Varying triggers could have impacted on the results of the current study, including the patients ' transport experience, differences in noise levels, waiting times at the veterinary hospital and the micro-environment of the kennel. Associations between stress in cats and various triggers such as these have been well demonstrated in the literature [ 30 ].
If further research finds a statistically significant association between stress behaviours and the level of outdoor access in the home environment, an important predisposing factor for feline stress during hospitalisation will be identified. Information about outdoor access could be easily obtained on patient admission to the hospital, and veterinary professionals could direct additional attention towards patients during hospitalisation, reducing their stress levels and improving their welfare.
Lack of space is a challenge for veterinary practices [ 12 ]; however, if increased stress could be linked directly to spatial restriction, this would represent a rationale for having larger kennel spaces, which could improve hospital stays for these populations. However, unless future research with larger sample sizes proves there are higher stress levels in cats that normally spend more time outdoors, all the recommendations made are based on assumptions.
The categorisation of participants allowed demographic information about outdoor access to be gathered, and the results can be compared with those of a recent study by Finka et al. [ 31 ], which had a higher proportion of indoor-only cats. Differences could be due to a difference in sample size or geographical location. Geographical bias may be present in that study, as Finka et al. [ 31 ] advertised their study in London-based practices, and protection from traffic is the most influential factor in UK cat owners ' choice to keep their cats indoors [ 32 ]. Therefore, there may be an over-representation of indoor cats in the study of Finka et al. [ 31 ] compared with the wider UK cat population. The results of the current study are based on patients at a referral hospital serving clients from both rural and urban areas, therefore the results may be more generalisable to the UK population.
The current study found that the stress scores of the cats increased after the first behavioural observation; these findings disagree with available published literature regarding acclimatisation. This finding could have been linked to immediate interventions having been performed before the start of the acclimatisation period in the current study, which may have prevented cats from fully acclimatising or introduced stress before the cat was placed in its kennel.
Zeiler et al. [ 33 ] found that cat demeanour scores significantly decreased over a study period of 3 – 5 days; this is a very different study period from that of the current study, so comparison is limited. If the current study ' s observation period had been extended, similar results may have been achieved; instead, the current study gives a unique perspective into changes in cat behaviour in the immediate period after admission.
Studies of both observational lengths have their uses in veterinary medicine. Behaviour changes immediately after admission are less well reported, and the findings of the current study serve to fill this gap in the knowledge. An increase in stress score following admission may influence a change in practice. Where interventions need to be performed on patients, such as EMLA application, weight measurement or intravenous catheter placement, these may be best performed immediately, rather than after the patient ' s stress levels have increased, up to 25 minutes after admission. However, these interventions being performed before observation in the current study may be a limitation on observing truly natural behavioural acclimatisation.
Indoor-only cats were the only population whose stress score increased at each behavioural observation; one possible explanation for this result is the effect of separation from their owners. Research shows that owned cats that were surrendered to shelters showed greater stress levels than stray cats admitted to shelters [ 34 ]. Although the populations in the referenced studies differ from those in the current investigation, indoor cats and their owners will typically spend more time in each other ' s environments, which could be a reason for the continuously increasing stress scores. In contrast, outdoor cats, which are accustomed to periods of separation from their owners, may have stress scores influenced by additional external factors. Although indoor cats ' stress levels stayed below those of cats in the other categories, stress levels increased in all cats by the final observation time, so it is essential that all veterinary patients receive support.
Some limitations arose due to the nature of conducting a preliminary study. Limited participant availability did not allow randomisation; however, the sample size was appropriate for a preliminary study and randomisation is not essential [ 17, 35 ]. A limited sample size may result in insufficient statistical power to answer the primary research question, meaning the true effect of outdoor access on stress behaviours in hospitalised cats may have been missed [ 36, 37 ]. Additional rationale has been provided for a study of higher statistical power to investigate the same outcome. Despite associated limitations, the environment in which this study was performed is the context in which veterinary professionals assess stress in feline patients, increasing the applicability of the findings to real-world scenarios.
Conclusions
The current study has established a baseline of knowledge about the relationship between cats ' outdoor access in their home environment and stress during hospitalisation. Despite no significant difference
36 Veterinary Nursing Journal