Client's understanding of instructions for small animals in a veterinary neurological referral center

Abstract

Background

It is not known how much information clients retrieve from discharge instructions.

Objective

To investigate client's understanding of discharge instructions and influencing factors.

Animals

Dogs and cats being hospitalized for neurological diseases.

Methods

Clients were presented questionnaires regarding their pet's disease, diagnostics, treatments, prognosis and discharge instructions at time of discharge and 2 weeks later. The same questions were answered by discharging veterinarians at time of discharge. Clients answered additional questions regarding the subjective feelings during discharge conversation. Data collected included: data describing discharging veterinarian (age, gender, years of clinical experience, specialist status), data describing the client (age, gender, educational status). Raw percentage of agreement (RPA) between answers of clinicians and clients as well as factors potentially influencing the RPA were evaluated.

Results

Of 230 clients being approached 151 (65.7%) and 70 (30.4%) clients responded to the first and second questionnaire, respectively (130 dog and 30 cat owners). The general RPA between clinician's and client's responses over all questions together was 68.9% and 66.8% at the 2 time points. Questions regarding adverse effects of medication (29.0%), residual clinical signs (35.8%), and confinement instructions (36.8%) had the lowest RPAs at the first time point. The age of clients (P = .008) negatively influenced RPAs, with clients older than 50 years having lower RPA.

Conclusions and Clinical Importance

Clients can only partially reproduce information provided at discharge. Only clients' increasing age influenced recall of information. Instructions deemed to be important should be specifically stressed during discharge.

Abbreviations

MCQ‐MA

multiple choice question—multiple answers

MCQ‐SA

multiple choice question—single answer

1.Q

first questionnaire

RPA/RPAs

raw percentage of agreement/agreements

SD

standard deviation

SEM

standard error of the mean

1. INTRODUCTION

Veterinarians usually focus on providing the highest level of medical care to their clients. That prioritization of the medical aspects of their profession largely ignores that educating and empowering the pet owner might have an influence on the therapeutic success. ¹ , ² , ³ , ⁴ , ⁵ The imbalance between those 2 parts of clinical veterinary medicine, animal care and owner communication, is reflected by a relative paucity of scientific literature in veterinary research investigating clinician and pet owner interaction in contrast to extensive publications in human medicine. ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ Even though there is growing interest in that research, studies specifically investigating comprehension and efficacy of discharge instructions are lacking in veterinary medicine.

In human medicine, clinician‐patient‐interaction and its effect on outcome has been more extensively investigated. Specifically, discharge instructions and their effects on comprehension and recall have been studied in human emergency departments. ⁶ Complete recall of discharge instructions varies between 8% and 84% of human patients released from emergency departments. ⁸ , ⁹ , ¹⁰ Providing written discharge can improve comprehension of information provided. Written instructions instead of verbal instructions only increased the correct use of pain medication from 40% to 71% of patients. ¹⁰ Another study in human patients concluded that recall of discharge information can be increased from 47% to 58% if written instructions are provided to patients. ⁶

There seems to be a need for similar investigations in veterinary medicine in order to improve communication between clinicians and pet owners. Therefore, the aim of this study was to investigate comprehension of discharge instructions in a veterinary neurological referral center.

2. MATERIALS AND METHODS

The study was performed using a prospective cohort design. Owners of dogs and cats being hospitalized as patients at the Neurology and Neurosurgery Service of the Department for Small Animals of Leipzig University were asked to participate in a study to improve owner instructions by answering a questionnaire at 2 time points after the animal has been discharged from the hospital. During the discharge conversation, owners were informed about their pet's disease, diagnostic tests and treatments performed, medication to be given by the owner, and necessary exercise restriction as well as the prognosis of their pet's disease. All this information was handed over to the owner as written discharge instruction as well. In addition, the owner received all medication, either as the complete package, as a bottle of liquid, or as a strip of tablets. In the latter, medication was placed in a separate bag being labeled with the name of the medication and additional instruction on how to apply it.

A questionnaire consisting of 3 parts was developed. Part I included questions characterizing the owner itself such as: age, gender, educational level, being a native German speaking person and having a medically professional background. Part II included questions regarding the owner's personal perception of the verbal discharge conversation such as: feeling informed, general atmosphere, personal emotions, understandability of clinician's explanation, clinician's empathy and others. Part III of the questionnaire addressed the diagnosis, performed diagnostic tests, treatment, follow up visits as well as the prognosis of the pet's disease. Part I and Part II questions were only answered once exclusively by the pet owners at the time of discharge. Part III questions had to be completed separately by the pet owners and the attending clinicians at the day of discharge as well as a second time by the pet owner only 2 weeks after discharge. The pet owners were not aware, that the questionnaire they will be asked to answer 2 weeks after discharge will contain exactly the same Part III questions they had already responded to on the day of discharge. There were the following types of questions: multiple choice questions (either single or multiple answers; MCQ‐SA and MCQ‐MA), open questions, and questions on a 6‐point Likert scale. The exact wording of questions, question types as well as response options were developed together with a human psychotherapist (Marie A. Harkenthal). All questions of all 3 parts as well as question types and response options are listed in Table 1.

TABLE 1.

Questions, question types, and response options of the questionnaire answered by owners and discharging clinicians.

	Question	Question type	Response options/answers	Raw percentage of agreement in % at discharge and 2 weeks later
Part I: Questions characterizing the owner Answered by the owner only	How old are you?	MCQ‐SA	Years: 18‐29; 30‐39; 40‐49; 50‐59; 60‐69; 70‐79; 80‐89; 90‐100
	What is you gender?	MCQ‐SA	Male, female, nonbinary
	Is German your native language?	MCQ‐SA	Yes, no
	Do you have a medical profession?	MCQ‐SA	Yes, no
	What is your level of education?	MCQ‐SA	Secondary school diploma; High school diploma; Vocational training college degree; Technical college degree; University degree
Part II: Questions characterizing verbal discharge instructions Answered by the owner only	I have been sufficiently informed about the treatment of my pet.	Six‐point Likert scale
	The amount of information was appropriate to me.
	The speed of the veterinarian talking was appropriate to me.
	The vet has mainly used words that were familiar to me.
	I had the chance to ask questions.
	My questions have been answered comprehensibly.
	The veterinarian reserved enough time for the discharge.
	The discharge was performed in an undisturbed surrounding.
	I felt stressed during discharge.
	I felt that I would be able to implement the instructions I received.
	I did not understand the veterinarian several times.
	The veterinarian was empathic.
Part III: Question regarding the disease, diagnostic tests, treatment and prognosis Answered by the owner and the dischargeing veterinarian	What is name of the disease we have diagnosed in your pet?	Open answer		91.1 91
	In which category belongs the disease of your pet?	MCQ‐MA	Inflammatory; genetic; infectious; metabolic; neoplastic; others; I do not know	46.6 46.1
	Which organ is affected by the disease of your pet?	MCQ‐MA	Brain; spinal cord/spine; nerves in limbs; muscles; others; I do not know	63.5 61.4
	Are there additional tests necessary after discharge?	MCQ‐SA	Yes; no; I do not know	56.7 62.5
	Which tests have been performed during hospitalization of your pet?	MCQ‐MA	Blood tests; urinalysis; ultrasound; x‐rays; CT; MRI; CSF tap; electrodiagnostics; EEG; I do not know	48.6 40.9
	Did your pet have a general anesthesia during hospitalization?	MCQ‐SA	Yes; no; I do not know	95.9 94.3
	Did your pet have a surgery during hospitalization?	MCQ‐SA	Yes; no; I do not know	93.9 96.6
	Does your pet have stitches to be removed?	MCQ‐SA	Yes; no; I do not know	98 98.9
	Do you have to give medicine to your pet after discharge?	MCQ‐SA	Yes; no; I do not know	98 98.9
	If you have to give medicine to your pet, to which category do those belong?	MCQ‐MA	Pain killer; antiseizure medication; heart medication; anti‐inflammatory medication; immunosuppressives; antibiotics; medication against vomiting; medication against diarrhea; gastroprotective, medication against pruritus; medications against hypertension; thyroid medication; medication to improve urination; medication for behavioral disorders; chemotherapeutics; medication to reduce brain water production; eye medication; others; I do not know	47.6 42
	How many different medicines do you have to give your pet?	MCQ‐SA	1; 2; 3; 4; 5; 6; different number; I do not know	81 76.1
	How often during the day do you have to give a medicine to your pet? If there are several drugs, select the one you have to give most frequently.	MCQ‐SA	Once daily; twice daily; three times daily; four times daily; a different frequency; I do not know	87.1 80.7
	Should you give any medicine before feeding your pet?	MCQ‐SA	Yes; no; I do not know	67.3 55.7
	How should you give medicine to your pet?	MCQ‐MA	Into mouth; into nose; into anus; into eyes; I do not know	95.9 94.3
	What are potential adverse effects of the medicine you have to give your pet?	MCQ‐MA	Sleepiness; deficits of coordination; vomiting, diarrhea, increased thirst; reduced thirst; increased appetite; reduced appetite; increased frequency of urination, reduced frequency of urination; side effects have not been mentioned by the veterinarian	29 19.3
	Have you received instructions on confinement of your pet to a restricted area?	MCQ‐SA	Yes; no; I do not know	83.8 81.8
	If you have received instructions on confinement, what were those specifically?	MCQ‐MA	Cage rest; confinement to play pen; confinement to 1 room; confinement to 1 room without furniture; separation from other pets; outside house leash walks only; I do not know	36.8 29.9
	If you have received instructions on exercise restrictions, what were those specifically?	MCQ‐MA	Leash walks only; restricted duration of leash walks; avoiding stairs; no jumping on sofa or bed; no playing with other pets; I do not know	44.2 38.4
	Are you supposed to come for a recheck to our hospital?	MCQ‐SA	Yes; no; I do not know	85.5 79.5
	If there was a recheck appointment recommended, when should it be?	MCQ‐SA	In 1 week; in 2 weeks; in 3 weeks; in 1 month; in 3 months; in 6 months; at a different time; I do not know	61.5 50
	When are you supposed to go for a recheck to your referring veterinarian?	MCQ‐SA	In 1 week; in 2 weeks; in 3 weeks; in 1 month; in 3 months; in 6 months; at a different time; I do not know	47.3 50.6
	Is it possible that your pet has to live permanently with signs if the disease?	MCQ‐SA	Yes; no; I do not know	64.2 70.8
	If your pet has to live permanently with signs of the disease, which are those?	MCQ‐MA	Seizures, other types of recurrent attacks, lack of limb coordination, reduced ability to move limbs; dragging of feet; head tilt; reduced vision; reduced hearing; pain; abnormal urination; abnormal defecation; others	35.8 20.7
	Is there a risk that the disease of your pet can be transmitted to other pets?	MCQ‐SA	Yes; no; I do not know	92.6 96.5
	Is there a risk that the disease of your pet can be transmitted to humans?	MCQ‐SA	Yes; no; I do not know	90.5 94.3
	Does your pet have a normal life expectancy?	MCQ‐SA	Yes; no; I do not know	70.3 73.9
	Is there a risk that signs of the disease of your pet may reappear at a later time point?	MCQ‐SA	Yes; no; I do not know	66.1 64.8
	Is there a risk that your pet may die from the disease we have diagnosed?	MCQ‐SA	Yes; no; I do not know	57.4 60.2

Note: In addition, the total raw percentage of agreement between clients' and clinicians' responses at discharge and 2 weeks later are listed below each other for all Part III questions.

Abbreviations: MCQ‐MA, multiple choice question—multiple answers; MCQ‐SA, multiple choice question—single answer.

The following criteria had to be fulfilled in order to ask a pet owner to participate in the study: the pet was hospitalized, clinicians of that service had performed all owner communication once the animal had been hospitalized as well as provided all verbal and written discharge instructions. Owners were excluded if the pet died or was euthanized during hospitalization, if the clinician thought that the owner cannot be addressed with that request because of the general circumstances, if owners were not able to pay the bill, if the owners had a recheck appointment in less than 3 weeks after discharge and if verbal discharge conversation was performed under time constraint due to unforeseen circumstances. For participating owners, the attending clinician reported the following information regarding the verbal discharge conversation: duration in minutes, number of attending adults, number of accompanying children, number of accompanying pets and if the pet to be discharged was present during discharge conversation or was handed over after the conversation was completed, location of discharge (general examination area with incompletely separated booths, separate room, general reception area, outside of the hospital, and other). In addition, the following information characterizing the discharging veterinarian was collected: age, gender, number of years working as a veterinarian, level of specialization (no special degree, national degree of specialization, diplomate of the European College of Veterinary Neurology).

Owners eligible to participate were informed about the study after completion of the verbal discharge instruction and handing out written instructions. They were provided with additional written information regarding aim and design of the study as well as a declaration that all information provided would be handled as required by the European Union General Data Protection Regulation. Owners agreeing to participate signed a consent form.

Following the discharge conversation and after receiving the written discharge instructions, owners could participate in 3 different ways based on their personal preference: receiving a paperwork questionnaire to be mailed back to the hospital, receiving a weblink either in the printed discharge instructions or via email. Owners were asked to complete questionnaires at 2 different timepoints: 1 on the day of discharge (Parts I, II, III) and a second 2 weeks after discharge (Part III only).

Data were analyzed by determining the individual agreement between responses of all owners and all clinicians to every single Part III question. The agreement rate for every single question as well for every individual owner was expressed as raw percentage of agreement (RPA). It was calculated for every single owner by dividing the number of questions, where owners and clinicians provided the same response by the total number of all Part III questions. Similarly, the RPA was calculated for every single question. The total RPA was calculated as the mean of all individual owner RPAs. The total RPA was calculated for the 2 time points, when owners responded to Part III of the questionnaire, at the time of discharge and 2 weeks later. Further analysis included only answers to the questionnaire provided at the time of discharging the pet.

For the total RPA including all Part III questions, the influence of answers to Part I questions (owner characteristics), Part II questions (subjective assessment of verbal discharge instructions characteristics provided by the owner) and objective data of the discharge conversation (duration, present persons and pets) as well as data characterizing the discharging clinician (age, gender and level of expertise) on the RPAs between owners and clinicians were analyzed. Furthermore, the influence of the same factors on RPAs between owners' and clinicians' responses was determined looking only at the following 2 questions of Part III separately: “What is the name of the disease we have diagnosed in your pet?” and “If you have to give medicine to your pet, to which category do those belong?” Responses were rated as in agreement if exactly the same answers were chosen by clients and clinicians in MCQ‐SA and MCQ‐MA. For the open answer question regarding the diagnosis, decision about agreement between clients' and clinicians' responses was achieved by consensus among 3 authors (Thomas Flegel, Katharina Dobersek, and Sabrina Bayer). If consensus was not achieved between those 3 authors, agreement was classified as “unclear.” Unclear agreement was treated similar as responses without agreement during statistical analysis. MCQ‐MA questions were classified as in agreement if all the same answers were selected by owners and clinicians. A response was considered as partial agreement, if a client selected only some of the answers selected by the clinician or if the client selected more answers than the clinician. Responses with partial agreement were treated as no agreement during statistical analysis.

2.1. Statistical analysis

Statistical analysis was performed using the software IBM SPSS Statistics 27 (SPSS Inc, New York, USA) and Microsoft Excel 2019 (Microsoft Deutschland GmbH, Munich, Germany). Continuous data were visually tested for normal distribution as well as by using the Kolmogorov‐Smirnov test. Data are reported as mean or median with the SD, range or 95% confidence interval, depending on their normality. The difference between the total RPA at the 2 different time points was tested by the paired t test for dependent samples. The differences of RPA between the 2 time points for every single question was calculated using a paired‐sample sign test. The influence of factors on the total RPA was tested by linear multivariable regression analysis with forward selection.

The Mann‐Whitney U test and the Kruskal‐Wallis test (depending on the number of groups to be tested) were used to detect differences in the total RPA of Part III questions between groups for the following variables: animal species, number of years working as a veterinarian, level of specialization of the veterinarian, gender of the veterinarian, location of the discharge interview, number of people present at the discharge interview, presence of the animal at the discharge interview, native language of the animal owner, level of education of the animal owner, medically professional background of the animal owner gender, and age group of the animal owner.

Furthermore, it was tested if there are differences in the total RPA between groups for the following variables using the Mann‐Whitney U test and the Kruskal‐Wallis test (depending on the number of groups to be tested): animal species, number of years working as a veterinarian (≤4 years; ≥7 years), level of specialization of the veterinarian, gender of the veterinarian, location of the discharge interview, number of people present at the discharge interview, presence of the animal at the discharge interview, native language of the animal owner, level of education of the animal owner, medically professional background of the animal owner gender, and age group of the animal owner. An influence of the duration of the discharge interview on the agreement on the 2 subquestions was tested using the Kruskal‐Wallis test.

Part II questions regarding the owners' personal perception were analyzed with the nonparametric Mann‐Whitney U test.

Significance values were adjusted using the Bonferroni correction for multiple tests where applicable. A value of P < .05 was considered significant for all analyses.

3. RESULTS

A total of 230 clients agreed to take part in the study by signing the consent form, of which 151 (65.7%) responded to the first survey immediately after discharge and 70 clients (30.4%) performed both surveys. Nine clients (3.9%) performed the second survey only. Those 160 responders are included in the further analysis. The majority of clients used the web‐based questionnaire (60.8%).

Thirty clients owned a cat (18.7%) and 130 a dog (81.3%). The 11 most frequent diagnoses in both species together were: intervertebral disc disease (37.2%), idiopathic epilepsy (8.2%), intoxication (6.5%), vestibular syndrome (3.9%), intracranial neoplasia (3.5%), meningoencephalitis of unknown origin (3.5%), peripheral neuropathy (2.2%), lumbosacral stenosis (2.2%), spinal luxation/fracture (2.2%), infection (1.7%), and steroid responsive meningitis arteritis (1.7%). Some more specific diagnoses have been grouped together in the list provided above. For 14.3% of cases, no definite etiological diagnosis could be established. For the latter, a more descriptive diagnosis was provided to the owner.

One hundred seven clients were female (71.3%), 42 were male (28.0%), and 1 was nonbinary (0.7%). For 5 clients (3.4%) German was not their native language. One hundred twenty‐eight clients (18.7%) had a profession related to medicine or veterinary medicine. The age and the educational level of all clients are presented in Figures 1 and 2.

FIGURE 1.

Age distribution of all clients responding to the survey at the time of discharge (n = 149).

FIGURE 2.

Educational level of all clients responding to survey at the time of discharge (n = 147).

Nine different veterinarians performed the verbal discharge instructions, 7 were female and 2 were male. Three discharging veterinarians were board certified neurologists. Discharging clinicians have practiced veterinary medicine for 6 months to 29 years. The median duration of the verbal discharge conversation was 16 minutes (n = 153; range: 4‐42 minutes). For 7 cases, clinicians forgot to measure the duration of the discharge conversation. The following locations were used for discharge conversations: general examination area with incompletely separated booths (8.1%), separate room (18.8%), general reception area (62.5%), outside of the hospital (8.8%), and other (1.8%). There was a single client present in 100/152 cases of discharge conversations (65.8%), whereas in the other cases there was at least 1 additional person. There were children of the clients present in 4 more cases (2.6%). The animal to be discharged was present during the discharge conversation in 12/153 cases (7.8%). The responses describing the subjective impressions of clients regarding discharge conversation are presented in Figure 3.

FIGURE 3.

Response of clients to Part II questions regarding verbal discharge instructions. Results are presented in percent (n = 150).

The general mean RPA between clients' and clinicians' responses to questions regarding the animal's hospitalization was 68.9% (SD: 21.9; SEM: 4.13; range: 29.0‐98.0) and 66.8% (SD: 35.4; SEM: 4.9; range: 19.3‐98.9) for the questionnaire at discharge and 2 weeks later, respectively. The total RPA of the first set of answers at discharge is significantly higher than the second set 2 weeks later (P = .03). The distribution of the total RPA at the 2 time points is shown in Figure 4. The RPAs to the following 3 questions were significantly lower 2 weeks after discharge compared to the day of discharge: “Should you give any medicine before feeding your pet?” (P = .017), “What are potential adverse effects of the medicine you have to give your pet?” (P = .035) and “If your pet has to live permanently with signs of the disease, which are those?” (P = .008).

FIGURE 4.

Total raw percentage of agreement between clients' and clinicians' responses to all Part III questions regarding the animal's hospitalization for the questionnaires answered at discharge and 2 weeks later, respectively. The middle line of the box represents the median, whereas the x in the box is the mean. The bottom line of the box represents the 1st quartile and top line the 3rd quartile. The whiskers indicate minimum and maximum values (n = 148).

Lowest RPAs were obtained for MCQ‐MA. For the 6 MCQ‐MA with RPAs below 50%, agreement could be increased to 78.4% by accepting questions as answered correctly even if 1 correct option of the multiple correct options was not selected by the owner. Similarly, RPA could be increased to 77.4% by accepting questions as answered correctly if 1 wrong option was selected in addition to all correct answer options. All RPAs for every single question are shown in Table 1.

The only factor influencing the total RPA between clients' and clinicians' responses including all questions was the age of the client, with older age being associated with lower agreement (P = .008, corrected R ²: .041; F value: 7.21, t value: −2.685, regression coefficient: −1.64, beta coefficient: −.217). The RPAs in different age groups are shown in Figure 5. Significant differences were seen between clients of 30 to 39 years and those of 50 to 59 years of age (P = .034; Cohen's r = .25) and between clients of 30 to 39 years and those of 60 to 69 years of age (P = .038; Cohen's r = .27). There was no significant difference between the age group 70 to 79 years and any other age group. However, the latter included 3 individuals only and therefore reliable statistics could not be applied to this group.

FIGURE 5.

Raw percentage of agreement between clients' and clinicians' responses to all Part III questions regarding the animal's hospitalization for the questionnaire answered at discharge in different age groups of clients. The middle line of the box represents the median, whereas the x in the box is the mean. The bottom line of the box represents the 1st quartile and top line the 3rd quartile. The whiskers indicate minimum and maximum values (n = 148).

There was not any factor influencing the RPA, when not the total RPA over all questions was evaluated, but if the RPA was selectively evaluated for responses to the specific questions “What is the name of the disease we have diagnosed in your pet?” and “If you have to give medicine to your pet, to which category does it belong?”

4. DISCUSSION

The total RPA between clients' and clinicians' responses to questions regarding the disease, diagnostic and treatment of pets discharged from a veterinary neurological referral center was 68.9%, when questions were answered on the day of discharge and 66.8% when answered 2 weeks later. However, there was a large variation of individual RPAs, ranging from 28.4% to 98.0% and from 19.3% to 98.6% for the first and the second Part III questionnaire, respectively. Those RPAs are within the wide range of discharge recall rates reported for humans of 8% to 84%. ⁶ , ⁸ , ⁹ , ¹⁰

There was a significant, but small decline of the total RPA 2 weeks after discharge compared to the total RPA on the day of discharge which is barely clinically relevant. Only 3/28 questions were answered significantly different at the 2 time points. Those were questions regarding giving medication before feeding, adverse effects of the medication, and residual clinical signs. That could imply that misremembering over time is not a major problem, at least not in the immediate post discharge time period. However, we do not know how many clients responded to the Part III questions 2 weeks after discharge just based on their memories and how many used the written discharge instructions to respond. We would argue that this question is irrelevant, since it is only important that clients can reproduce the information provided, while it does not matter which resource is used for that.

Veterinary studies for direct comparison are lacking to the best knowledge of the authors, though there are several studies investigating other aspects of the client‐veterinarian communication. A few of them are exemplarily mentioned here. The adherence of clients to their veterinarians' recommendations in dental practice was found to be 30% only. ² However, the odds of adherence were 7 times as high if clients were provided with clear instructions rather than options. Another study assessed the communication between veterinarians and horse owners about the zoonotic risks of the Hendra virus. ³ It was found that 24.9% of owners were initially unreceptive, emotionally overwhelmed or denied the potential risk. Those findings emphasize the importance of providing comprehensible explanations in order to increase client understanding. Authors concluded that veterinary communication skills should be further investigated. In addition, animal directed talk using utterances addressing the pet itself might facilitate many tasks that have to be achieved during client‐clinician interaction. ¹¹ Such animal directed talk was not possible in most cases of the study presented here, since pets were intentionally usually not present during discharge conversation, since we felt it would distract clients. Furthermore, client communication expectations were evaluated in a veterinary oncology referral center. ¹² The authors concluded that not only the content but the way information is provided to the owner is crucial. It does not only facilitate comprehension of medical information, but it generates a psychosocial environment that supports the client in dealing with their diseased pet.

Written instructions seem to have an influence on the recall since adding those to verbal instructions increased the correct use of pain medication from 40% to 71% in human patients. ¹⁰ Another study in human patients concluded that recall of discharge information can be increased from 47% to 58% if written instructions are provided to the patients. ⁶ Those recall rates are probably suitable for comparison, since pet owners of the study presented here received combined verbal and written instructions. Therefore, RPAs achieved in this study are in a similar range as reported in human medicine.

Some MCQ‐MA had relatively low RPAs. That applied for instance to questions regarding the adverse effects of medication (RPA 29.0% 1.Q), residual clinical signs (RPA: 35.8%, 1.Q), instructions for confinement of the pet to a certain area (RPA: 36.8%, 1.Q). Obviously, the RPAs are naturally lower in multiple answer questions if only those answered were accepted as correct, where all correct options were selected. Accordingly, by accepting 1 wrong selection, the RPAs could be increased to 77.4% for those answers. The question addressing the potential risk to die from the disease was with 57.4% (1.Q) close to the total RPA of 68.9 (1.Q), but one would expect or would hope for a much higher RPA for such a fundamental question. It is not clear if that is caused by a natural reluctance of the clinicians to touch that rather difficult topic in the moment of discharge or if the clients block such unpleasant information out of their minds. In addition, the high variation between RPAs for different questions (range from 19.3% to 98.9%) might partially reflect a different focus of clinicians and pet owners. Similarly, human patients are more interested in diagnosis and prognosis, whereas clinicians tend to focus on treatment in a general practice setting. ¹³

Only 1 factor influenced the total RPA. Specifically, subjective factors on the individual perception of the discharge atmosphere did not have any influence. The study was conducted during the time of the COVID‐19 pandemic, where access of clients to the hospital was strictly limited. Therefore, many discharges had to be performed in the relatively noisy general reception area (62.5% of all discharge conversations). That was recognized by the owners by reporting that discharge was performed in an undisturbed surrounding in only 60.7%, surprisingly however, that did not influence the RPAs. The clients' age was the only factor influencing the total RPA, with clients being at least 50 years having lower RPAs. Therefore, communication should probably be tailored to the clients' age.

Having a medical background of the clients did not have a significant influence on RPAs. That can be interpreted in different ways. On 1 hand, it could be an indication, that the way the clinician communicates is more important than the clients' education or profession. Medical knowledge might not be able to compensate for poorly structured or even confusing explanations by the clinicians. More positive explanations would be that the information was provided in a generally comprehensible way in this study, so that medical understanding did not add any value to it or clinicians did tailor their explanations to the clients' needs. There were no instructions in the study design to provide information to all clients in the same way, so that clinicians were free in their way of addressing the educational level or professional background of clients. On the other hand, it is possible that all clients independent from their educational level or profession are nervous enough to experience difficulties to follow the clinician's explanations, even though 59.7% of the owners did declare not to be stressed. However, there might be a gap between the personal perception and the objective level of stress during discharge.

Even though not specifically investigated in this study, the style of communication might influence clients' recollection of information. Pet owners appreciate a partnership‐centered communication expressing empathy and understanding for their fears and concerns. ¹⁴ , ¹⁵ This communication style might be used differently by clinicians of different age. A study found a negative correlation between veterinarians' years practicing small animal medicine and the degree of involving clients in the shared‐decision making process. ¹⁶ Authors argued that more experienced clinicians might use a more directive communication or that clinicians might develop a more paternalistic communication style over time. In the study presented here, however, the number of years practicing small animal medicine did not influence the RPAs of answers provided by clients and clinicians.

The main limitation of this study is the nonblinded study design. While clinicians were instructed not to change their usual discharge habits, it is safe to assume that the knowledge of the ongoing study influenced the way animals were discharged. We could not think of any study design without the clinicians being aware of it. Therefore, the true agreement rates outside of this study could potentially be lower than presented here. In addition, excluding some clients from the study (if the pet died or was euthanized during hospitalization, if the owner was subjectively considered to be a challenging person, if owners were not able to pay the bill) could have added a bias to the results. Including the responses of those clients which are potentially more stressed would probably have decreased RPAs and might have resulted in valuable findings in that subgroup. However, we felt that clients cannot be asked to take part in a study if they are in such exceptional emotional state.

In summary, clients are only able to recall correctly about two thirds of the information provided on discharge. Therefore, discharge instruction that are deemed to be critical should be stressed specifically and should potentially be repeated. That applies particularly if clients are elder people.

CONFLICT OF INTEREST DECLARATION

Authors declare no conflict of interest.

OFF‐LABEL ANTIMICROBIAL DECLARATION

Authors declare no off‐label use of antimicrobials.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC) OR OTHER APPROVAL DECLARATION

Data collection was carried out in accordance with the General Data Protection Regulation 2016/679 of the European Parliament. This research project was approved by the Ethics Committee of the Faculty of Veterinary Medicine at Leipzig University (EK 18/2021).

HUMAN ETHICS APPROVAL DECLARATION

Authors declare human ethics approval was not needed for this study.

Flegel T, Dobersek K, Bayer S, et al. Client's understanding of instructions for small animals in a veterinary neurological referral center. J Vet Intern Med. 2024;38(3):1639‐1650. doi: 10.1111/jvim.17085