Accommodating blind and partially sighted clients in veterinary surgeries
The following article was published in the October 2014 issue of the Journal of the British Veterinary Association and cites work in the EGDF 2012 Mobility Research Report
Veterinary surgeons provide an important service to blind and partially sighted guide dog owners. By adopting basic disability awareness and visual impairment training, practices can ensure that the assistance needs of those clients are met, facilitating access to veterinary care.
Gary England is dean of the School of Veterinary Medicine and Science at the University of Nottingham, where he is professor of comparative veterinary reproduction. He serves as chief veterinary consultant to Guide Dogs and has worked with their breeding stock and owners for more than 20 years.
Tim Gebbels read modern history at Queen's College, Oxford and is a nationally recognised television actor. He has been totally blind since childhood and has been a guide dog owner for 17 years, as well as having worked as a volunteer for Guide Dogs.
Chantelle Whelan has a BSc in Psychology and an MSc in Animal Behaviour and is currently studying for a PhD on the premature retirement of guide dogs at the University of Nottingham. Her research is funded by Guide Dogs and focuses on the human-animal bond in assistance dogs.
Sarah Freeman holds the European Diploma in large animal surgery and is professor of veterinary surgery at the University of Nottingham, where she contributes to teaching, research and clinical work. She is a member of the Nottingham Assistance Dog Research Group and also leads a research team on evidence-based decision making in horses with colic.
THERE are approximately 5000 guide dogs in the UK that provide mobility, independence and improved wellbeing to blind and partially sighted adults and children. Approximately 60 per cent of guide dog owners are completely blind or have severe visual impairment; the remainder have varying degrees of residual vision. With the increase in the number of working dogs and their routine veterinary consultations occurring every six months, it is increasingly likely that many veterinary practices will have blind and partially sighted owners among their clients.
More than two thirds of people that are blind and partially sighted feel that their personal GP practice is not fully aware of their needs, specifically around physical assistance and staff awareness; nearly all blind and partially sighted people receive no information from their GP in a format that is acceptable to them (such as large print or e-mail) (Nzegwu 2005). In 2012, the European Guide Dog Federation's mobility research report (based on owner questionnaires of Guide Dog Owners across 19 EU member states) documented problems with accessing facilities for people with visual impairment across Europe: ‘Extremely worrying is the lack of access to medical facilities such as doctors’ surgeries, with 33 per cent reporting difficulty in access occasionally, frequently or always! 36 per cent report that they leave occasionally, frequently or always without achieving the objectives of their visit' (Brooks 2012). Frequent problems are a lack of training for staff to understand the blind person's needs as well as substantial challenges in accessing the physical space. It is doubtful that veterinary practices perform any better than our medical counterparts.
The Equalities Act (2010) (which replaced the Disability Discrimination Act) places legal responsibilities on practice owners to ensure that they make reasonable adjustments to how services are provided to accommodate people with disabilities. The aim of this article is not to detail those adjustments but rather to consider how a little extra time, effort and communication can enhance the visit of a blind or partially sighted owner to veterinary practices.
Meeting and greeting at reception
There are approximately 360,000 blind and partially sighted people in the UK. Those with residual vision might have limited visual acuity and/or a limited field of view. These conditions will impact upon their mobility, ability to make some observations or undertake detailed tasks, and will change the way in which they access material for reading.
Some sighted people might feel awkward when dealing with a blind and partially sighted person because they are unsure how to behave (Shyne and others 2012) but there are three key aspects that should be considered:
Staff should speak always directly to the owner of the guide dog as the primary carer of the dog and not by default to any sighted person present or to the dog. Sometimes, the guide dog owner can take time to recognise a voice, so even if you are familiar with the client, ensure that you always introduce yourself by name from the start of the conversation. Other staff members or students present should also be introduced so the client is aware of who else is there, and to avoid later embarrassment when a colleague who has been silent then speaks.
Orientation and assistance
Staff should proactively ask what assistance the guide dog owner might require during the visit. This could include asking whether they would like orienting in the room, which would include a short description of the size of the room, what predominant furniture is present and who else is present; for example, the number of clients and other animals in the waiting room. It is also good practice to inform the guide dog owner of the number of people ahead of them in the consultation list and the length of time they are likely to have to wait.
The guide dog owner should be offered assistance to a seat in the waiting room; this is important even if they have visited the practice previously as they will not know which seats are occupied, what other animals are present and where there could be an unwanted interaction. Guide dog owners will be unable to read other animals' body language and, therefore, will not be aware of nervous or aggressive animals within the waiting room. There is also a potentially increased risk of dog-on-dog attacks for dogs working in harness (Brooks and others 2010). Upon reaching the seats it is helpful to provide additional information about their specific location (eg, ‘the seat is immediately in front of you, facing you and the two adjacent seats are empty’). Of course the owner might decline assistance and could, for example, just require verbal directions to the seating area, which could include the approximate number of steps and in which direction the seats are located.
Interacting with the guide dog
In many cases the owner might be relying upon the dog for guiding and so the dog should not be distracted or fussed without asking the owner for permission to do so. This is particularly important while the dog is working (indicated by wearing of the harness and the owner holding the harness handle).
Moving around the practice
Guide dog owners should be approached when it is their turn for the consultation; it can be unhelpful to call a name from a distance when the route to the consulting room is unclear or might be partially obstructed, for example, by display stands.⇓
When moving around a practice, the guide dog owner might rely on the dog for guiding, but it could be preferable for a member of staff to provide sighted guiding. Asking whether the owner would like to be guided will not cause offence and neither will a suggestion that guiding them might be easier in a particular environment. There could be many potential obstacles within a waiting room, including fixed and temporary furniture or stands, other clients and animals, all of which might require different levels of avoidance.
In these cases it is preferable to stand on the owner's right side and allow them to take hold of the assistant's left arm/elbow with their right hand (Guide Dogs 2009). In this manner, the owner can be guided and there is no attempt to direct them by pushing. There is no need to take hold of the dog's harness or lead. When guiding, it is appropriate to describe where you are going, what hazards are coming up or the direction in which you will be turning, often using the approximate number of steps ahead that this will occur (eg, ‘We will be turning right in a few steps’). When approaching a closed door, inform the owner and describe whether the door opens towards or away from you.
When the dog is guiding the owner, but they are both following a sighted guide, it is also helpful to provide verbal directions or a commentary on the journey.
In the consulting room
On entrance into a new room, briefly describe its function, size, the number of people present and the general layout of the room. In the consultation room, it might be particularly important to describe where the consultation table is in order to prevent owner injury from bending down to handle their dog or remove equipment the dog is wearing.
Guide dog owners will have the same range of engagement with the health status of their dog as any other client. Some will be extremely vigilant, they might live with sighted people or walk with sighted friends and, therefore, be able to provide significant clinical history. Do not have a low expectation of what information the owner can provide. Most will groom and examine the dog daily and perform regular body condition scoring and pick up faeces after their dog, so can be aware of some health changes earlier than many sighted clients. Some owners will also have a degree of useful sight.
Do not be embarrassed to ask the full range of clinical history questions and to use the same phrasing as for any other consultation. The owner will not be concerned by the use of the word ‘see’ (eg, ‘Have you seen him limping?’). Nor will they be upset if they are asked to describe the appearance of something (eg, faecal quality) or something that has happened. Blind and partially sighted owners want to be treated like any other owner, although many have a very special bond with their dog because of the mobility support it provides them.
It is often helpful to provide a commentary during the clinical examination so the owner is aware of where the veterinary staff are in the room, and when they are approaching the dog. This avoids the awkward silences and also makes sure the owner is able to anticipate actions and help to calm and restrain the dog. Continual narration also helps ensure that the owner is aware of the progression of the consultation, as they will not recognise any non-verbal communications, such as gesturing, that are often inadvertently used.
Guide dog owners will not be embarrassed by an offer to ‘show’ them something and this can be facilitated by asking how they would like it done. It is perfectly acceptable to offer to demonstrate concepts using plastic models, again asking the owner if they would like to feel the model to allow them to conceptualise it, or to palpate things on their own dog. It is often helpful at the end of the consultation to summarise the findings and the diagnostic/treatment plan in separate blocks of material that can then be checked off against the owner's understanding.
Dispensing drugs for guide dog owners to administer can sometimes be problematic; however, spending a few moments discussing what is easiest for the owner to manage can avoid any potential non-compliance issues. It is extremely difficult for a blind or partially sighted person to measure the volume of a liquid or to accurately administer a given number of drops of liquid, or to administer tablets that have to be broken into smaller parts and these are all best avoided if possible. It can also be difficult to ensure that tablets given in food are fully consumed and, therefore, direct oral administration is usually preferred (clients should be asked if they are comfortable to do this and might like the opportunity to ‘practice’). Some tasks are particularly difficult, especially treating conditions of the eye, and, for some treatments or circumstances, the client may need to organise regular repeated administration at the practice by a practice nurse.
The size and shape of any tablets that are to be administered should be described and the owner should be asked if they would like to feel the packaging or products to ensure that they are familiar with them and to mitigate confusion later on. Owners are often familiar with managing their own medications but problems can arise when several medications are dispensed at the same time, especially if these are in similar packaging (eg, loose tablets dispensed into similar sized bottles). Providing different packaging for different products (eg, placing one set of tablets into oversized packaging) is a very simple way of identifying products. There is also often a need to provide instructions that can be reviewed at a later time (anyone can confuse instructions such as ‘two tablets from the large pot three times a day and three tablets from the small pot twice per day’). Many guide dog owners live with sighted people and, in these situations, printed labels are sufficient. Others will be able to recognise the shapes of words and interpret from that or use low vision aids to read. Guide dog owners with significant sight loss, who live alone, might wish instructions to be provided via an alternate method. Many will use a voice recorder or the dictation application on their mobile phone, but it could also be helpful to offer to text or e-mail instructions as a back-up (which can be converted through software to audio formats). Guide dog owners are realistic and won't expect information to be provided in Braille. Many are partially sighted and, therefore, using large print text might be suitable.
Hospitalisation of the guide dog
For many blind and partially sighted people the guide dog is transformative for their mobility. Hospitalisation of the dog can therefore mean that they are not able to get to work or have a normal social life, and this might be an extremely sensitive issue for a guide dog owner. Possible hospitalisation and the owners' mobility needs are best discussed in the privacy of the consulting room, rather than at the reception desk.
When unexpected immediate hospitalisation is necessary, a plan should be put in place to enable the guide dog owner to return home safely. Owners might not have a long cane with them or be trained to use a long cane and so, although taxi transport can be provided, access to their home can still be difficult.
Sometimes it is possible to avoid hospitalisation, for example by offering a special appointment to allow minor sample collection or diagnostic investigations while the guide dog owner waits, and this could be used to minimise the impact on the partnership. A guide dog should not be allowed to work for 24 hours after administration of a sedative or anaesthetic and, if this has occurred, the owner should be notified (in advance, if possible) and alternative transportation home should be organised.
Invoicing and provision of information
For working guide dogs, invoices will generally be settled directly by the Guide Dogs charity; however, for non-Guide Dog purchases, most blind and partially sighted people will use cash, debit or credit cards with no particular issues.
At the time of a consultation, it is perfectly acceptable to ask guide dog owners if they would like clinical information leaflets or practice hand-outs in a printed form. Some guide dog owners have residual vision or a sighted person at home that can read documentation to them. Offering these options is preferable to not providing this information at all. Alternatively, guide dog owners can be directed to sources of information available on a website. Sadly, many websites are poorly organised and difficult to navigate for visually impaired people. Frequently, websites use confusing graphics, rely on the ability to differentiate colours, do not allow for increasing font size and are formatted in such a way that makes it is difficult to use text-to-speech software (eg, JAWS, WindowEyes, Thunder, NVDA and Narrator) to read. Ideally, when setting up or redesigning a practice website, website designers could ensure that sites are accessible for these screen readers but, as a minimum, accessibility can be improved by avoiding multiple columns and tables, providing short descriptions of all images and avoiding the use of images as hypertext links. Webpage designers should also be aware that blind and partially sighted people might wish to use additional equipment to translate materials such as a refreshable Braille display. While most guide dog owners are resolute about website accessibility problems, many could be easily overcome by specifying accessibility criteria when practices are planning website upgrades.⇓
While guide dog owners might not have high expectations of society in general for providing written information in an accessible format, information can often be made accessible relatively easily. For example, communication with clients can be achieved using a telephone call, text or e-mail rather than via posted vaccination cards or letters. Noting a client's needs and preferred accessible format on the dog's clinical record can help both parties for future contacts and communications.
Practice owners might never have considered the accessibility of their practice for blind and partially sighted people and, while there is little that can be done to ensure accessibility outside of the practice property (eg, tactile paving on drop kerbs), accessibility within the practice can be easily improved with some thought and planning (Dalke and Corso 2013).
Within the practice grounds, accessibility can be improved by good signage at the practice entrance/gate, and a safe and smooth pedestrian route through the car park. Key issues for blind and partially sighted owners are obstructed routes or ones with restricted widths that prevent the passage of the dog and the owner side-by-side. Dogs are particularly good at avoiding obstructions; however, partially sighted owners might not rely on the dog to guide them at all times, particularly if the dog is fearful of veterinary treatment. Therefore, glass doors and panels provide a significant challenge and should be carefully marked at an appropriate height.
General guidance for visually impaired clients is to ensure that signage preferably uses symbols with large lettering (first letter capitalised and the others lower cased - as many visually impaired clients with residual vision will recognise the shape of words), and with high-colour contrast. Access can be improved by ensuring that there are good levels of lighting and preferably that the choice of decor provides an enhanced colour contrast between the floor and walls, or possibly that there is colour and/or textural contrast between walkways and waiting areas for example. (This could be kept in mind when facilities are being refurbished). Stairs should have a handrail, be well lit and should ideally have good contrast between risers and treads.
Braille labelling for rooms is not particularly important, as it is often haphazardly placed (on the door or to the right or left of the door at variable heights) and, currently, only a minority of blind and partially sighted people can read Braille.
Guide dog services are provided by Guide Dogs, a charity that receives no funding from government and provides transformative mobility and well-being support for thousands of blind and partially sighted adults and children in the UK. The Guide Dogs' vision statement is that blind and partially sighted people can enjoy the same freedom of movement as everyone else. Adoption of basic disability awareness concepts, open communication and dialogue about needs and assistance, visual impairment training for staff and provision of written information in an accessible format by veterinary professionals can go a considerable way to supporting Guide Dogs' mission and will improve access for blind and partially sighted clients to veterinary practices.
After reading this article, try to find your own way, blindfolded, from the practice entrance to the toilet in a journey that includes washing and drying your hands. Reflect on how you found the walk and what you might want to change or do differently around the practice to make the trip easier.
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