Discussion

The aim of this study was to assess the longer-term impacts on Indian veterinarians who had attended a training programme on canine surgical neutering 10–12 months previously. This follows on from a recently published report demonstrating the immediate improvements in knowledge and attitudes regarding their own confidence amongst a similar cohort attending the same training programme (Rayner et al. Reference Rayner, Airikkala-Otter, Mellanby, Gibson, Susheelan, Gamble and Mazeri2023). Here, we were interested in exploring the sustained effects of the training programme; these included participants’ attitudes regarding their own motivations for using newly acquired knowledge and skills in the workplace setting, their ability to effect changes and how receptive their employers were to this; the type of changes implemented; and opportunities for skills transfer with their colleagues. The period of 10–12 months was chosen as this was deemed adequate time for the development of these described effects within the context of a busy working environment. The practical training programme had a strong ‘hands-on’ ethos which focused specifically on practical sessions to improve skills; this has been shown to address a current, key training need for this specific target audience of Indian veterinarians (Rayner et al. Reference Rayner, Bastola, Bedre, Gibson, Gamble and MacKay2025). The educational programme was structured with the intention of creating a supportive, non-pressurised environment for participants to develop, practice and consolidate common surgical and clinical skills necessary for conducting canine spay neuter surgeries, as well as other, related, surgical and clinical procedures whilst upholding patient welfare. Therefore, a key programme objective was to improve participants’ confidence in their practical abilities and, thereby, attain the competence necessary to integrate these skills into their future professional activities. It is relatively straightforward to demonstrate short term success of a CPD opportunity using methods such as pre-and post-training assessments; however, to provide evidence of sustained behavioural changes in the workplace and improvements in patient care, an outcome-focused approach is necessitated. Various models for assessing outcomes of CPD activities have been developed; most notably that devised by Moore et al. (Reference Moore, Green and Gallis2009) which has incorporated several other frameworks with the intention of integrating planning and assessment throughout learning activities. Within this overarching assessment, they have incorporated the four levels of competency defined by Miller’s (Reference Miller1990) pyramid, namely: “knows” (declarative knowledge), “knows how” (application of knowledge), “shows how” (competency) and “does” (workplace performance). An alternative, five-level approach has been described by Guskey and Sparks (Reference Guskey and Sparks2000) focusing on CPD outcomes’ assessment within the teaching profession. In addition to capturing aspects of usefulness of the training to participants, it also importantly considers the role of the employer in facilitating the adoption of learning in the workplace. Their five level approach comprises: level 1 - participants’ reactions, such as enjoyment, usefulness and opinions on the learning experience; level 2 - participants’ learning, i.e. knowledge and skills acquisition as defined by the learning objectives; level 3 - organisational (employer) factors to support changes suggested by the participant as a result of training programme attendance; level 4 - use of knowledge and skills, enabling implementation in everyday practice in their workplace; and level 5 - clinical outcomes, i.e. notable improvements in patient care and other areas. These levels provide opportunities for assessment of CPD impact on participants at different stages which can be integrated into an overarching strategy for measuring outcomes (Balmer Reference Balmer2013).

Participants’ feedback on their experiences (aka level 1 of Guskey & Sparks’ approach) and the immediate impacts of any training programme of factors such as knowledge (level 2), are relatively straightforward to evaluate through a pre- and post-training evaluation. These may include knowledge and skills testing, self-evaluation of confidence and general feedback on their experiences (Shea & Shaw Reference Shea and Shaw2012; Schnabel et al. Reference Schnabel, Maza, Williams, Irby, McDaniel and Collins2013; Shaw et al. Reference Shaw, Barley, Broadfoot, Hill and Roter2016; Rayner et al. Reference Rayner, Airikkala-Otter, Bacon, Walters, Gamble and Langford2020, Reference Rayner, Airikkala-Otter, Mellanby, Gibson, Susheelan, Gamble and Mazeri2023) and, depending on their format, assess three of the four levels in Miller’s pyramid of competency (‘knows’, ‘knows how’ and ‘shows how’). The fourth level in Miller’s (Reference Miller1990) pyramid of competency (‘does’) requires an assessment focus in the workplace, with a focus on long-term changes in practices and patient outcomes, which was the primary focus of this study. Of particular interest to us was whether participants felt motivated in their workplaces to apply what they had learnt. Numerous reports have shown that simple attendance at a CPD event to be insufficient to motivate behavioural change (Gates et al. Reference Gates, McLachlan, Butler and Weston2021). Recent research has highlighted the need for skills-based learning opportunities for Indian veterinarians and a shortage of such opportunities (Rayner et al. Reference Rayner, Bastola, Bedre, Gibson, Gamble and MacKay2025).

The WVS surgical training programmes in India are heavily oversubscribed resulting in high competition for places, including newly graduated, unemployed veterinarians wanting to improve their practical skills and, thereby, chances of employment; it is likely that the attending participants were already motivated to seek out this specific opportunity and, by inference, may be more inclined to implement changes. Indeed, nearly 90% agreed or strongly agreed that they had felt motivated to make improvements in their working practices. However, it is known that intrinsic motivation is also more likely to occur through attainments in knowledge and competency; evidence for this was noted in the significant improvements in knowledge after the training programme compared to before, alongside high, sustained levels of confidence in their abilities. It is suggested that implementing changes in their workplaces and witnessing positive outcomes likely consolidates confidence and an ensuing sense of achievement. Whilst motivation is a driving force required for change, a key factor in the successful implementation of this is the degree of employer compliance (level 3), and this is seldom evaluated (Gates et al. Reference Gates, McLachlan, Butler and Weston2021). Lack of employer engagement can act as an impediment to veterinarians’ ability to implement their acquired knowledge and skills to improve workplace practices (level 4) and patient care and welfare (level 5), both of which are considered by many as the ‘gold standard’ for evaluating effective outcomes of a training programme attendance. Our study focused on evaluating changes in practices nearly a year after attendance which was considered a sufficient period for these opportunities to occur. We found a high level of support in engagement from employers in both willingness to engage with participants by listening to suggestions for improvements and agreeing to these. It was interesting to note that nearly 98% felt they could approach their employer, with employers supporting implementation of some (63%) or all (30%) of their changes. Whilst the employers included in this study may not be a representative sample of the general veterinary workforce in India, these findings are encouraging; however, it is evident that a degree of resistance from the workforce exists. Of notable consideration is that many of the participants were likely to be junior veterinarians (median age: 26.5 years) and may have only been recently employed in their current positions; as such, this may have been a barrier to the implementation of suggested changes by their employer. Around a quarter of workplaces invested in new equipment and a third in implementing the use of new drugs. Examples of newly purchased equipment comprised: endotracheal tubes for securing the airway during general anaesthesia; surgical scrub solution for facilitating surgical asepsis and reducing the incidence of nosocomial infections; and anaesthetic equipment for improving patient safety and comfort during surgery. Investments in key pieces of equipment are foundational steps in raising standards of clinical care, enhance patient safety and improve their overall welfare experience.

We chose to investigate aspects of the educational programme’s teaching content which we felt were of key importance in conducting canine spay neuter surgery, as well as having wider implications for animal welfare in other surgical and clinical scenarios; these were peri-operative analgesia, the responsible use of antibiotics, surgical practices and post-operative wound management. The aim was to demonstrate, via subjective, self-reporting evaluation, evidence that veterinarians had critically reflected on their current practices and had, subsequently, altered their behaviours accordingly (level 4). The effective use of analgesia throughout the peri-operative period has a profound improvement on the welfare experience of the individual patient undergoing and recovering from a surgical procedure. Our findings showed that the prevalence of routine delivery of peri-operative analgesia improved after the training programme with the largest improvement seen pre-operatively (a rise from 80 to 95% for both male and female dogs). Published findings on the use of pre-operative analgesia in surgical procedures vary amongst veterinary general practitioners globally. In one study, analgesic drugs were routinely administered before and during canine OHE by Brazilian veterinarians (Lorena et al. Reference Lorena, Luna, Lascelles and Corrente2014); Swiss veterinarians routinely used pre-operative analgesics for dogs and cats 71–96% of the time for a surgical procedure (Perret-Gentil et al. Reference Perret-Gentil, Doherr, Spadavecchia and Levionnois2014); 98% of Canadian veterinarians reported using analgesics for canine OHE and castration (Reimann et al. Reference Reimann, Dewey, Bateman, Kerr and Johnson2017); and for canine surgeries, 72% of Australian veterinarians reported administering pre-operative analgesia, but only 24% discharging their patients with ongoing analgesia for OHE (Weber et al. Reference Weber, Morton and Keates2012). It was encouraging to see most veterinarians in our cohort using a pre-emptive approach to pain management, as well as high post-operative pain support, which contributes to a smooth anaesthetic experience, reduced post-operative pain and the promotion of uncomplicated wound healing (Lamont et al. Reference Lamont, Grimm, Robertson, Love and Schroeder2024).

An important influence on both animal and human welfare is the responsible use of antibiotics. Antimicrobial resistance (AMR) remains a critical, global, health threat and it is estimated that AMR was directly responsible for 1.27 million human deaths in 2019 and contributed to 4.95 million deaths (Murray et al. Reference Murray, Ikuta, Sharara, Swetschinski, Aguilar, Gray, Han, Bisignano, Rao, Wool, Johnson, Browne, Chipeta, Fell, Hackett, Haines-Woodhouse, Hamadani, Kumaran, McManigal, Achalapong, Agarwal, Akech, Albertson, Amuasi, Andrews, Aravkin, Ashley, Babin, Bailey, Baker, Basnyat, Bekker, Bender, Berkley, Bethou, Bielicki, Boonkasidecha, Bukosia, Carvalheiro, Castañeda-Orjuela, Chansamouth, Chaurasia, Chiurchiù, Chowdhury, Donatien, Cook, Cooper, Cressey, Criollo-Mora, Cunningham, Darboe, Day, Luca, Dokova, Dramowski, Dunachie, Bich, Eckmanns, Eibach, Emami, Feasey, Fisher-Pearson, Forrest, Garcia, Garrett, Gastmeier, Giref, Greer, Gupta, Haller, Haselbeck, Hay, Holm, Hopkins, Hsia, Iregbu, Jacobs, Jarovsky, Javanmardi, Jenney, Khorana, Khusuwan, Kissoon, Kobeissi, Kostyanev, Krapp, Krumkamp, Kumar, Kyu, Lim, Lim, Limmathurotsakul, Loftus, Lunn, Ma, Manoharan, Marks, May, Mayxay, Mturi, Munera-Huertas, Musicha, Musila, Mussi-Pinhata, Naidu, Nakamura, Nanavati, Nangia, Newton, Ngoun, Novotney, Nwakanma, Obiero, Ochoa, Olivas-Martinez, Olliaro, Ooko, Ortiz-Brizuela, Ounchanum, Pak, Paredes, Peleg, Perrone, Phe, Phommasone, Plakkal, Ponce-de-Leon, Raad, Ramdin, Rattanavong, Riddell, Roberts, Robotham, Roca, Rosenthal, Rudd, Russell, Sader, Saengchan, Schnall, Scott, Seekaew, Sharland, Shivamallappa, Sifuentes-Osornio, Simpson, Steenkeste, Stewardson, Stoeva, Tasak, Thaiprakong, Thwaites, Tigoi, Turner, Turner, Doorn, Velaphi, Vongpradith, Vongsouvath, Vu, Walsh, Walson, Waner, Wangrangsimakul, Wannapinij, Wozniak, TEMWY, Yu, Zheng, Sartorius, Lopez, Stergachis, Moore, Dolecek and Naghavi2022). In India, the use of antibiotics is high, with alarming rates of antibiotic resistance reported (Manesh & Varghese Reference Manesh and Varghese2021; Vijay et al. Reference Vijay, Bansal, Rao, Veeraraghavan, Rodrigues, Wattal, Goyal, Tadepalli, Mathur, Venkateswaran, Venkatasubramanian, Khadanga, Bhattacharya, Mukherjee, Baveja, Sistla, Panda and Walia2021b, Reference Vijay, Ramasubramanian, Bansal, Ohri and Walia2023). Veterinarians are intrinsically positioned in the heart of the human-animal-environment, or One Health, triad and, consequently, hold a position of great responsibility in influencing outcomes. Therefore, they must lead the way in upholding and promoting antimicrobial stewardship (Caneschi et al. Reference Caneschi, Bardhi, Barbarossa and Zaghini2023). There is an urgent need for improved awareness of AMR amongst veterinarians globally; in India, specifically, recent studies have highlighted the focus for clearer prescribing guidance and legislations around antibiotic use by policy-makers (Rao et al. Reference Rao, Sulaiman, Natchimuthu, Ramkumar and Sasidhar2015; Kumar et al. Reference Kumar, Gupta and Meena2019; Mutua et al. Reference Mutua, Sharma, Grace, Bandyopadhyay, Shome and Lindahl2020; Vijay et al. Reference Vijay, Bedi, Dhaka, Singh, Singh, Arora and Gill2021a; Eltholth et al. Reference Eltholth, Govindaraj, Das, Shanabhoga, Swamy, Thomas, Cole, Shome, Holmes and Moran2022). The judicious use of a single, intravenous, pre-operative, narrow spectrum, penicillin-based antibiotic for spay neuter surgeries conducted during the course, with a follow-up dose if surgery time exceeds 90 min, have been considered prudent to mitigate the potential increased risk of surgical site infections whilst participants are learning. However, the course curriculum clearly explains this reasoning to participants as part of a wider, comprehensive teaching session on the responsible use of antibiotics in both routine spay neuter surgeries and other clinical/surgical scenarios in the workplace, in accordance with global guidelines on the responsible use of antibiotics (OIE 2020; WSAVA 2024) and advocate the principles of the British Small Animal Veterinary Association/Small Animal Medicine Society ‘ProtectMe’ guidelines (BSAVA/SAMSoc 2024). Our findings showed that participants’ working practices had changed favourably in several areas after attendance, with a decrease in their routine use of antibiotics post-operatively and an increase in a single dose administered pre-operatively. Furthermore, there was a decrease in the first line use of Category B classes (highest priority critically important antibiotics), such as fluoroquinolones and third-generation cephalosporins (EMA 2020), with a concomitant increase in ampicillin, amoxicillin and amoxy-clavulanate usage. An important consideration when contextualising these findings is that, although the focus of the training programme was on the safe approach to canine spay neuter surgeries in free-roaming dogs, the majority (66%) of participants were employed in private practice after attending, with only 13% employed in a charity/NGO setting. It is possible that participants faced varying degrees of resistance from their employers, particularly those working in private practice, where long-standing practice policies and entrenched attitudes regarding antibiotic use may have prohibited change. By contrast, one could argue that veterinarians overseeing large-scale spay-neuter campaigns to manage dog populations may have more influence on antibiotic protocols. Whilst these findings, overall, are encouraging, further research is necessary to understand current attitudes towards, and barriers preventing, change. Additionally, from a broader perspective, whilst educational initiatives are needed, they must form part of a higher-level, structured and multi-faceted approach to understand the factors influencing the appropriate use of antibiotics (Fazaludeen Koya et al. Reference Fazaludeen Koya, Ganesh, Selvaraj, Wirtz, Galea and Rockers2022) which can then inform regulatory changes, and support initiatives such as antibiotic stewardship programmes and awareness campaigns.

The most notable improvement in the participants’ surgical practices was the routine use of an ET tube to secure patients’ airways during surgery (increasing from 56 to 80%). Patient safety is improved multi-fold through the provision of a patent airway, facilitation of mechanical ventilation and protection of lower airways from aspiration of fluids (Mosely Reference Mosely, Lamont, Grimm, Robertson, Love and Schroeder2024). The routine use of IV cannula placement and the administration of IV fluids also increased post-attendance. Improvements were also noted in the management of the surgical wound healing with, for example, fewer veterinarians bandaging the wound, and a greater uptake of routine patient pain and wound scoring. All these contribute to improved standards of care during surgical neutering and recovery.

A component of an outcomes-based evaluation of a learning opportunity may also include the knowledge and skills transfer to workplace peers. Indeed, there was a high degree of such sharing of their experiences, with their colleagues reportedly interested and supportive. Peer-to-peer learning has been shown to be effective within the context of undergraduate learning (McMichael et al. Reference McMichael, Ferguson, Allender, Cope, Kalantzis, Haniya, Searsmith and Montebello2021; Ormandy Reference Ormandy2021; Kelly et al. Reference Kelly, McCorry, Rackard, Doherty and Graham2022) and whilst studies are lacking in the effectiveness of this more ad hoc approach to learning in the workplace setting, it is reasonable to assume that this is beneficial, especially when receptivity is high amongst colleagues. This sharing of information may show a degree of similarity with the more formally assembled ‘communities of practice’ (CoP) which is a system of social learning where individuals come together to share knowledge and collaborate around a common theme. The type and extent of peer-to-peer learning was not examined in this study, and whilst it is known that Indian veterinarians communicate and share information regularly through social media (Rayner et al. Reference Rayner, Bastola, Bedre, Gibson, Gamble and MacKay2025), knowledge sharing may be occurring outwith the workplace via these types of platforms.

The authors acknowledge that there were limitations in the methodology. Firstly, logistical restrictions prevented the inclusion of a comparative control group of veterinarians who had not attended the training programme. Consequently, improvements in variables such as knowledge assessed by the pre- and post-programme assessment may have been influenced by other learning opportunities, such as attendance at other CPD opportunities or peer-to-peer interactions. We also acknowledge that the data were reliant upon participant self-reporting. This approach has the potential to introduce bias, such as social desirability bias, and may have influenced response choices to ones that were predicted to appear more ‘favourable’ by the participant. However, as the follow-up questionnaire was completed online and anonymity was maintained, it was predicted that this likelihood was reduced. The response rate for the second questionnaire was low (35%) and is in accordance with other published data (Moore et al. Reference Moore, Gilbert, Thatcher, Santos and Overton2004; Wu et al. Reference Wu, Zhao and Fils-Aime2022). It is possible that the data may be skewed to include a disproportionately larger number of more motivated respondents, who may be more willing to implement changes. Furthermore, the younger median age (26.5 years) of participants may also be associated with this, as well as other unknown characteristics. Lastly, participants who did not have practical experience of any of the scenarios explored in the pre-training questionnaire were asked to respond from a theoretical perspective based upon their current knowledge and understanding; this may have resulted in some differences in responses compared to their more experienced counterparts. Despite these limitations, the results provide evidence of a sustained improvement in multiple aspects of the working practices of the Indian veterinarian participants, as well as identifying potential opportunities to refine training methods to enhance long-term benefits.