Nurses need to take charge

Jill developed a Certificate in Advanced Veterinary Practice (CertAVP) at University of Liverpool

RVN Jill Macdonald talks about why we should apply a fee for nurse consultations and clinics, how this may ultimately help us to move forward in the profession, and the simple steps we can take in practice to implement a fee for nurse time.

The content of this short article formed a small section of one of her presentations at BSAVA 2018 (‘the Future of VN Consulting’), and is a theme that was picked up by several at congress.

Charging a fee for nurse consultations and clinics has always been a passion of mine. Way back in about 2000 (I know, SUCH a long time ago!) the practice where I was head nurse implemented a fee for nurse clinics. The effect that it had on several areas was and is worth note.

What difference does a charge make?

Firstly, nurses felt more valued as professionals, since the time and effort that they were expending on setting up, planning and delivering consult-room care was being rewarded on a financial level. We were now also income generators for our practice business.

The vets were more even more keen to refer cases on to us, since the work was going to be chargeable (rather than costing the practice money).

Clients seemed to appreciate the clinics much more. ‘Free’ has no value, and paying for a consult meant that we had very few missed appointments, and clients seemed to trust and respect us more, and take up more of our recommendations.

‘Free’ has no value

By creating revenue from this work, we were able to re-invest – new cat scales, a doppler, revamped consult rooms, and even ANAs to support the nurses during certain consult sessions.

The level of preventative care was massively enhanced. We were performing routine, chargeable, flea and worm checks for example – ensuring that pets were in good health, were receiving appropriate treatments for their situation, and administering these treatments if necessary. Pets with long-term conditions were seen in-between their regular vet check-ups, meaning that any changes were spotted sooner, and clients were supported in their care. We couldn’t have realistically sustained this level of nurse activity without charging for it..

..clients seemed to trust and respect us more, and take up more of our recommendations

Client perception

Did clients complain about the fee? Not at all. In fact, we got more questions about it before we charged. Previously, clients didn’t seem to understand why the vets charged a fee and the nurses didn’t. We planned ahead, were open and transparent about the fee, and explained why were were going to be charging it, before it was implemented and our clients were really supportive, as they already really valued the nursing team.

Fee structure

As time has gone on, my passion has turned into somewhat of a bugbear. I’ve been running the Nurse Clinics course with ONCORE for about 3 years now, and one of the (many) topics we discuss is fee structure for clinics. We start off by talking about why clinics should be charged, and the same themes emerge.

  • We are trained professionals with nursing qualifications, and that process comes at some cost – from both a time and monetary perspective
  • Nurses have expertise and experience that clients don’t have – that’s why they want to come to us
  • We need equipment and materials to provide the clinics – again, at a cost to the practice
  • The cost of running the clinics has to be taken into account – premises, wages, receptionist provision etc
  • We are professionally accountable – so ultimately if something goes wrong, we could lose not just our job but our professional status. So that’s a given – but to then do this work without charging for it would be ludicrous in any other profession
  • For the VN profession to progress, professionally and financially, we need to have an impact on revenue creation within practice

Nurses have expertise and experience that clients don’t have – that’s why they want to come to us

Fee anxiety

So the general consensus is that a nurse’s time and expertise should be charged for, the same way that a vet’s is. However, the number of practices actually applying a fee to their clinics is minimal. There is a discomfort – an anxiety almost; associated with applying a fee for nurse’s time. Quite often nurses feel that clients would simply not be willing to pay for nurse consults – as we are ‘just nurses after all.’ ‘We can’t diagnose, so how can we charge?’ ‘Clients wouldn’t pay when we are just offering advice.’ I think this is just a confidence issue, and we can get past it.

Are we seen as sales people?

The perception that nurse consults create revenue through other means (for example by diet or other product sales), and therefore a charge is not required, creates a further issue. By following this principle, we are effectively very well qualified sales persons. We are offering a ‘free consult’ if clients ‘buy the product we’re selling’.

I would rather charge for my professional time, and let the client make the decision on what they buy, without coercion.

I have even seen practices that charge for a consult if the client doesn’t buy the ‘diet food’, but waive the fee if they do. What message does this give to our clients? I would rather charge for my professional time, and let the client make the decision on what they buy, without coercion.

Obstacles for progression

In one of my recent presentations at BSAVA, I talked about the obstacles that may be in the way of progression of nurse consultations, of course one of these being the lack of understanding (both on the part of vets and nurses) on work that can be delegated to veterinary nurses, highlighted in the recent RCVS report on the Schedule 3 consultation.

Whilst the dreaded ‘entering a body cavity’ phrase springs into everyone’s mind whenever S3 is mentioned, it does of course also apply to the work that nurses perform in clinics and consults, and the medical aspects of nursing care delivery

I look forward to seeing how this work progresses, since this lack of clarity will lead to lack of confidence, which will lead to a reduced level of delegation and responsibility offered to (or taken up by) nurses. I don’t actually think we need to add anything to the work that is permitted under schedule 3. Nurses are currently not utilised to the current potential permitted, so why don’t we start there before we add in further opportunities?

Ongoing medical management

There is a lot more that nurses can be doing in the consult room, and whilst many practices are, thankfully already utilising their nurses in this way, nurses can and should have a fundamental role to play in the ongoing management of medical cases. We’re good at it – talking to clients, supporting them, explaining things, listening to their concerns, finding solutions. All of these factors assist with making sure the treatment actually reaches the patient (so called ‘compliance’) and ultimately will improve patient outcomes. This could be for a diabetic patient, a dog with osteoarthritis, or an overweight animal. They will all benefit from ongoing nurse support, and it’s worth something.

We need to reset the precedent

The trouble is, we’ve set the standard. Nurse clinics are FREE, and yes, not just free, but FREE in capital letters. Instead of promoting the amazing clinical results that nursing support can achieve and the difference nurses can make to disease management – we use the fact that they are FREE! I have seen it on so many websites. As I said in my talk, we now have to reset the precedent in charging for clinics, not just set it. But it can be done.

To get started, my advice would be:

  • Sit down as a practice and talk about utilisation of your nurses. What clinics do you run, where could you develop? How can nurses enhance patient care in the consult room?
  • How do you all feel about charging a fee? List the pros and cons. Discuss it!
  • Have clinical meetings to work out what you want to cover in each clinic so that this is standardised. Creating a professional clinic protocol will give you more confidence that your clinics are WORTH something. (I may revisit this topic in a later article as I do think this stage is vital).
  • Work out what it actually costs you to run a clinic – it may surprise you. You need to account for premises costs (rent, rates, utilities, insurance, cleaning, maintenance) plus staff, training and CPD, equipment, consumables.

Once you’ve worked out what you want to charge, plan ahead before you implement:

  • Be very transparent about the fees to your clients. Make a poster, create a flyer, put it on your website – be proud that you are charging and explain why.
  • Ensure reception staff are clear about the fees too, so they know how to explain them.

Once you’ve applied the fee:

  • Monitor the work, so that you know how many clients have been seen by nurses, what they have been seen for, and the revenue created by this.

All of these areas, and many more, are covered on our ‘Nurse Clinics – putting your ideas into practice’ course – and I really do think there are many vital stages of clinic setup that are missed in many practices.

Nurses have a unique skill-set

Some may say that our role as nurses is to simply support the work of vets, not to create revenue. So yes, our role is to support the work of vets, but I feel we have a lot  to offer in our own right. What we do is different – we bring a unique skill set, we never have and never will want to take over the role of vets, but we can do so much more to enhance patient care through our work, and feel so much more rewarded in our work, but to move on, it has to be sustainable. To be sustainable it has to create revenue – this is a basic business premise – and veterinary practice is a business, as we all know and understand.

To be sustainable it has to create revenue – this is a basic business premise

Lack of recognition, lack of responsibility, not doing ‘the job we were trained for’, and a level of remuneration not commensurate with our skills and qualifications are common grievances for veterinary nurses. To change this we need to move forward. To move forward we need to become a source of income for veterinary practice.

I’d love to hear your opinions on this topic, so please do email me ( if you’d like to add to the discussion.

This article was written by Jill Macdonald, who owns and manages ONCORE Online Learning. Jill is a veterinary nurse of nearly 20 years, and has worked in first opinion practice, in a head nurse role, in veterinary undergraduate and postgraduate education, and as a locum; and now dedicates her time to ONCORE and other education provision. She is currently also leading an educational project to devise a veterinary nurse specific client communication guide. She is passionate about developing and enhancing the pivotal role that veterinary nurses hold in practice.

Nurse-led clinics – setup, implementation and specialised clinics.