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‘No-one knows where you are’: veterinary perceptions regarding safety and risk when alone and on-call
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  1. Amy Irwin1,
  2. Janika Vikman1 and
  3. Hannah Ellis2
  1. 1 Psychology, University of Aberdeen, Aberdeen, UK
  2. 2 Glenythan Vet Group, Methlick, United Kingdom
  1. Correspondence to Dr Amy Irwin, Psychology, University of Aberdeen, Aberdeen, UK; a.irwin{at}abdn.ac.uk

Abstract

Background Veterinary work is considered high risk and involves working with a range of hazards, including large animals, high workload and long hours. A key potential hazard is making home visits and providing out-of-hours emergency care, where vets often work alone, without support and must travel long distances. The current study aimed to examine UK veterinary perceptions of safety culture, lone working and on-call tasks to gain a deeper understanding of the risk and hazards involved.

Methods An online mixed-methods survey was used to gather quantitative data relevant to practice safety culture and qualitative data regarding veterinary perception of lone working and on-call work. A sample of 76 UK veterinarians were recruited.

Results The quantitative results suggest that there may be practice safety culture issues around a lack of communication and discussion pertaining to safety, particularly in terms of maintaining personal safety. Key themes within the qualitative data included the pressure to treat patients, potentially at personal risk, and feeling unsafe when meeting clients alone and in remote locations.

Conclusion These findings indicate that personal safety requires more attention and discussion within veterinary practices, and that safety protocols and requirements should be shared with clients.

  • clinical practice
  • stress
  • veterinary profession
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Introduction

Veterinarians are persistently exposed to a variety of risks and hazards through the treatment of their animal patients. This is illustrated by a high occupational injury rate; for example, a survey of Canadian vets reported that 93 per cent of respondents had been injured at work in the previous five years.1 This injury rate is consistent across different countries including Australia (70 per cent of vets reported injury across a 10-year period2) and the USA (67.8 per cent of survey participants reported an animal-related injury3). The risk of injury has been reported as 2.9 times higher for vets than for general human physicians.4 The cause of injuries encompassed bites, kicks, falls, crushing, exposure to anaesthetic gas, needlestick and vehicle crashes. Injury types included cuts, puncture wounds, concussion, back strain and burns.1

Research indicates a variety of risk factors associated with veterinary accidents and injuries. These include lifting and moving patients,5 working with livestock,1 chemical hazards,6 driving long distances and working long hours.7 8 Risk also appears to vary across practice type. Australian research reported that large and mixed-animal practices had a recent injury rate 10 times higher than other practice types.9

Lone working

The Royal College of Veterinary Surgeons (RCVS) details the professional responsibilities of veterinarians, with an emphasis on the health and wellbeing of animals in their care. The provision of care includes 24-hour emergency services, incorporating travelling to attend patients outside the practice.10 Treating animals away from the practice base can lead to heightened risk. Australian research indicates that conducting clinical work outside the practice was associated with 55 per cent of injuries reported.11 Despite this, 38 per cent of those reporting an injury on a farm were not utilising any safety precautions (such as restraint), and some of those using safety equipment commented that the equipment was of poor quality or in a poor state of repair.11 The authors suggest that veterinarians prioritise treatment above personal safety, which may lead to failure to consider protective safety measures while working in the field.

Travelling to treat animals at the client’s home often involves the veterinarian working alone. A lone worker is an individual who engages in work without the presence of coworkers or direct supervision.12 This includes mobile workers engaging in tasks away from their fixed base, such as truck drivers, health visitors, social workers and vets.13 Lone working is associated with several risks, including the possibility of assault,14 the prospect of accident or injury,15 and a lack of help from others. Based on these risks the Health and Safety Executive advises risk management for lone workers, including assessment of employee vulnerability and any risk of aggression or violence.13 Vets may also be at risk from their human clients. A study examining Canadian vets reported that 2 per cent of the sample reported being assaulted by a client over a five-year period, and 66 per cent indicated they had experienced verbal abuse from clients.1 Jeyaretnam and Jones16 also highlight that conducting home visits and responding to emergency calls outside the practice could increase the likelihood of an attack. However, despite this potential risk for vets when answering calls alone, there is little research investigating this aspect of veterinary work.

Safety culture

Veterinarians working alone need to balance competing demands, such as personal risk versus treatment requirements, and adverse driving conditions versus duty of care to the patient. The practice safety culture may have an influence on these kinds of decision. Safety culture refers to employee perception of the value and importance of safety as evidenced through protocols, training programmes, communications and procedures.17 Safety culture can encompass the safety of both staff and patients; for the purposes of this paper, the focus is on staff safety only. Safety culture is a leading measure, whereby measurement of safety culture can be used to identify potential problem areas and produce proactive actions to improve worker safety.18

Zohar19 suggests that safety culture assessment should consider organisational-level culture, relevant to the actions of top management, and group-level culture, informed by workgroup attitudes and procedures relevant to safety. This division of safety culture has been the focus of work assessing lone worker safety culture perceptions.15 20 Lone worker safety culture has been shown to be predictive of safety behaviours across a range of industries, including trucking and general industry.15 21 In terms of veterinary practice, to the authors’ knowledge, only one study has sought to assess veterinary practice safety culture,22 and was primarily concerned with patient safety rather than the safety of the veterinary professionals. The current study seeks to expand the assessment of lone safety culture to vets with the aim of identifying potential problem areas in order to support the enhancement of vet safety through interventions.

Research aim

The current study has two main aims: first, to investigate lone worker safety culture within the veterinary context; and secondly to investigate veterinarian perception of any risks and safety issues associated with lone working (on-call and home visits). The study utilised a mixed methodology collecting quantitative data relevant to safety culture and qualitative data to explore perceptions of lone working. In both cases, given the exploratory nature of the research, objectives were generated as opposed to directional hypotheses. The research objectives were as follows:

  • R1: measure perceptions of lone worker safety culture among veterinary practitioners and identify any areas of possible concern.

  • R2: determine if individual differences (supervisory role, gender, practice type) influence perception of lone worker safety culture.

  • R3: explore veterinarian perception of lone working in order to understand the experience of home visits, working on-call and any potential safety issues.

  • R4: investigate the thoughts and feelings of veterinarians regarding lone working, risk and safety.

Methods

Participants

Participants were recruited from the UK and Ireland and included assistant vets, vets and practice partners. The only criteria for participation were that all participants should be full-time, qualified, vets.

Participants were primarily recruited using direct emails to practices listed on the RCVS online register of accredited practices. In an effort to recruit participants from a broad spectrum of practices, 1050 emails were sent out to randomly selected practices from the register over a period of six months during 2018–2019. A total of 76 participants were recruited, representing a response rate of 7 per cent. In addition to the emails sent, the study was also advertised on Facebook and Twitter. The survey was anonymous, non-incentivised, constructed using SNAP 11 Professional and included an information sheet, consent form, quantitative and qualitative questions, and a debrief.

Questionnaire

Section 1

Demographic information was collected, which included age, gender, job role, practice type, practice location, supervisory duties and years of experience.

Section 2

In order to follow Zohar’s19 suggestion that safety culture should be assessed at both the organisational and group levels, two safety culture measures were included in the current study. The first measure consisted of six items drawn from a measure of organisation-level safety culture for lone workers in industry.21 The wording was changed to produce vet-specific rather than industry-based wording, for example, ‘Top management at this company’ was changed to ‘Top management in my vet practice’. The second measure also had six items, with five drawn from a measure of group-level safety culture for workers in industry and one original item added specific to veterinary work: ‘Checks in with us when we are in unsafe neighbourhoods’.21 Both scales used a 7-point Likert scale for responses (from strongly disagree to strongly agree), with a low score (4 or less) indicating a negative safety culture.

Section 3

In order to investigate risk and safety culture in more detail, six qualitative questions were included (table 1).

Table 1

Qualitative questionnaire items, presented with associated research objective

Data analysis

Quantitative analysis

The initial data set included 77 completed surveys; one survey was removed due to spurious qualitative responses. Three of the surveys had missing data points, but due to the small number of respondents these surveys remained in the sample and part of the analysis. The quantitative safety culture scales were first examined at the item level and then summed (none of the items were reverse-coded) and a mean score produced for each of the two scales. Analysis of variance (ANOVA) was used to determine if safety culture scores differed according to gender, practice type or supervisory role.

Qualitative analysis

The aim of the qualitative analysis was to gain a better understanding of how vets perceived working alone and on-call, including their emotions, thoughts and attitudes. The approach best suited for this type of analysis was considered to be inductive thematic analysis.23 24 This is a bottom-up approach, and so the codes and themes generated closely follow the content of the survey data. The analysis was conducted in six phases, primarily by the first author.

Phase 1 was a familiarisation process where the text data were read multiple times with preliminary observations noted. In phase 2 initial codes were initially generated at a semantic level and were designed to simply describe the content. Later interpretative codes were generated, and these codes sought to encapsulate meaning from a psychological perspective, usually seeking to further understand thoughts and emotions. This stage was also used as a measure of data saturation within the sample. The generation of new codes was monitored throughout the coding process. It was noted that most codes (85 per cent) were produced within 50 participants, with the remaining codes generated within 70 participants. No new codes occurred within the final six participants. This was judged to indicate that data saturation had been reached within the sample of 76 participants.25

Phase 3 focused on searching for themes, and this was done through reviewing the codes and looking for shared meaning. The aim was to produce themes that were meaningful and enhanced understanding of the data. Phase 4 involved reviewing the themes. The themes were discussed and reviewed between the initial coder and the remaining two coauthors until agreement was reached in terms of the boundaries and meaningfulness of themes. Braun et al 23 do not recommend the calculation of inter-rater reliability; instead, this process of discussion and agreement is suggested to enhance the rigour of the analysis. Phase 5 produced names and definitions for each of the themes. Phase 6 produced the results section of this paper.

Results

Participant characteristics

A total of 76 participants (53 women, 23 men, M age: 36.9, sd: 11.62) were recruited from the UK and Ireland over a seven-month period. The participants included vets (n=62) and vet partners (n=14). The majority of practices catered for small animals (n=32), with the remainder focused on farm animals (n=12) and equines (n=8). There were also a number of mixed practices (n=24). A range of locations were reported, including rural (n=37), small towns (n=21), large towns (n=11) and city (n=7). Almost half the sample reported that they had a supervisory role (n=32), with the remainder indicating they had no supervisory duties (n=42).

Quantitative results

Safety culture

The first step in the analysis was to generate a mean score for each item within the safety culture measures in order to gain a descriptive picture of safety culture and to identify any potential areas of concern (items with a low score); this is illustrated in table 2.

Table 2

Descriptive analysis of safety culture items, shown with mean and sd

Table 2 illustrates that organisational-level safety culture is perceived more positively than group-level safety culture. The four items with the lowest scores referred to discussing safety issues (G4), complimenting attention to safety (G2), checking in with veterinarians in unsafe locations (G6) and investing in safety training (O3).

Following the descriptive analysis the safety culture items were summed and averaged to produce two culture scores. The reliability of both scales was assessed using Cronbach’s alpha, indicating good reliability in each case: organisational level (M: 5.25, sd: 1.18, α: 0.91), group level (M: 4.41, sd: 0.96, α: 0.92). A paired t test (power analysis conducted using the ‘pwr’ package in R26 found an adequate power level of 0.7 for this analysis) indicated that the organisational-level culture scores were significantly higher than the group-level culture scores (t(70): 7.126, P<0.001).

A series of one-way ANOVAs were carried out with gender, practice type and supervisory role as between-subject grouping variables. The analyses for gender and practice type were non-significant for both safety culture scales. The analysis for supervisory role produced significant findings for both culture types (see table 3), although it should be noted that power analysis conducted using R26 and the ‘pwr’ package indicated that this analysis was underpowered due to the disparity in group sizes.

Table 3

One-way ANOVA of safety culture across job role and supervisory role

Qualitative results

Thematic analysis generated six key themes relevant to the perception of risk, hazards and safety while working alone and on-call (table 4).

Table 4

Perceptions of risk, hazard and safety across six key themes: coping with the unknown, difficult clients, pressure to treat, feeling unsafe, dangerous patients and on the road

Coping with the unknown

Participants emphasised the importance of knowledge about clients and locations both in terms of knowing what to expect and with reference to managing risk:

If you do not know that person or the area then you automatically put yourself at risk as you are going to their house or left alone in practice with them. (P6)

Difficult client interactions

Participants reported that clients could engage in various abusive behaviours both in the practice and during a home visit. Vets were aware that the risk of these behaviours was heightened when the client was under the influence of a substance. Problems could also arise when a client did not agree with a proposed treatment plan, the costs involved or the procedure. Dealing with these situations was considered problematic and on occasion frightening:

Hostile situations where I have not agreed with the client and refused to pass or sign something. (P15)

Pressure to treat

Several vets referred to the RCVS code of professional conduct indicating that all emergency calls must be attended. Participants felt that the conditions for refusing or cancelling a call on the grounds of personal safety were quite vague:

Not really, I know what my own boundaries are, but I don’t know how these would stand with an RCVS complaint. (P53)

Vets felt under pressure to attend patients due to their perceived duty of care:

I would find this *cancelling call* difficult and very stressful as my concern would be my duty of care to the animal. (P34)

Participants also considered owners to be blasé about safety, expecting commitment to difficult and potentially dangerous procedures and to handling difficult and potentially aggressive animals:

Dangerous horses and owners expecting me to put myself at risk, especially when dealing with a very bad colic. (P59)

Feeling unsafe

A key concern was the issue of vets not only being alone on calls, but the lack of tracking or checking systems. This meant that vets felt no one knew where they were at any given moment (particularly out of hours), and so if anything did happen it might be some time before it was noticed that they were missing, and even then they might be difficult to find:

No one else is aware of where I am, aside from my partner if I am at home when I take the call. If something was to happen to me then I may be difficult to locate. (P11)

Answering calls, making home visits and working alone were linked to feelings of worry and stress:

Lone working, out of hours, is one of the commonest contributors to stress and anxiety among vets. (P73)

Dangerous patients

Participants recognised that patients could be a source of injury, particularly if the animal was aggressive or unhandled:

Badly handled and dangerous stock. (P10)

Importantly, vets relied on owners to help handle the animals, particularly when dealing with animals in pain and in need of restraint. However, some owners appeared unable to help or to manage their animal:

Many owners are unable to adequately hold a horse that is in some form of pain distress and will often rely on the vet to try restrain and inject the horse. (P55)

On the road

Home visits necessitate travel to a variety of locations; this was considered potentially risky or hazardous under certain conditions, including night-time driving and adverse weather conditions. A key concern was the potential for a road traffic accident, often paired with worries about a lack of checking system:

Car accident on quiet country roads= no one will know until you don’t turn up for work the following morning. (P16)

Additional safety concerns

Participants reported concerns regarding safety equipment, training and managing fatigue (table 5). A key concern appeared to be a lack of discussion, or provision, of personal safety equipment designed to minimise injury:

Table 5

Theme relevant to additional safety concerns, with a focus on equipment and training

No. Had to ask multiple times to have a hard hat purchased. (P62)

Safety culture

In addition to reporting concerns relevant to working alone, risks and hazards, vets also reported mechanisms used by their practice to enhance safety and manage risk (table 6).

Table 6

Theme describing positive safety behaviours aligned with good safety culture

Some vets reported that their practice supplied safety equipment, although the nature of that equipment varied widely, from hard hats to steel gauntlets:

The animal care assistant always wears a hard hat when handling horses in the clinic. (P21)

Multiple practices reported setting up a checking system, often paired with call triage:

Calls go to call centre who then contact resident on duty who contacts referring vet and accepts referral if appropriate. (P13)

Discussion

The current quantitative results indicate that organisational-level safety culture was perceived more positively than group-level safety culture, and that vets in supervisory roles tend to be more positive about safety culture overall. The combined results suggest that there may be safety culture issues around a lack of communication and discussion pertaining to safety. The qualitative data provide extensive insight into the experience of vets working alone and on-call. Key themes discussed the pressure to treat patients, potentially at personal risk, and feeling unsafe when meeting clients alone.

Safety culture

Managerial and supervisory commitment to safety is a core aspect of safety culture.18 Employee perception of this commitment is influenced by the extent to which supervisors and managers are engaged in safety activities, including training, communication about safety and implementation of safety protocols.27 The current data suggest that discussions and communication about personal safety may be lacking within vet practices. As a result, vets appeared to be unsure about the assessment of risk and safety while working on-call, and the balance between duty of care and personal risk. Several vets reported feeling unsafe or vulnerable when working away from the practice, but then continued with the visit and treatment. The RCVS code of professional conduct10 includes a section on personal safety, but specific criteria or guidance for judging personal safety and risk appear to be lacking. This suggests that more support and guidance are required to enable vets to more accurately, and confidently, judge when they should refuse a call or request additional support to avoid a risky situation.

Maintaining the balance between treatment demands and personal safety was further complicated by the perception that clients do not care about the safety of their vet. This was particularly problematic when dealing with livestock and equines. There could be a lack of appropriate restraint or competent handling, yet vets felt pressured to proceed with treatment regardless. This result is mirrored by research examining pet owner perceptions of veterinary safety practices,28 where a lack of communication between the vet and the client regarding safety was linked to reduced utilisation of safety procedures by vets. Recent research highlights vet–client communication as an important element to increase client adherence to treatment regimens, encourage mutual respect and increase client satisfaction.29 The authors suggest that relationship-based communication and care can improve the partnership between the client and the vet, making interactions more positive.29 This kind of mutual trust and respect is also likely to encourage increased discussions around safety.

Vets engaged in supervisory activities reported higher ratings for both group and organisational lone worker safety culture. Similar findings have been reported in the trucking industry, where supervisors rated safety culture more positively than drivers.20 The difference in perception may represent two different viewpoints. The supervising, and usually more senior, vet could consider safety culture through interpreting management or practice policies, a viewpoint potentially subject to bias (positive interpretation of policy).30 The more junior, or less experienced, vet might be more likely to interpret safety culture based on the actual behaviours of their supervisor and colleagues.20

Lone working

The provision of emergency services and home visits as a lone veterinarian was associated with feeling vulnerable and unsafe. A key theme within the data was the recognition that when operating out of hours, without a checking system, the location and duration of the call were not tracked or reported. This produced the fear that if something went wrong, or an accident occurred, no one would realise until much later. This is an issue also faced by farmers who often work alone, with the risk that if an injury occurs there will be no one around to help.31 Farming has increasingly begun to turn to technology to resolve this issue, leading to the development of various apps, alerts and tracking systems.32 These may also be suitable as a method to enhance vet safety.

Health and safety challenges are also common across lone workers providing care in the community, such as healthcare and social work.33 Within the field of human care, researchers suggest that if workers feel unsafe there may be a consequential negative impact on the quality of care provided.33 34 Carers also reported a high tolerance for personal risk, often linked to worries regarding patient status if care was discontinued. Combined with the current study, this suggests that veterinarians, similar to healthcare workers, may be aware of the risks inherent in working alone, but have a high level of risk tolerance due to their perceived duty of care or focus on treatment.35 This could be problematic if tolerance leads to both additional personal risk and a potential reduction in the quality of care provided.

Lone working and the associated risks were reported as a source of stress and anxiety for some vets. This finding reflects research indicating that out-of-hours, on-call, duties can function as a significant stressor within clinical veterinary work.36 Client-based problems have also been listed in a taxonomy of stressors for US vets, with complaints, being unwilling to pay and unrealistic treatment expectations all listed as causes of stress.37 Given concerns regarding the prevalence of stress within the veterinarian profession,38 this would suggest managing safety while alone and on-call, including dealing with difficult client interactions, should be an important aspect of veterinarian stress management programmes.

Limitations

The current data are specific to veterinarians in the UK, so caution should be exercised in applying these results to other countries. In addition, the safety culture measure used, although validated as a generic measure of safety culture by the scale authors,21 has not been validated for use with veterinarians specifically. It should also be noted that the concept of lone working in veterinary practice encompasses multiple aspects, but that much of the qualitative data in the current study reflect callout situations. Finally, due to difficulties experienced with participant recruitment, the sample size was smaller than hoped, most likely due to the time requirement associated with answering the series of open-ended questions within the survey. Power analysis indicated that although within-subjects analysis was adequately powered, between-group analysis was not, and so the ANOVA results should be viewed with caution.

Safety recommendations

The current study highlights the risks of working alone and on-call, but also generates some suggestions for enhancing safety and managing risks. First, where possible vets should be paired with other workers. This would ensure the provision of competent animal handling during treatment and would limit the risk of assault. Secondly, safety and risk management should be defined clearly and discussed regularly within the practice, this should include the conditions for refusing a callout. Ideally safety protocols and requirements should also be communicated to clients. Thirdly, protective safety equipment should be provided to vets, and its use encouraged (the use of hard hats is recommended within equine practice).39 Fourthly, a checking system for vets working out of hours should be put in place, either operationalised through call triage or through a technological tool such as global positioning system tracking.

References

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article.

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