Perceptions of a hospital-based animal assisted intervention program: An exploratory study lable at ScienceDirect Complementary Therapies in Clinical Practice 25 (2016) 150e154 Contents lists avai Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp Perceptions of a hospital-based animal assisted intervention program: An exploratory study Kathleen Abrahamson a, *, Yun Cai a, Elizabeth Richards a, Krista Cline b, Marguerite E. O'Haire c a Purdue University School of Nursing, 502N, University Street, West Lafayette, IN 47907, United States b Butler University, Indianapolis, IN, United States c Purdue University School of Veterinary Science, West Lafayette, IN, United States a r t i c l e i n f o Article history: Received 30 August 2016 Received in revised form 14 October 2016 Accepted 19 October 2016 Keywords: Animal assisted activities Animal assisted interventions Acute care Hospital staff * Corresponding author. E-mail address: kaabraha@purdue.edu (K. Abraham http://dx.doi.org/10.1016/j.ctcp.2016.10.003 1744-3881/© 2016 Elsevier Ltd. All rights reserved. a b s t r a c t Research has shown that there are multiple benefits of animal assisted interventions for patients. However, the impact of interaction with these animals in staff is understudied, particularly in the acute care setting, and is thus a novel contribution to the literature on human-animal interaction. The purpose of this qualitative pilot study was to contribute to the body of knowledge surrounding the experiences and perceptions of hospital staff who have participated in a hospital-based animal assisted intervention program. Nine face-to-face semi-structured interviews were conducted (4 staff nurses, 3 support staff members, and 2 hospital volunteers). Five themes emerged from the respondent interviews: (1) de- scriptions of the therapy dogs; (2) contacts with the dogs at work; (3) connection with the dogs outside of work; (4) benefits; (5) drawbacks. Our findings reflect abundantly positive hospital staff experiences. © 2016 Elsevier Ltd. All rights reserved. 1. Introduction In recent years, increasing research has been conducted on the effects of interactions with animals. Research has shown that there can be multiple outcomes, including physiological, psychological, and social benefits of animal-assisted interventions in a wide range of settings [13]. Studies have shown that having a companion ani- mal can help to reduce the cardiovascular effects of stress during laboratory experiments [1]. Animal-assisted therapy has been shown to benefit individuals in other ways as well. Children and adults have shown reduced anxiety, reduced depression, and reduced social isolation when interacting with a therapy animal in single time point studies in schools, clinics, and laboratory settings [7]. However, we tend to see that health fields, especially in the acute care setting, have been slow to assess and recognize these benefits and the importance of bonds with animals [16]. One setting of particular interest is the hospital setting, given the growing prevalence of visiting therapy animals and the high stress nature of the hospital environment. Patients may experience short-term stress during their transient stays, yet hospital staff such son). as nurses and other support staff are continually exposed to this environment. Indeed, the issue of work related stress and stress management in the area of nursing has been an area of examination for decades [10]. The stress that nurses experience is detrimental not only for the nurse who may experience physical, mental, or emotional symptoms [17], but can also put patients at risk [Fresco, 2000]. Multiple stress management techniques have been pro- posed, ranging from managing the work environment to reducing external sources of stress, to managing the individuals' interper- sonal factors [10]. Given the positive outcomes of animal-assisted intervention in other areas, we extended this work to focus on the effects for hospital staff and volunteers, particularly in acute care settings. One of the reasons we may see limited use of animal assisted inter- vention in the acute care field is the perception of infection control issues as well as staff burden issues. With respect to infection control, when appropriate protocols and guidelines for animals visits are in place, hygiene issues are easily eliminated [11]. How- ever, the effect of animal-assisted intervention on staff burden and stress has received little empirical attention thus was the focus of this study. Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name mailto:kaabraha@purdue.edu http://crossmark.crossref.org/dialog/?doi=10.1016/j.ctcp.2016.10.003&domain=pdf www.sciencedirect.com/science/journal/17443881 http://www.elsevier.com/locate/ctcp http://dx.doi.org/10.1016/j.ctcp.2016.10.003 http://dx.doi.org/10.1016/j.ctcp.2016.10.003 http://dx.doi.org/10.1016/j.ctcp.2016.10.003 K. Abrahamson et al. / Complementary Therapies in Clinical Practice 25 (2016) 150e154 151 2. Statement of purpose The purpose of this exploratory pilot study was to contribute to the body of knowledge surrounding the experiences and percep- tions of hospital staff and volunteers in acute settings who have participated in a hospital animal assisted intervention. program. 3. Study context The context of this study was a 180-bed medical and surgical community hospital located within a medium sized Midwestern metropolitan area. At the time of data collection the animal assisted intervention program, administered by the hospital's department of volunteer services, was three years old. All of the animals participating in the program at time of data collection were dogs, and each dog and handler were required to achieve accredited therapy dog status from Therapy Dogs International, a national therapy dog accrediting agency. Animals provided services in reception areas, surgical waiting rooms, the emergency depart- ment, and medical/surgical units (including pediatrics) as reques- ted by staff members and patients. Animal rounds occurred mostly during daytime hours, and at least weekly but not daily. Schedules were established to match handler availability. The stated purpose of the program was to “enhance the experience of patients and visitors” (www.XYZ.org). 4. Methods Nine face-to-face semi-structured interviews were conducted by an Adult Nurse Practitioner from the research team between August 2015 and November 2015. Interviews were conducted at the hospital site that was implementing the pet therapy program, and were recorded for transcription. Identifying information was removed from transcripts prior to analysis. Interview respondents included 4 staff nurses that worked on units were the animals were present; 3 hospital staff members who interacted with the animals in the course of their workday (welcome desk receptionist, unit clerk, program manager), and 2 hospital volunteers. Respondents were identified through a list of names of persons who had frequent workplace interactions with the animals provided by the hospital volunteer director. An email request was sent and volun- teers participated in the interview. The study was designed as an exploratory pilot and convenience sampling methods were selected. As such, it is possible that the volunteer nature of sam- pling rejected positive bias into our findings. This pilot study was approved by the IRB of author institutions. Transcripts were thematically analyzed using NVIVO 11 soft- ware. Analyses were guided by an inductive content analysis approach. Themes were not developed prior to analysis but instead were allowed to emerge from the data. It should be noted, however, that the 22-item interview guide asked directly about contact with the animals and perceptions of those contacts, and as such influ- enced the themes that emerged from interview responses. Although probes were utilized to follow-up upon responses, the interviews did not substantially deviate from the interview guide. The interview guide centered upon the domains of frequency of contact, nature of contact, perception of contact's influence on their daily experience, and perception of contact's influence on the overall hospital environment. Respondents were also asked to describe examples of experiences with the animals that they perceived as particularly noteworthy. Transcripts were first analyzed independently by authors YC and KA. Themes were dis- cussed and agreed upon, then transcripts were reviewed to assure that the identified text was consistent with the agreed upon themes. Five themes and 3 sub-themes were identified. 5. Findings Five themes emerged from the respondent interviews: (1) de- scriptions of the therapy dogs; (2) contacts with the dogs at work; (3) connection with the dogs outside of work; (4) benefits; (5) drawbacks. The sub-set of the theme “benefits” consisted of: (1) decreasing staff stress; (2) promoting social interactions and interaction with patients; and (3) providing comfort and company to patients. 5.1. Descriptions of the dogs The therapy animals in this program were all dogs, and each of the respondents described themselves as someone who likes dogs during the course of the interview. When asked to describe their contact with the animals they frequently spoke in descriptive terms, such as: “a big, white fluffy dog … so adorable”; “… like a teddy bear”; “gentle and so sweet”; “gentle eyes”; warm and fuzzy”. 5.2. Contact with the dogs at work Most respondents noted they had contact with the dogs once or twice a week and that individual time spent with the animals was generally under 15 min per visit. All respondents stated that they would have physical contacts with the therapy dogs every time the animals came to their working area. Most described feeling excited about the animal visits and made efforts to see and have physical contacts with the dogs. Respondent comments included: “I … go see them unless I am really busy.” “We always pet them.” “… we will seek them out if we see them” “I'd always try to stay a little bit late so I could see [the dog].” “I try to get as much contact as I possibly can.” “‘I've got to see a patient; will you guys just wait for a few mi- nutes? I just need so bad to give so and so a hug.’ Whichever dog is here, even our hospitalist will come out into the hallways and just spend that time with the patients and talk about their dogs.” Sometimes, respondents noted missing the therapy dogs when they were not present: “If we missed him and he wasn't here for a week, we would be like, ‘hey what's going on?’”. “Several of the nurses and I … will talk about some of the older ones that we haven't seen in a while.” 5.3. Connection with the dogs outside of work Respondents relayed instances where they had talked or thought about the animals outside of work hours, often with their family, friends or neighbors: “… we talk with [our neighbor] all the time about Teddy” “I talk about [the dogs] with my kids” “I will tell stories to people … ‘Hey, I was at work and Teddy came to visit or this big Great Dane came to visit’. I will tell people how good the program is and I will wonder what those http://www.XYZ.org K. Abrahamson et al. / Complementary Therapies in Clinical Practice 25 (2016) 150e154152 dogs are up to today and if they are getting into trouble or working hard.” “[Teddy] is on my Facebook.” 5.4. Benefits All respondents provided examples of areas where they perceived that the animal-assisted intervention program was beneficial. Program benefits fell within 3 sub-themes: perception of decreasing staff stress; promoting social interactions and interac- tion with patients; and providing comfort and company to patients. 5.4.1. Decreasing staff stress A frequently noted benefit of the program was a perception that hospital staff felt more relaxed and happy when interacting with or thinking about the therapy dogs: “[The dog] … brightens everyone's day.” “Several of us make the comment these dogs coming in are more therapy for the staff because if they are having a really stressful day and they just happen to be in the hall, our “Teddy break” is something that makes it go away for a second and is needed.” “It just gives everyone a smile break.” “[It is] something else on their mind besides their worry.” “… it is a stress release” “We will see them go by and for the rest of the day we will have a better attitude. It de-stresses you, it makes you laugh, makes you smile and … takes that emotion and stress and just lets it out and the blood pressure goes down.” “It is a very good reprieve from whatever is going on …” “I need my dog fix.” “It just lets go of everything and then even when the pet is gone and you are back to reality, you still have that bit of calm that is with you just for that few minutes. I swear, it is almost like a physically transfer because it is that big of a difference.” 5.4.2. Providing comfort and company to patients Respondents perceived that the dogs were beneficial to the patient experience and health, and even provided a “healing magic”: “There was one time that Teddy had jumped into the bed with a patient and that patient was going downhill really fast and he just laid with her for a good hour. By the end of the day, her health turned around and she was better.” “I think patients who are a little bit depressed benefit from the animals and also patients who don't have visitors.” “I think it made [the patient] feel like she was at home again. In this strange, cold medical environment, she had a friend there.” “It is very beneficial especially in some of our older patients or patients dealing with pain because it just helps when you pet an animal to release some of that oxytocin and make you feel a little better.” “… to have something as simple as [the dog] and to see [pa- tient's] look of relief and joy” “This is the best medicine” 5.4.3. Promoting social interaction The therapy dogs also acted as an “ice breaker” for the inter- action between staff members, visitors and patients. Respondents noted that the animals created a bond or a “pet connection” be- tween nurses and patients: “It definitely is like a social lubricant. It allows you to say, ‘look at the dog, he is beautiful and he is so warm and fuzzy’. It kind of helps you find common ground with patients sometimes if you are having trouble with that.” “Everybody is just a little bit more open because I think in a way you are almost talking to the dog instead of the person in front of you.” “We [had] pictures of one of them at Halloween time; they put a stethoscope on the dog and maybe a doctor shirt or something like that. They were like, ‘NO, NO, we have to get a picture, wait we have to get everybody together.’” 5.5. Drawbacks Respondents were specifically asked if they perceived there to be any negatives or drawbacks to having the dogs in an acute care setting. Three respondents noted that the dogs' presence may sadden patients who missed their own dogs, but gave no specific examples of this occurring. No respondents mentioned allergies or distraction during caregiving as concerns. One nurse respondent felt it important that the dogs be limited to certain areas of the hospital due to infection control concerns. Interview respondents relayed that the dogs and the handlers were trained to work in the hospital setting, decreasing the risk of a harmful event. Two nurses raised the concern that their patients did not benefit as much as they could from the animals because of the short duration of their hospital stay. 6. Discussion The benefits of animal ownership and interaction between humans and animals are increasingly being documented through scientific research [14]. Animal-assisted intervention has been shown to improve short-term client outcomes in a variety of health service settings such as dentist offices [8], pediatrician offices [12], mental health treatment facilities [2,9], long-term care facilities [5,6], and other general hospital settings [13]. Less well docu- mented is the impact that animals can have in an acute care setting for patients and staff. Potentially, animal-assisted intervention could be less beneficial within the hospital setting for a variety of reasons: patients are sicker and perhaps less able to interact meaningfully with the animals; animals could become a distraction during intense or life-saving situations; infection control is a top priority and may be compromised by animal presence; and animal handlers may not be comfortable in the more medically-intense situations. The aim of this pilot analysis was to contribute to the body of knowledge surrounding the experiences of staff who have experienced a hospital pet therapy program. Our findings reflect abundantly positive respondent experiences. The benefits of the program for hospital staff included re- ductions in stress, promotion of social interactions, and a percep- tion of comfort and company provided to patients. These outcomes reflect findings in non-hospital populations from interactions with animals, primarily the themes of reduced stress and increased K. Abrahamson et al. / Complementary Therapies in Clinical Practice 25 (2016) 150e154 153 social isolation. The presence of animals has been linked to short- term reductions in physiological indicators in stress such as cortisol and blood pressure [3] as well as the social facilitation of connection between humans in community and classroom settings [15]. The capacity of animals to assist hospital staff in these ways represents a novel application of animal-assisted intervention that extends beyond its originally intended purpose to assist patients alone. The flow on effects for staff and other personnel who encounter animals has been understudied, and these findings indicate that further attention and acknowledgement is warranted to comprehend the full range of outcomes from these programs, particularly in acute hospital settings. A number of things may have contributed to the positive respondent experiences. First, the hospital program required ani- mals and handlers meeting the training requirements to become accredited therapy dogs, and dogs are also required to meet accrediting temperament standards. Patients are given a sign to hang on the door to indicate if they wish a dog visit, and nurses are able to distribute these signs only to patients where the risk of negative impact from the dogs is low. Handlers also check at the nurses' station prior to patient contact to assure that patient status has not changed. Methodologically, the sampling method of gain- ing a list of respondents from the volunteer coordinator may have induced positive bias, whereby only individuals who liked or frequently engaged with the animals chose to respond. Though the voluntary nature of survey research inherently includes a potential selection bias, future research would benefit from efforts to recruit a diverse sample of staff as well as studies that include interviews with patients and family members. Also, objective data was not obtained to evaluate actual changes in patient condition. Future research can expand upon this work to include measures of health status in both patients and staff. Beyond improving physical health, our respondents indicated a perception that the animals improved the patient experience. This finding mirrors prior work indicating that children have a better perception of the hospital environment after the introduction of an animal-assisted activities program [4]. As reimbursement agencies begin to focus more on the patient experience as a quality measure and link to increased reimbursement, specifically through achievement of high Patient Experience scores on the Federally mandated HCAHPS survey (www.CMS.gov), ‘soft’ interventions such as pet therapy may become more common. An important avenue for future investigation is the impact these animals can have on patient experience survey scores as well as staff satisfaction and retention. It is interesting to note that the stated purpose of the program did not include enhancing the experiences of staff mem- bers, only patients and families. Dissemination of research that demonstrates the positive impact animals can have on hospital staff can assist program managers to direct efforts toward staff as well as patients. Our findings support the development of such studies. References [1] K. Allen, J. Blascovich, W.B. 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She is interested in nursing home quality improvement and dementia care. Dr. Richards is an Assistant Professor in Purdue Univer- sity School of Nursing, West Lafayette, IN. Her research is focused on population-based physical activity promotion and health outcomes of human-animal interaction. 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Abrahamson et al. / Complementary Therapies in Clinical Practice 25 (2016) 150e154154 Krista Cline received a dual-title Ph.D. in Sociology and Gerontology from Purdue University. She is currently Associate Professor of Sociology and Criminology at Butler University. Her research interests include the hu- man-animal bond, health and aging, obesity, and gender issues. Dr. Maggie O’Haire is an Assistant Professor of Human- Animal Interaction at Purdue University. She received her Bachelor of Arts in Psychology from Vassar College in New York and her PhD in Psychology from The University of Queensland in Australia. She currently leads a program of research within the Center for the Human Animal Bond in the Purdue College of Veterinary Medicine. Her research team focuses on studying the unique and pervasive effects of interactions with animals. Example projects include classroom-based, animal-assisted intervention for chil- dren with autism spectrum disorder and the effects of service dogs for veterans with posttraumatic stress dis- order and their families. Perceptions of a hospital-based animal assisted intervention program: An exploratory study 1. Introduction 2. Statement of purpose 3. Study context 4. Methods 5. Findings 5.1. Descriptions of the dogs 5.2. Contact with the dogs at work 5.3. Connection with the dogs outside of work 5.4. Benefits 5.4.1. Decreasing staff stress 5.4.2. Providing comfort and company to patients 5.4.3. Promoting social interaction 5.5. Drawbacks 6. Discussion References