Edited by: Emily Patterson-Kane, Independent Researcher, Rolling Meadows, IL, United States
Reviewed by: V. Wensley Koch, Retired, Loveland, CO, United States; Susan Marie Elrod, Auburn University, United States
This article was submitted to Veterinary Humanities and Social Sciences, a section of the journal Frontiers in Veterinary Science
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Ethically challenging situations (ECS) are common in veterinary settings and can lead to moral stress. However, there is no published information about how a global pandemic affects the frequency and types of ECS encountered by veterinary team members. An online mixed methods survey was developed to determine the frequency, stressfulness and types of ECS experienced by veterinarians, animal health technicians and veterinary nurses since the advent of the global COVID-19 pandemic in March 2020. Responses from 540 veterinary team members from 22 countries were analyzed. With the advent of the COVID-19 pandemic, the median frequency of ECS encountered by respondents increased from several times per month to several times per week (Spearman Rank Correlation 0.619,
Under normal circumstances, ethically challenging situations (ECS) are commonly encountered in veterinary settings and can lead to moral stress. Previous surveys have identified the most common ECS as client financial limitations restricting treatment options (
The COVID-19 pandemic, described as the second transboundary mega-crisis to impact contemporary societies in the 21st century after the global financial crisis (
Key stakeholders in veterinary ECS have historically been considered to be the veterinarian or veterinary team member, the animal patient and the client (
Understanding the types of ECS encountered by veterinary team members during an unprecedented global crisis can assist in preparing for and potentially circumventing such challenges in the future.
To the authors' knowledge there are no published data on the impact of a transboundary mega-crisis on the ECS faced by veterinary team members. To address this gap, we conducted a survey to determine (1) the frequency, stressfulness and types of ECS encountered by veterinary team members during a global pandemic and (2) veterinary team members' approaches to recent ECSs.
We developed a survey comprising 29 questions, presented in three sections (see
In the second section, participants were asked to consider the most recent situation in which they felt significant difficulty determining the ethically right thing to do. They were asked to choose a situation that had run its course and were advised that the example could come from any aspect of patient care or any other kind of situation in their workplace. They were asked to answer the following closed-ended questions in relation to that nominated situation: the type of ECS (from the same list as above), who or what was their primary obligation in this situation, how stressful was the situation, which strategies or resources they employed in the face of this situation, how helpful those strategies or resources were, how they rated the acceptability of the eventual outcome, what (if any) barriers to achieving an acceptable outcome they encountered, and, in reflecting on the case, what additional types of assistance or resources they would have found useful.
In the final section, participants were asked 9 demographic questions, including their professional role, country of work, year of graduation, year of birth, gender, caseload, hours worked per week in their current role, whether they were taught ethics as part of the training toward their qualification, and whether they had undertaken any ethics training after gaining their qualification. Participants were also asked how confident they are in dealing with ECS in their workplace, and to what extent they are free to make and act on ethical decisions in their workplace. For each closed-ended question, participants could select “other” and provide a free-text response. The final question asked participants “is there anything else you would like to add about your experience with ethically challenging situations since the advent of COVID-19?” This question was included to act as a safety net, to facilitate identification of pertinent issues that were not addressed in the preceding questions (
Research Electronic Data Capture (REDCap) was the survey platform used. REDCap is a secure web application used for building and managing surveys, as well as data storage and export, hosted by the University of Sydney.
The survey was piloted by veterinarians and veterinary nurses from a variety of backgrounds (industry, companion animals, equine practice, wildlife, veterinary education). Questions were refined on the basis of feedback from these individuals. The study was approved by the University of Sydney Human Research Ethics Committee (project 2020/291).
A three-pronged online recruitment strategy was employed to maximize the networking potential of the study team and professional networks, and to distribute survey invitations as widely as possible across geographic boundaries (
Respondents were encouraged to share the survey link with colleagues, a snowball sampling technique which is an efficient and valid approach for recruiting unknown populations in online surveys (
To meet the inclusion criteria, respondents were required to be a veterinarian, animal health technician or veterinary nurse over the age of 18 years. Participation was open to all geographic locations from the period 13 May 2020 to 14 July 2020. The landing page of the survey was a participant information statement, providing detailed information about the purpose of the study, the estimated completion time (15–20 min), information about data storage and feedback, and assurance of the confidentiality and anonymity of responses. Submission of responses via REDCap indicated consent to participate. Data were stored on the physically and electronically secure, restricted-access University of Sydney server, which is routinely backed up and accessible only by the study team.
Where respondents had selected “other” from the drop-down menu and subsequently specified a response already represented by an option in the drop-down menu, it was re-categorized as such. Only those responses which were not reflected in the drop-down menu were retained in the “other” category.
Survey data from REDCap were downloaded into Microsoft® Excel® for Microsoft 365 MSO (16.0.13328.20262). Responses were organized into categories for the purpose of descriptive statistics. Summary statistics were calculated for the demographic variables and for the ECS variables. Likert-style data were plotted using stacked bar graphs.
For the question on the frequency of specified types of ECS encountered since the COVID-19 pandemic, the categories “several times per day,” “daily” and “several times per week” were combined into “at least weekly” in order to better visualize the patterns present in the data.
For the question on the stressfulness of specified types of ECS encountered since the COVID-19 pandemic, the categories “very stressful” and “maximally stressful” were combined, as were the categories “a little bit stressful” and “moderately stressful” in order to better visualize the patterns present in the data.
IBM SPSS version 24 was used for statistical analysis. Pre- and post-COVID ECS distributions were assessed for normality, and median scores were calculated. The correlation (Spearman rank, rSP) between respondents pre vs. post COVID-19 ECS was estimated. Differences between groups were tested using the chi square test for categorical variables. A two-sided
Thematic analysis of free-text responses was performed as described by Braun and Clarke (
In total, 551 respondents completed the survey and pressed the “Submit” button at the end of the survey indicating their consent to participate. Of these, two were test responses and 9 pressed submit without providing any answers to survey questions. Therefore, 540 responses were analyzed. With the exception of one respondent, who did not answer one question, all respondents completed all questions. Therefore, 540 responses were analyzed for all questions, with the exception of the questions asking respondents to specify the most recent type of ECS they had encountered (
Frequency table for the demographic information on respondents to mixed methods survey on ethically challenging situations encountered by veterinarians, animal health technicians and veterinary nurses globally in the COVID-19 era in 2020 (
Gender | Female | 434 | 80.4 |
Male | 102 | 18.9 | |
Other | 4 | 0.7 | |
Role | Veterinarian | 423 | 78.3 |
Veterinary nurse | 97 | 18.0 | |
Animal health technician | 11 | 2.0 | |
Other animal health professional | 9 | 1.7 | |
Caseload | Companion animal practice clinical | 367 | 68.0 |
Mixed animal practice clinical | 38 | 7.0 | |
Academia/teaching | 34 | 6.3 | |
Zoo and/or wildlife practice clinical | 27 | 5.0 | |
Equine practice clinical | 13 | 2.4 | |
Exotic/unusual pet practice clinical | 12 | 2.2 | |
Practice management | 12 | 2.2 | |
Non-government organization | 10 | 1.9 | |
Scientific research/laboratory animals | 8 | 1.5 | |
Government | 8 | 1.5 | |
Other | 5 | 0.9 | |
Industry (e.g., pharmaceutical companies, food companies) | 4 | 0.7 | |
No longer working as a veterinarian | 1 | 0.2 | |
Hours/week | 0–10 | 21 | 3.9 |
11–20 | 31 | 5.7 | |
21–30 | 64 | 11.9 | |
31–40 | 186 | 34.4 | |
41–50 | 165 | 30.6 | |
50+ | 73 | 13.5 | |
Country | Australia | 319 | 59.1 |
United States of America | 125 | 23.1 | |
Canada | 26 | 4.8 | |
United Kingdom | 25 | 4.6 | |
New Zealand | 12 | 2.2 | |
Singapore | 10 | 1.9 | |
Germany | 6 | 1.1 | |
China | 4 | 0.7 | |
Netherlands | 3 | 0.6 | |
Other |
13 | 2.4 |
The frequency of ECS encountered by veterinary team members increased following the advent of the pandemic (
Bar chart for the median frequency of ethically challenging situations (ECS) encountered by veterinary teams prior to and since the advent of the COVID-19 global pandemic, based on the responses of 540 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020.
Comparison of frequency of ethically challenging situations (ECS) encountered by veterinarians, animal health technicians and veterinary nurses prior to and since the advent of the COVID-19 global pandemic (
Frequency of ECS prior to COVID-19 global pandemic | Less than once per month | 56 | 57 | 23 | 10 | 4 | 3 | 153 |
Several times per month | 8 | 108 | 74 | 22 | 4 | 1 | 217 | |
Several times per week | 0 | 4 | 60 | 38 | 13 | 0 | 115 | |
Daily | 1 | 0 | 0 | 25 | 11 | 0 | 37 | |
Several times per day | 1 | 0 | 1 | 0 | 12 | 0 | 14 | |
Never | 0 | 0 | 0 | 0 | 0 | 4 | 4 | |
Total responses | 66 | 169 | 158 | 95 | 44 | 8 | 540 |
The frequency at which respondents encountered different types of ECS is presented in
Stacked bar chart for the most commonly experienced ethically challenging situations encountered by veterinary team members since the advent of the COVID-19 pandemic, based on the responses of 540 based veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020.
Of the 22 respondents who additionally selected “other,” two did not provide an answer at all, and two simply provided contextual information which did not specify an ECS. The remaining 18 responses are included in
Other situations where decision-making may be ethically challenging, as described by participants.
Veterinarian | Australia | Disagreements between colleagues. One person wants to do A and another wants to do B. |
Veterinarian | Australia | Challenging decision about clients surrendering their animals out of failure to take care of them due to the imposed lockdowns. |
Veterinarian | USA | Challenging to deal with staff who do not want to work or do not want to be effective at work or who just want a paycheck. |
Veterinarian | Australia | Challenging decisions involving a difficult case, when clinicians do not collaborate and communicate effectively in order to achieve a better outcome. |
Veterinary nurse | Australia | Seeing clients from other clinics that have been turned away from them as they are “too busy” to see them, when we are also double or triple booked. Some are from up to several hours drive away because everywhere is too busy. |
Veterinarian | Germany | Home schooling an 8-year-old while working full time! how to deal with (euthanasia) home visits which I consider ethically essential. |
Veterinarian | Australia | Allowing more than one owner into the clinic to be with their pet during euthanasia. |
Veterinarian | Australia | Whether to wear PPE during home euthanasia visits. On the one hand I am wanting to protect the clients. I am not so worried about my own health. However, it feels impersonal. Also lack of physical contact with the owners at this time is challenging. Such as not being able to shake their hand or give them a hug. |
Veterinarian | UK | Decisions around euthanasia which has to be carried out by others on site - mainly animal technicians - due to lack of ability to use animals in research due to lack of lab facilities (wastage). |
Veterinarian | Germany | Hearing or reading pseudoscience, conspiracy theories, anti-vax-non-sense.there is always the question whether to keep my mouth shut or take the risk of a shitstorm;) |
Veterinarian | USA | Information barrage from human healthcare, veterinary healthcare, federal, state, and university sources regarding epidemiology, legal, and policy changes. |
Veterinarian | USA | We have had several owners and visitors wishing to enter the building, but our policy says they cannot. |
Veterinarian | USA | Allowing DVMs to see enough cases to have reasonable income while limiting the schedule. |
Veterinarian | USA | Provision of futile medical care to animals who are suffering. |
Veterinarian | Australia | Challenging decisions about tolerance for risk of potential SARS-CoV-2 exposure to clients, carried by visiting veterinary team. |
Veterinarian | Australia | I work as a vet in the live export industry. COVID-19 has put pressure on supply chains for both chilled meat and live animal exports. Now more than ever, it feels like I am stuck between two competing ideologies for and against the live export industry. People's opinions and heightened emotions are inhibiting sound decision making processes around balancing animal welfare with food security. |
Veterinarian | USA | Lack of volunteers to perform duties; lack of donations to support operation. |
Veterinarian | Australia | Difficulty with conflict with clients with regards to COVD protocols. |
The most stressful ECS was perceived to be
Stacked bar chart for the most stressful ethically challenging situations encountered by veterinary team members since the advent of the COVID-19 pandemic, based on the responses of 540 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020.
When respondents were asked to consider the most recent situation in which they experienced significant difficulty deciding upon the right thing to do, 539 provided a response that specified the type of ECS (
Bar chart of the frequency of the of the most recent type of ethically challenging situation encountered by veterinary team members since the advent of the COVID-19 pandemic, based on the responses of539 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020.
When asked how stressful they found their most recent ECS, most respondents (54.2%) reported that this situation was either very stressful (37.2%,
Almost half of respondents considered that ultimately, their primary obligation was to individual animal patients (480%,
Among the 68 response in the “other” category, respondents listed self (22.1%,
The most commonly reported resource employed by respondents to help in the face of an ECS was discussion with colleagues (63.1%,
Bar chart of the frequency of the resources and strategies used by veterinary team members when faced with the most recent ethically challenging situation they have encountered, based on the responses of 540 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020. Note that respondents could select multiple options.
While only 15.2% (
“I used my knowledge of the clients, their known health status, our mutual trust, the need for euthanasia of their pet in the home environment and the refusal of a referral/emergency service to allow it.” (198, veterinarian, Australia)
Others appealed to a sense of what was “right” but did not elaborate on norms or rules they referred to in deliberation.
“I could only do what I felt was right for the client and the pet and what I could live with.” (222, veterinarian, US)
or
“What I felt was ultimately right although difficult/scary for me to do.” (270, veterinarian, Australia)
Other resources respondents used (7.8%,
More than one third of respondents (35.9%,
Only 4.6% of respondents (
The most common barrier to resolving an ECS to the respondent's satisfaction (
Bar chart of barriers to resolving the most recent ethically challenging situation encountered by veterinary team members, based on the responses of 540 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020. Note that respondents could select multiple options.
Other reported barriers included lack of personal resources (
When asked to reflect on the ECS and consider which types of assistance they would have found useful, almost half (46.7%,
Bar chart of the types of assistance respondents felt would have been useful in resolving the most recent ethically challenging situation they encountered, based on the responses of 540 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020. Note that respondents could select multiple options.
Among respondents who selected other, desired assistance for navigating ECS tended to fall into one of three major categories. The first category comprised practical support, and included human resources (
Most respondents (54.3%,
Following their qualification, 51.7% of respondents (
Most respondents were confident enough that they could get by (42.8%,
The majority of respondents (52.4%,
Overall, there were 17 major themes identified across responses to the three open-ended questions. When asked to describe the most common ECS since the advent of COVID-19, 540 respondents provided a comment (100%), providing 13829 words for analysis. The length of these comments ranged from 1 to 245 words. The most prominent themes were biosecurity (featuring in 48.7% or
Bar chart of the frequency of major themes from respondent descriptions of the most common ethically challenging situations encountered since the advent of the COVID-19 global pandemic, based on the responses of 540 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020. Note that a single response could be coded for multiple themes.
When asked to describe the most stressful ECS since the advent of COVID-19, all respondents provided a comment (
Bar chart of the frequency of major themes from respondent descriptions of the most stressful ethically challenging situations encountered since the advent of the COVID-19 global pandemic, based on the responses of 540 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020. Note that a single response could be coded for multiple themes.
Readers are referred to
When asked if there was anything else they would like to add about their experience with ECS since the advent of COVID-19, 195 respondents (36.1% of the total sample) provided a comment. Of these, 22 wrote “no,” “none,” “n/a,” or “nil,” leaving 173 comments totaling 8038 words remaining for analysis. The length of these comments ranged from 2 to 298 words. Many respondents utilized this section to expand on themes they had already mentioned, particularly biosecurity (39.9%,
Frequency of major themes from respondent's additional comments regarding ethically challenging situations during the COVID-19 pandemic, based on the responses of 173 veterinarians, animal health technicians and veterinary nurses, surveyed between May and July in 2020. Note that a single response could be coded for multiple themes.
Readers are referred to
This is the largest global survey on ECS encountered by veterinary team members. The results of this study indicate that veterinary team members experienced increased frequency of ECS during a global pandemic. The median frequency of ECS encountered by veterinary team members increased from several times per month to several times per week with the advent of the COVID-19 global pandemic. The pre-pandemic frequency of ECS reported by veterinary team members is comparable with previous surveys on the frequency of ECS experienced by veterinarians. Pre-COVID-19 surveys suggested that veterinarians experience an ECS at least weekly, with 57% of UK veterinarians reporting 1-2 ethical dilemmas per week (range 0 to more than 10 times weekly) (
The increase in frequency of the ECS reported by respondents is likely due to a range of factors, including an increased frequency of established ECS such as client financial limitations, increased workload experienced by many veterinary teams, and the emergence of new or novel ECS associated with the COVID-19 pandemic itself.
We found that the COVID-19 pandemic was associated with both established and novel ECS in veterinary settings. The most common ECS, experienced by over two-thirds of respondents at least several times per week since the advent of the pandemic (64.4%,
Previous surveys have identified client financial limitations as common ECS encountered by veterinarians and veterinary team members. For example, veterinary anesthetists and technicians reported that animal care was impacted by financial constraints in 29% of ethically challenging cases (
The next most commonly encountered ECS was
Our thematic analysis revealed that ECS experienced during COVID-19 were often associated with uncertainty around biosecurity. It is possible that appropriate biosecurity guidelines, protocols and contingency plans may have reduced the conflict between personal well-being, and that of family or household members, and professional role, by ensuring that veterinary team members and organizations can operate with minimal risk to themselves, their colleagues and their families. These include strategies to discourage sickness presenteeism – which presents a risk to colleagues, clients and those in their networks – and encourage sickness absenteeism, such as paid pandemic leave for those required to self-isolate or undergo COVID-19 testing, and employment or contracting of trained staff to cover for those absences.
To this end, the pandemic exposed a lack of preparation among veterinary facilities. In their survey of small animal emergency hospitals in the US, Wayne and Rozanski reported that prior to the pandemic, fewer than half (44%) of hospitals had contingency plans for short-term disruptions such as snow days, while only 24% had disaster or business continuity plans. The remaining 32% had no plans for either short or long-term disruption (
Challenges arising from a conflict between personal well-being and professional role may arise in part due to uncertainty around the primary obligation of veterinary team members. Almost half (48.0%,
Tannenbaum described the veterinarian as the “servant of two masters” – human clients, on the one hand, and animal patients on the other (
Recognizing that most veterinarians are employed, in its Animal Welfare Strategy, the British Veterinary Association describes the veterinarian's trilemma as arising from duties to animals, clients and employers (
There is a perception that in human healthcare, the primary obligation is – in theory – clearer. Oaths, such as the Hippocratic Oath, act as a moral compass in the face of ECS (
We found that 48.1% (
Part of the dilemma around the question “what counts as an essential service” is that the answer varies depending on the perspectives and time frame taken into account. As one UK-based veterinary nurse wrote, “Dental disease-not immediately life threatening but potentially may cause life altering issues if not treated” (respondent 430). It has been noted that some veterinary services, including preventative measures against diseases with a significant public health or economic impact such as rabies or tuberculosis, have been reduced or suppressed during lockdown (
Veterinary team members commonly reported having to make
In addition to impacts on animal welfare, non-contact euthanasia in particular may cause distress in clients. The veterinary euthanasia experience can alleviate or aggravate the grief of clients. A survey of 2354 pet owners in the UK conducted prior to the pandemic found that their experiences of administration practices (such as paperwork and payment), as well as emotional support at the time of the animal's euthanasia, were key influences on their satisfaction with the euthanasia experience (
In addition to the types of ECS that respondents could select from in the survey, a number of respondents specified “other” ECS, and indeed, these were experienced as very or maximally stressful by 42.9% (18/42) respondents who encountered them. This may reflect recall bias, where the ECS that comes to mind is the most salient to the respondent. Had the types of ECS specified as “other” been offered as choices that respondents could select from, it is possible that some would have been reported as very frequent. This information can be used to refine future studies on ECS, and incorporated into ethics teaching scenarios where possible.
Respondents used a range of strategies and resources to resolve ECS. Most respondents (66.3%,
Almost two thirds of veterinary team members (63.1%,
The next most frequently used resources were workplace policies (used by 32.2% of respondents,
Ethical frameworks were knowingly used by only 15.2% (
In addition, increased workload may lead to or exacerbate cognitive fatigue. Consecutive online surveys of 24-h small animal emergency veterinary hospitals in the US found that most reported caseload increases of at least 10%, with 44% reporting increases of at least 25% (
Poor moral reasoning may lead to decision regret, rumination and moral stress, which negatively impact the well-being of veterinary team members. Importantly, insufficiently mature ethical reasoning or lack of ethical sensitivity may lead to negative animal welfare implications if veterinary team members cannot identify or effectively advocate for a course of action that is in an animal's interests (
Almost all respondents (93.9%,
Though less common,
Interestingly, conflict between veterinary team members and their employers (as opposed to colleagues) has not emerged as an explicit theme in previous surveys of ethical challenges encountered by veterinary team members. The free-text responses suggest that factors contributing to the emergence of this conflict include conflict around pandemic measures, including biosecurity measures such as mask-wearing or determining what is an essential service. Other factors may include disagreements about workload management, perceived pressure to generate income, poor team morale do to concerns about job security (
Further studies are required to determine how the pandemic has exacerbated this conflict to a point of significance. Managing conflict between employers and veterinary team members has the potential to improve team morale and working conditions, as well as perceived job security.
Professional reassurance that their decision was the correct one was the leading form of assistance desired by respondents (46.7%,
Despite these barriers, respondents reported overall a high degree of autonomy in making ethical decisions, with 70.4% (
Our findings suggest that increased or better quality training of veterinary team members in navigating ECS may increase the strategies and resources available to them. Most respondents (54.3%,
None of the above studies, including the current study, investigated the amount and quality of ethics training, nor its impact on the subsequent perception of frequency or stressfulness of ECS in veterinary team members. A survey of the American Veterinary Medical Association Council of Education (COE)-accredited institutions found that 18 of 30 offered a formal course in animal ethics (
Most (51.7%,
In the current study, very few respondents (4.6%,
Despite concerns raised in the current study, 82.0% (
It is argued that moral distress or moral injury arising from ECS are indicators of problems with healthcare systems rather than individual team members working within them (
Client financial limitations, already the most common ECS faced by veterinary team members, occur commonly in veterinary settings, but are exacerbated in the context of a pandemic. We therefore recommend that veterinary team members, veterinary facilities, professional organizations, Governments and non-government organizations prepare to accommodate clients with financial limitations, and take steps to increase access to veterinary care. This requires a multifactorial approach, combining strategies from animal health insurance and third-party credit to low-cost clinics, access to emergency funds for veterinary care and preventative programs, including disease surveillance, and continuing education of policy makers and the public about the importance of animal health and welfare. The Access to Veterinary Care Coalition have already outlined a number of potential strategies to expand access to veterinary care for companion animals (
In the context of the pandemic, veterinary team members were faced with the dilemma of balancing their personal well-being – and the well-being of their family or household members – against their professional obligations. This is not a new dilemma. Veterinary team members are at potential risk of exposure to zoonoses. However, the focus of training is typically prevention of animal to human disease transmission. In the authors' experience, the COVID-19 pandemic is the first time there has been widespread awareness of the risks presented to veterinary team members from each other and clients. The dilemma of whether to prioritize personal safety over professional role can never be entirely eliminated. However, evidence-based, appropriately implemented biosecurity protocols can reduce risks associated with providing veterinary services. Such protocols must be clear, able to be adopted by all veterinary team members, and incorporated into training programs and continuing professional development. Additionally, veterinary clientele need to be informed about such protocols and educated regarding their rationale.
To be effective, biosecurity protocols should incorporate strategies to reduce sickness presenteeism. This will require significant cultural change. A global survey on sickness presenteeism comparing the self-reported behavior of health care workers and non-healthcare workers with influenza like illness found that the majority of both groups would continue to work, despite health care workers knowing the risks of transmitting influenza-like illness to vulnerable patients (
Conflicts between the interests of animals and their owners were commonly reported by veterinary team members in this and previous surveys. Further information is required to understand the nature of such conflicts, for example, whether these emerge from different beliefs about the moral status of animals, differences of opinion between owners and veterinary team members regarding the level of suffering an intervention or lack of intervention may cause, conflicts resulting from insufficient information or evidence, differences in values between veterinary team members and clients and so forth. Understanding the bases of these conflicts is an critical in communicating about and potentially resolving them (
Many respondents reported that they referred to their professional oath or code of conduct in resolving ECS. We recommend that professional organizations and registration bodies consult with their stakeholders about how these documents help or hinder resolution of ECS in the context of the COVID-19 pandemic. For example, it may be that in some cases, these documents provide clarity or confusion around the primary obligation of veterinary team members, the types of services considered essential or the role of veterinary team members in an emergency. This information should be compiled and used to refine oaths and codes, to ensure that these resources are as helpful as possible for those navigating ECS. Individual veterinary team members may wish to review their oath and code of professional conduct in the light of the challenges they faced, and provide feedback proactively to their respective regulators and boards.
Pressure from an employer or client was viewed as a major barrier to resolution of ECS by respondents in this survey. To overcome pressure from employers, those studying moral injury in the human healthcare field recommend bringing the “employers” (administrators) and “employees” (clinicians) together, to understand each other's respective roles and responsibilities. It has even been recommended that individuals from each of these groups “shadow” their counterparts (
While most respondents had had some form of ethics training, few employed ethical frameworks to aid in decision making. There is scope for veterinary educators to develop curricula and continuing professional development allowing attendees to work through ECS that may be encountered in the context of a pandemic, such as those outlined in this paper, in a psychological safe environment, without time pressure.
Veterinary teams can establish structures to provide advice about alternative courses of action, help in mediating conflicting perspectives and (where appropriate) professional assurance that the best, least worst or right course of action was taken. Discussion of active ECS with an ethics committee may address these needs, though there are practical and resource constraints to consider (
We believe that it is important for veterinary team members to appreciate that the primary resource utilized in navigating ECS was discussion with colleagues, relied upon by almost two-thirds of respondents. Discussion of ECS with colleagues may be a means of identifying all stakeholders, identifying alternative approaches or options, or simply as a means of being reassured that one has not overlooked an obvious stakeholder or option, and made the best possible decision in the circumstances. It may also be a means of learning that a different approach might have been better, and could be a vital learning opportunity. However, as has been previously recognized (
The COVID-19 pandemic, like previous pandemics, has highlighted the problematic nature of human-animal interactions, with human behaviors such as incursion into wildlife habitat, habitat destruction, unnatural human-animal contact, the consumption of wildlife, overcrowding of animals, live animal markets and transport of animals being identified as risk factors for the spread of zoonotic disease (
A major limitation of this study is its inability to characterize the source population from which respondents were sampled. The exact populations of veterinarians, animal health technicians and veterinary nurses globally are unknown, so a response rate could not be calculated.
Where possible, we asked veterinary, nursing and animal health technicians organizations to distribute the link to our survey to their members via electronic mailing lists (see
Unrestricted, open surveys introduce the risk that respondents may not be who they say they are, that respondents may complete the survey multiple times to create a “ballot box stuffing” effect, or that web robots may be used to generate spam data (
Questionnaire design may have influenced respondents. For example, a respondent may not previously have considered a potential ECS before reading this option in this question. However, the first two questions in the survey asked respondents to describe the most common and most frequent ECS they encountered in their own words before proceeding to the next section. This encouraged respondents to consider the ECS they had encountered before suggesting any particular types of ECS.
The open-ended questions provided space for participants to describe situations that they encountered, but the anonymity of responses meant that further clarification was not possible. Thus, it is possible we might have misunderstood certain responses, leading to inappropriate categorization in the thematic analysis.
The length of the survey may have discouraged potential respondents. Indeed, many who did take the time to complete the survey indicated that they were time-poor and overworked, and the pandemic has been associated with increased rates of burnout among veterinary team members in some contexts (
Finally, this survey can only provide a cross-sectional snapshot of ECS faced by veterinary team members during a brief time period (May to July 2020). At the time of publication, many countries and regions are experiencing subsequent waves of the pandemic. The COVID-19 pandemic has been described as a “creeping crisis,” with undefined end-points, no clear path to exit from restrictions, and potential to “change shape along the way” (
The datasets generated for this article are not readily available because we have approval to disseminate aggregated data, but not individual data. Requests to access the datasets should be directed to
The studies involving human participants were reviewed and approved by The University of Sydney Human Research Ethics Committee approval number 2020/291. The patients/participants provided their written informed consent to participate in this study.
AQ: literature review, study design, survey building and piloting, ethics application, data analysis, writing, editing, and submission. SM: study design, survey refinement, ethics application, data analysis, editing, and supervision. PM: study design, survey refinement, ethics application, editing, and supervision. MW: data analysis, editing, and supervision. All authors contributed to the article and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors would like to acknowledge the respondents for taking the time to complete this survey, Dr. Kathrin Schemann, from the Sydney Informatics Hub, and Dr. Sandra Steele for advice regarding the data analysis, and Kristina Vesk OAM for providing constructive comments on a draft of this paper. We are grateful for the comments offered by reviewers during the peer review process, which we believe have helped improve this manuscript.
The Supplementary Material for this article can be found online at: