An analysis of client complaints and their effects on veterinary support staff

Abstract Background Veterinarians and support staff have been reporting the negative mental health effects from client complaints (CC). A previous study was performed evaluating these effects in veterinarians however no such study has been performed on veterinary support staff (VSS). Objectiv The purpose of this study was to investigate the frequency and effects of CCs on VSS. Methods A cross sectional anonymous survey using a web‐based questionnaire was created evaluating the frequency, type, and effects from CC. The survey was distributed to five different VSS Facebook groups and respondents provided demographic information and reported the frequency and effects of such complaints. Results A total of 681 questionnaires were collected during the study period but 130 were incomplete and were excluded from analysis. This resulted in 551 completed questionnaires available for review. One hundred and ninety (34.4%) VSS reported being subject to a CC in the previous 6 months with cost of care the most common reason (78.6%). Two hundred and sixty VSS (47.2%) reported feeling depressed because of CCs made against them, 295 VSS (53.5%) stated CCs negatively affected their enjoyment of their job, and 146 (26.5%) have considered changing their career because of CCs. Conclusions CC have detrimental effects on VSS career satisfaction, mental health and hospital practices. Further studies are warranted to mitigate the detrimental effects of CCs.


INTRODUCTION
With the recent global pandemic in particular, several studies have shown the high stress health care workers are experiencing (Huo et al., 2021;Matsuo et al., 2020;Yamada et al., 2021). Working in both human and veterinary health care exposes workers to excessive stress due to the constant direct contact with sometimes critically ill patients and their families. Professional burnout is a syndrome that develops against a background of such chronic stressors leading to the depletion of the emotional energy of the affected working person (Sweileh, 2020).
Characteristics of burnout include the following: the feeling of emotional exhaustion where the person cannot give themselves to work as before, dehumanisation where they develop a negative attitude towards patients and a lack of professionalism (Aronsson et al., 2017;Chemali et al., 2019;Sweileh 2020). Burnout was common among veterinary technicians in specialty teaching hospitals and was positively associated with perceived medical errors, desire to change careers and depression (Hayes et al., 2020). Job stress is identified as the principal cause of burnout and job stressors for veterinary technicians include interpersonal relationships, workload and work scheduling (Foster & Mapes, 2014;Hayes et al., 2020;Leiter & Durup, 1994). A previously unexamined stressor is client complaints (CCs). A recent study evaluated the frequency and effects of CCs among small animal veterinary internists (Bryce et al., 2019). While CCs were relatively rare, the effect of CCs was pronounced, with more than 70% of small animal veterinary internists reporting feeling depressed due to a CC, and more than 40% considering changing their career because of CCs. Such complaints have been more thoroughly evaluated in human medicine among the many medical specialities. A commonly cited cause of complaints and even litigation is poor patient outcomes combined with breakdowns in communication between physicians and their patients and families (Levinson et al., 1997). Studies in human medicine showed dissatisfied patients cited feeling rushed, ignored, receiving inadequate explanations and spending less time with patients during routine visits as common causes of breakdown in communication (Hickson et al., 1994). Veterinary medicine is unique in that both veterinarians and support staff have to also deal with the financial aspect of health care for client's pets (Coe & Bonnett, 2007

MATERIALS AND METHODS
The questionnaire (Appendix 1) developed for this study was modified from a previous study (Bryce et al., 2019

Questionnaire validation
Face validity, which is the degree to which the questionnaire appears to assess the desired qualities, was established through discussions with veterinarians through feedback after they had completed the questionnaire previously. This is in line with studies evaluating work stress where similar pilot groups of cohorts were asked to assess the questionnaire prior to the study group (Bryce et al., 2019;Frantz et al., 2019;Holmgren et al., 2009;Mucci et al., 2015). After the initial questionnaire was generated, 10 VSS and 10 veterinarians of various clinical experience and specialties completed the questionnaire and expressed they did not have any trouble understanding the survey questions and would not hesitate to complete the survey again if needed. The estimated time to complete the questionnaire through this initial evaluation was approximately 10 min. The study protocol was approved by the investigators' Hospital's Institutional Review Board and Committee.

Statistical analysis
Responses to survey questions were tabulated and descriptive statistics (number and percentage) were generated.

Respondent demographics
The majority of VSS were female (533/551 respondents, 96.7%) veterinary technicians (445/551 respondents, 80.8%) who were less than 40 years of age (387/551 respondents, 70.2%) and had been working in the veterinary field for less than 20 years (450/551 respondents, 81.7%) (see Table 1). Most VSS worked in small animal practice outside of academia (538/551 respondents, 97.6%). The majority of respondents were in the United States and within this region, there was relatively equal distribution between across this country. A minority (90/551 respondents, 16.3%) were international which was defined as outside the United States.

Frequency and type of CCs
One hundred and ninety VSS (34.4%) reported receiving a CC in the previous 6 months (see Table 2 described their hospital administration as concerned about online reviews. One hundred and eleven VSS (20.2%) felt online reviews were a fair representation of the service they provided.
More than half of the study population (298/551 responses, 54.1%) reported being verbally assaulted by a client in the previous 6 months and a few (7 responses, 1.3%) reported being physically assaulted by a client in the previous 6 months. More than one fifth of respondents (117/551 responses, 21.2%) reported being threatened with litigation by a client in the previous 6 months.

Perception of CCs
Most VSS either strongly agreed (77/551 responses 14%) or agreed (229/551 responses, 41.6%) they felt the need to please clients to avoid a CC (see Table 3 The majority of VSS were female and less than 40 years of age, similar to a previous study evaluating burnout in veterinary specialty teaching hospitals (Hayes et al., 2020). Previous studies in health care workers have found females are more empathic and report higher levels of stress compared to men (Antoniou et al., 2003). Women may also be more focused on their emotions and rely on the social support of their peers to deal with such stress (Gabriel et al., 2016;Lim et al., 2010). Studies in human medicine report younger individuals may also be more affected by CCs (Cheung & Yip, 2015;Xie et al., 2011 Almost 50% of respondents in this study agreed or strongly agreed that they feel depressed because of CCs made against them. This was a self-reported diagnosis, and the authors did not attempt to objectively score depression levels in VSS as has been previously reported (Hayes et al., 2020). The authors also did not attempt to evaluate prevalence of burnout in this population although a positive association between burnout and depression has been previously reported suggesting burnout could also be common in this study population as well (Bianchi et al., 2015;Hayes et al., 2020).
Previous studies in human medicine have reported that CCs have the potential to improve medical practices (Gillepsie & Reader, 2016;Harrison et al., 2016). These findings were echoed in the present study with (58.6%) respondents who agreed that CCs are an objective means to evaluate performance. Indeed, respondents reported witnessing improvements in both hospital management (227 VSS, 41.2%) and medical practices (202 VSS, 36.7%) in response to CCs. The specific type of improvements was not evaluated in this study, but this finding suggests that there are some beneficial effects to receiving and improving practices. Such a positive reaction to CC likely instils the ability for the personnel to learn from their mistakes and may reduce underreporting of negligence or malpractice. Analysing and responding to CCs has been demonstrated in human medicine to improve the quality of health care (Gillepsie & Reader, 2016;Harrison et al., 2016). The potential benefit of CCs to improve medical practices in veterinary hospitals requires further evaluation.
There are several limitations to the study reported here. The investigators did not have access to the membership rosters of the different Facebook groups and the results were anonymous so we cannot be sure all who answered were VSS. Another limitation was the predominantly female responses over male which could have affected the results as previously described in this discussion. VSS may be reluctant to disclose a CC due to professional or personal embarrassment and thus the frequency of CCs among VSS may be higher than is reported here. The investigators attempted to encourage forthright answers by guaranteeing anonymity although there is no means to verify the selfreported numbers here. Two of the Facebook groups used to enrol VSS focused specifically on emergency and critical care technicians which may have biased the results towards a more stressful and strenuous work environment; it would have been more ideal to enrol technicians from a broad category of specialties and practice environments to provide a better cross section among all practice backgrounds. The large majority of the respondents were from small animal hospitals outside academia, and it would have been interesting to compare responses to large animal facilities and/or academic environments. In addition, it would have been interesting to compare geographical differences or comparing VSS of different clinical experience as it is difficult to know if certain locations have higher litigation rates for CC against veterinarians. There is also the 'healthy worker effect' which suggests individuals who are unwell tend to leave the job resulting in an overall 'healthy' bias in the remaining population (Li & Sung, 1999). All information that you provide is ANONYMOUS and CONFIDEN-TIAL and held in the strictest confidence. You will not be asked to provide any information that can be used to identify you nor can you be identified by the investigators by filling in any part of this survey. As such please answer each question honestly! This is an electronic form of consent for the study. By ticking the boxes below, you agree to participate in the study. Change the way they practice medicine Prescribed more medications than medically indicated

ORCID
Consented to treatment requested/demanded by the owner even though they did not feel it was necessary Offered invasive procedures against professional judgement at the owner's request/demand Admitted an animal to the hospital when the animal could have been discharged home safely or managed as an outpatient Carried out more tests than necessary Avoided a particular type of procedure Not accepted "high risk" patients in order to avoid possible complications Discounted services (ie tests, medications) for a client to avoid a complaint even if they thought the complaint had no merit Provided free services (ie tests, medications) to avoid or resolve a complaint with a client even if they thought the complaint had no merit