procedure and postsurgical follow-up (Mossop and others 2015). Implementing or expanding the use of simulated consultations (Radford and others 2003, Adams and Ladner 2004, Chun and others 2009, and peer-assisted learning including peer and/or instructor assessment, could also improve preparation for communication situations students will encounter in practice (Epstein 2007, Strand andothers 2013).
The authors' findings and recommendations are consistent with and build on those of other researchers who have studied learning preferences and motivations and barriers to participating in CPD/CE (Moore and others 2000, Dale and others 2010, Neel and Grindem 2010. CPD/CE may be made more accessible in part by accommodating the learning styles and preferences of practitioners (eg, by offering training in varied formats or by incorporating it into other more traditional courses), and by addressing the most pertinent topics at each stage in a veterinary surgeon's career Walsh 2002, Dale andothers 2013).
Digital technologies have greatly expanded the number of ways in which to receive information. Broadening the range of training formats available to practitioners, including, in addition to live offsite and practice-based training, web-accessed training modules (de Almeida and Agnoletti 2015), online professional communities (Baillie and others 2011), digital games and simulators (de Bie and Lipman 2012), training apps (Frankel 2014) and recorded programming (eg, podcasts) (Sandars 2009), could also make communication CPD/CE more practical, affordable and relevant.

Limitations of the study
While this study helped further define what good communication can offer the practice of veterinary medicine and how it may be more completely incorporated into veterinary learning, there were some limitations. The lower response rate from US compared with UK practitioners makes drawing conclusions from this audience less reliable as a representation of the practitioner community in the USA. There are also limitations in using surveys for research of this nature. Survey data usually provide less detail than interviews, which are the most common data collection method for qualitative research Clarke 2006, 2013). Unlike interviews, surveys do not permit the research to develop rapport and to ask follow-up questions, which can enhance the understanding of a topic and questions may be misunderstood or misinterpreted Clarke 2006, 2013). Finally, though the authors used a collaborative coding method to increase rigour in interpreting the themes from the data, intercoder/inter-rater reliability calculation is being employed increasingly to ensure the reliability of qualitative analysis (Vaismoradi and others 2013).
In this study, most free-text comments were made by more senior practitioners. This might have skewed the overall results, particularly regarding the state of communication skills and communication challenges faced by younger practitioners. Finally, in the words of some respondents, asking about the importance of communication in communication situations could be viewed as somewhat circular. It may be that asking the questions in other ways (eg, by asking practitioners what specific communication skills were most important when dealing with difficult topics rather than whether communication is important) could have better identified and illuminated some of the key issues and topics in the study.

Conclusions
Communication training is a valuable pursuit that should begin from the earliest days of veterinary school and continue through a lifetime in practice. While this is widely recognised, it has not been fully reflected by the emphasis on communication in undergraduate curricula or the willingness of practitioners to participate in postgraduate communication training. The authors' findings indicate that further work should be done to align communication training with individual needs and abilities, and to build on the communication training framework that has been developed in recent years. Making communication an integral part of all undergraduate and postgraduate training will help ensure that more practitioners have the opportunity to improve this essential clinical skill. Future studies should address equipping veterinary practitioners for the variety of communication situations and challenges they face. Ongoing dedication to this aspect of veterinary decision-making/practice however will yield significant and lasting benefits to the veterinary profession and the clients and patients it serves.