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Compendium January 2012 (Vol 34, No 1)

Feline Focus: Environmental Enrichment for Indoor Cats: Implementing Enrichment

by Meghan E. Herron, DVM, DACVB, C. A. Tony Buffington, DVM, PhD, DACVN

    In a previous article,1 we described our approach to implementation of effective environmental enrichment, which begins with the diagnosis of environmental features to determine how well they meet the behavior and welfare needs of indoor-housed cats. We formulate this diagnosis based on a pertinent history and physical evaluation. A pertinent history allows us to identify features of the cat and environment that may precipitate or contribute to observed behavioral and physical problems. (Click here for a detailed behavioral history questionnaire.) Physical evaluation of the environment means determination of the presence and quality of physical and behavioral resources available to the cat. As discussed in the previous article, we organize the environment into five basic “systems”—physical, nutritional, social, elimination, and behavioral—and methodically investigate each one to identify any features that may benefit from improvement.

    Our first article offered practical means of meeting cats’ environmental needs within each system. The objective of this article is to present methods for reviewing the information obtained with the client and developing an effective implementation plan. Rather than “blaming the client” for any identified environmental shortcomings, we choose to emphasize areas of improvement that the client believes can be accomplished. Effective communications skills increase the probability of implementation of and adherence to the plan.

    Communicating With Clients

    How clinicians communicate with clients affects the success of therapy because client adherence to recommendations depends in part on the veterinarian-client relationship. In medicine, as in life, improved interpersonal interactions between the caregiver (whoever in the practice is communicating with the client: veterinarian, technician, receptionist, etc.) and the client lead to increased commitment and satisfaction for all concerned.

    Every aspect of our communication, both verbal and nonverbal, affects our relationship with clients (FIGURE 1). Verbal elements of communication include what we say and how we say it. What we say needs to be calibrated to the ability of the client to understand our language. The use of technical jargon, while a useful shorthand between colleagues, can lead to misunderstanding and confusion for some clients. How we say what we say is equally important. Our cadence, tone of voice, and volume all communicate our level of empathy and concern. Nonverbal actions also speak to the client. Where and how we stand—whether our postures are “open” and welcoming or “closed” and distant—affect clients’ understanding of our message.

    One of the best ways to monitor the effects of verbal and nonverbal communication is to watch the body language of the client.2 Clients may look quizzical when they do not understand, withdraw if they feel threatened, or become distant while “processing” information (FIGURE 2). By adjusting our communication to their responses, we can improve the quality of our relationships.

    An example of a communications interaction is presented as a “value chain” in FIGURE 3 .3 A value chain is a specific, consecutive order of operations and activities in which the end product is built up, step by step, by every single operation. Every operation makes the end product more complete; every operation builds on the previous operation and adds value to the end product. The end product of a consultation value chain is the creation and maintenance of an effective relationship between caregiver and client. As shown in FIGURE 3 , the caregiver first creates rapport and trust with the client by using verbal and nonverbal processes and evaluating nonverbal responses to determine the success of his or her effort. Once trust is achieved, the client begins to disclose his or her concerns, to which the caregiver responds with demonstrations of empathy. Recognition of the presence of trust and empathy in the encounter promotes positive reappraisal of the situation by both members in the relationship. A relationship-centered approach to communications that we have found to be very helpful in guiding successful discussions about enrichment is outlined in BOX 1. Although a comprehensive discussion of effective caregiver-client communications skills is beyond the scope of this paper, a number of useful resources are available. Some of our favorites are listed in BOX 2.

    Box 1. A Stepwise Approach to Relationship-Centered Client Communicationsa,b

    Step 1. Set the stage for the interview.

    • Welcome the client.
    • Use the client’s and patient's names.
    • Introduce yourself and identify your specific role.
    • Ensure client readiness and assure confidentiality.
    • Remove barriers to communication.
    • Ensure comfort and put the client/patient at ease.

    Step 2. Set the agenda.

    • Indicate the time available for the consultation.
    • Explain your plan.
    • Obtain a list of all issues the client wants to discuss (e.g., specific problems, requests, expectations, understanding).
    • Summarize and finalize the agenda; negotiate specifics if there are too many agenda items.

    Step 3. Begin the interview with nonfocused interviewing.

    • Explain your understanding of the situation and ask about the accuracy and completeness of your account.
    • Use open-ended listening skills—silence, neutral utterances, and nonverbal encouragement—followed by reflective listening and empathetic statements as appropriate.
    • Focus the interaction as appropriate to get the client talking.
    • Obtain the client’s personal description of the problem.
    • Extend the personal story to the broader context of the problem.
    • Continue to develop a free flow of personal information.
    • Ask closed-ended questions for clarification.
    • Obtain additional data from nonverbal cues, physical characteristics, autonomic changes, accoutrements, and environment to get clues about the impact of the situation on the client (emotion seeking).

    Step 4. Continue the interview with emotion-focused interviewing.

    • Develop an emotional focus to identify the emotion(s) expressed by the client, using the following emotion-seeking questions:
      • Direct: “How did that make you feel?”
      • Indirect: “How has this affected others in your home?”
    • Address the expressed emotion(s), using the following emotion-handling skills:
      • Name the emotion
      • Understand the emotion
      • Respect the emotion
      • Support the emotion
    • Use the "core dynamic skills" (focused open-ended listening, emotion seeking, and emotion handling) to better identify and deepen the story.
    • Conclude and address any other current issues as time permits.

    Step 5. Transition to the caregiver-centered process.

    • Briefly summarize the information gained in the interview.
    • Check the accuracy of your summary.
    • Proceed to develop an enrichment plan as described in Step 6.

    Step 6. Design an enrichment plan. Once client agreement and an extended evaluation have been obtained, the following steps will help you create an enrichment plan and owner recommendations:

    • Identify the presence of factors in each of the five basic needs areas (space, food and water, litterboxes, social contact, and body care and activity) that can be changed to enrich the cat’s environment.
    • Agree with the client on which changes are most important and likely to be made.
    • Provide written recommendations.

    aCornell K, Brandt JC, Bonvicini K, eds. Effective communication in veterinary practice. Vet Clin North Am Small Anim Pract 2007;37(1):201 pp.

    bSmith RC. Patient-Centered Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:317.

    Identifying Factors to Enrich the Environment

    Identify the presence of factors that can be changed to enrich the cat’s environment. Review each of the basic needs systems (space, food and water, litterboxes, social contact, and body care and activity) in an extended evaluation questionnaire with the client. (Click here for a sample questionnaire focused on these needs systems.) First, thank the client for completing the form. Next, identify any rows marked “DK” (don’t know) and clarify the intended meaning for the client to get an answer. Then praise the owner for all “yes” answers and explore the importance of any “no” answers. Remember, the objective is never to blame the client for any deficiencies, but to identify areas of improvement in the basic needs systems that the client believes are changeable.

    There are a number of potential “solutions” within each area. We present these as options to clients, saying something like, “These are things that have worked for other clients. They might work for you, or get you thinking about something that you can do in your setting.” This “menu” approach allows us to: (1) avoid offering unworkable solutions, which are met with “yes, but…” by the client; (2) acknowledge the client’s greater understanding of their home environment; and (3) create “buy-in” to enhance adherence.

    Creating SMARTR Goals

    Once clients understand the benefits of change and have agreed on a goal, the steps to achieving it don't have to be difficult. A set of clear objectives that are well defined, measurable, realistic, and time driven is a great place to start. A simple process for writing down goals, called SMARTR goal setting, can help ensure that goals are clearly communicated, well defined, and agreed upon by all involved in the change.

    SMARTR goals are:

    • Specific
    • Measurable
    • Action oriented
    • Realistic
    • Time-driven/timely
    • Rewarded

    Let’s say, for example, that a client has an obese, inactive cat. Based on your discussion with the client, you agree that providing the cat a feeding toy will provide environmental enrichment and help increase activity. The following is an example of how the SMARTR goal process can be used to create a personalized plan to achieve this goal:

    1. Specific: Goals need to be clear, focused, concise, and well defined. Avoid general terms, and be as detailed as possible.

    • A vague example: I want to feed my cat using a toy.
    • A SMARTR specific example: I will buy a feeding toy, place half the cat’s daily food in the toy, and offer it to my cat at feeding time with the other half of the food in her bowl. Until she understands what it is, I will leave the top open so food falls out easily. Once she starts to use it, I will start with a large opening, making it progressively smaller as she learns about using the ball.

    2. Measurable: SMARTR goals can use time frames, dates, dollar amounts, product names, etc. to measure success.

    • An unmeasurable example: I will buy a feeding toy.
    • A SMARTR measurable example: I will buy a feeding toy today.

    3. Action oriented: The goal must require the client to take action, not react. Winning the lottery may be one of the few examples of achieving a goal without making much effort. However, the odds are less than one in 4 million. Check the goal to see if it includes a list of actions the client can take to accomplish it.

    • A non–action oriented example: I’ll find a store to buy a feeding toy soon.
    • A SMARTR action-oriented example: I will stop at the store my veterinarian recommended and buy a feeding toy on my way home from our meeting today.

    4. Realistic: Check to see that the goal is manageable, attainable, and believable for the client! As we know from experience, letting others set goals for us can lead to low motivation and high anxiety—low motivation because they were imposed on us, and we are expected to comply, and high anxiety because we may not understand, agree with, or be able to execute the goal in our situation. The chances for success improve when clients set goals they understand, agree with, and can accomplish.

    • A not-so-realistic example: I will keep my dogs away from this cat toy.
    • A SMARTR realistic example: I will offer the toy to my cat in a safe space where she will not have to worry about the dogs.

    5. Time driven/timely: SMARTR goals have a starting time, a timetable, and an ending time. Goals can also be broken down into smaller objectives: short-term (to be accomplished within 6 weeks), medium-term (to be accomplished within 6 months), and long-term (to be sustained for the life of the pet).

    • An example of an undefined timeline: I want the cat to start using the toy soon.
    • A SMARTR timeline: I will start using the toy this weekend, when I have time to watch the cat and troubleshoot any problems that might arise.

    6. Rewarded: As important as goal setting is, we tend to value what we are rewarded for. Clients can be “rewarded” by:

    • Being heard and involved in treatment plans (since they will be responsible for carrying them out)
    • Having clear ways to measure progress
    • Being praised for successes and helped with troubleshooting failures during follow-up consultations.
    • Seeing continued positive reinforcement of desired behaviors

    A number of factors can be used to enhance the success of SMARTR plans:

    • Write goals in positive terms.
    • Tell clients to post goals in a prominent place, so everyone in the household can stay focused.
    • Be sure the SMARTR goals are the client’s goals.
    • Stay flexible; situations can and will change as life circumstances change.

    If a SMARTR goal becomes unrealistic, change it. The key is to be clear on the objective to be achieved and willing to change tactics to match changing situations by making another SMARTR plan as necessary to achieve and maintain success.

    Box 2. Examples of Caregiver-Client Communications Skills Resources

    Web Sites

    To meet the need for communication training in veterinary practice, IHC provides training opportunities for practicing veterinarians, veterinary technicians, and other members of the veterinary team using the training materials from the Bayer Communication Project.

    The IVCI is a community of professionals whose collective goal is to enhance communication in veterinary medicine for patients, clients, and veterinarians. Communication is paramount to success in every facet of the veterinary profession, including communication with colleagues, within health care teams, with individual clients, and with the public at large.

    The FRANK Veterinary Communication Program offers veterinarians expert guidance on enriching the veterinarian-client-patient interaction, which is at the very heart of a successful clinical practice.

    Books

    • Robert Charles Smith. Patient-Centered Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. ISBN-10: 0781732794.
    • Suzanne M. Kurtz, Jonathan Silverman, Juliet Draper. Teaching and Learning Communication Skills in Medicine. 2nd ed. Oxford, UK: Radcliffe Publishing; 2005. ISBN: 1857756584.
    • Debra Roter, Judith A. Hall. Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits. 2nd ed. Santa Barbara, CA: Praeger Publishers; 2006. ISBN: 0275990176.
    • Karen K. Cornell, Jennifer C. Brandt, Kathleen A. Bonvicini, eds. Effective Communication in Veterinary Practice. Veterinary Clinics of North America, Small Animal Practice. Vol. 37, no. 1. 2007.
    • Carol Gray, Jenny Moffett, eds. Handbook of Veterinary Communication Skills. Ames, IA: Wiley-Blackwell; 2010. ISBN: 1405158174.

    Follow-Up

    One of the keys to any successful therapy program is to follow the progress of the patient. We tell clients what our follow-up schedule is and ask them to agree to a preferred method and time to be contacted. Our first contact with the client occurs within a week after initial recommendations are made, followed by repeat “check-ins” at 3 to 6 weeks, 3 months, 6 months, and 1 year. This allows us to monitor the patient’s progress, to make adjustments as needed, and to continue to support and motivate the client. It also helps to determine when the owner is becoming frustrated or having problems with the plan so that encouragement or suggestions to help keep the plan going can be offered.

    Conclusions

    Many indoor-housed cats appear to survive perfectly well by adapting to less-than-perfect surroundings. As veterinarians, however, we are concerned more with optimizing the environments of indoor cats than with identifying minimum requirements for indoor survival. Cats have a variety of unique behaviors and needs; we encourage owners to set their pets up for success by providing a diverse, behaviorally enriched environment free from physical, psychologic, and social stressors. Our current approach is to let the client choose the most appropriate intervention for his or her particular situation, and for us to effectively create and communicate a plan for change with him or her. How we communicate this information, both verbally and nonverbally, is directly related to the prognosis for success. The effectiveness of environmental enrichment efforts depends on the cat, the housing situation, the client, and the quality and dedication of the veterinary team overseeing and supporting the client’s efforts.

    Further information about environmental enrichment for indoor-housed cats is available at: http://indoorpet.osu.edu/.

    Downloadable PDF

    Dr. Herron discloses that she has received financial benefits from Ceva Animal Health, HomeAgain, and Novartis Animal Health. Dr. Buffington discloses that he has received financial benefits from commercial companies, including the Mars Scientific Advisory Council.

    References

    1. Herron ME, Buffington CAT. Environmental enrichment for indoor cats. Compend Contin Educ Vet 2010;32:E1-E5.

    2. Mast MS. On the importance of nonverbal communication in the physician-patient interaction. Patient Educ Couns 2007;67:315-318.

    3. Finset A, Mjaaland TA. The medical consultation viewed as a value chain: a neurobehavioral approach to emotion regulation in doctor-patient interaction. Patient Educ Couns 2009;74:323-330.

    References »

    NEXT: Focus on Nutrition: Pet Food Safety: The Roles of Government, Manufacturers, and Veterinarians

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