Baldwin, Kathleen M. PhD, RN, ACNS-BC, ANP-BC, GNP-BC, CEN
Humans and companion animals have coexisted since prehistoric times, but the first documented therapeutic use of animals occurred in England in 1792 at a Quaker-run psychiatric hospital, where patients cared for small farm animals as part of their therapy. From that time forward, a few practitioners continued to integrate animals into patient therapy, most often for patients with psychiatric or neurologic problems. In the 1940s, therapy animals were first integrated into patient treatment in a United States military convalescent hospital. Many practitioners continued to integrate animals into therapy programs; the practice grew slowly until the 1980s when it gained momentum.
Today, therapy animals are most often used for patients with psychological or behavioral problems in inpatient or outpatient settings, in rehabilitation facilities, or in long-term care. Integrating AAI into other units in acute care facilities has been problematic, but not impossible.
Humans and animals in collaboration
Perhaps the best-known AAI organization is the Delta Society, founded in 1977 and headquartered in Bellevue, Wash. The Greek symbol delta, shaped like a triangle, was chosen as the symbol for the Delta Society because founders believed it depicted the collaboration between pets, pet owners, and healthcare professionals to help patients recover. The mission of the Delta Society is to "help lead the world in advancing human health and well-being through positive interactions with animals."
The Delta Society's Pet Partners program provides rigorous training and testing for volunteer animal and human teams. After a team successfully completes the training, it's registered by the society. The Delta Society then covers its Pet Partners with a $1,000,000 liability policy in the event of an incident when they're working. The Delta Society estimates that over 10,000 human-animal teams are registered as Pet Partners, providing therapy to over 1,000,000 people annually. Every state and many other countries have Delta Society Pet Partners providing therapy.
There are two types of AAI provided by Pet Partners: animal-assisted activity (AAA) and animal-assisted therapy (AAT). Both play an important role in helping patients heal.
AAA, casual visits by Pet Partners, can involve one or many patients. There are no specific treatment goals, visit content isn't structured, and visit times can be as short or as long as needed. Rounding in long-term care facilities or group homes is an example of AAA.
AAT, a goal-directed intervention, integrates an animal into the treatment process. Improved physical, social, emotional, and/or cognitive function is the goal. AAT is provided in a variety of settings and may be group or individual in nature. There are specific therapy goals, the visit is structured, and progress is measured and documented.
Although dogs are the most common animals used in therapy and will be the focus of this article, cats, horses, dolphins, birds, and rabbits or other small animals have also been used. Some outpatient programs also continue to use caring for farm animals as therapy. See Animal-assisted therapy uses for some of the activities in which AAI can be integrated into the plan of care.
In addition to the Delta Society, the American Kennel Club (AKC), a major voice for dogs in the United States, has recognized the importance of AAI by developing a therapy dog program that awards an official AKC title for therapy dogs. Dogs that participate with one of the AKC-recognized therapy dog organizations and have performed 50 or more therapy visits are eligible for the title. The AKC developed this title based on frequent, ongoing requests from their constituents.
The question of disease transmission
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Many hospitals use dogs in therapy settings, usually with patients whose acute medical issues have resolved. Fears about therapy dogs spreading disease to acutely ill patients have often been the reason for prohibiting animal visitation. These fears are unfounded, except in a few special situations.
Dogs fed a raw (uncooked) protein diet should be prohibited from participating in AAI because research shows that they're much more likely to shed Salmonella bacteria than dogs that are fed standard dog food. There's a risk that dogs with Salmonella could infect patients, although no cases have been reported. Substantial anecdotal evidence exists showing that dogs don't pass infectious diseases from one patient to the next, but no well-controlled studies have been done.
Authors of one study found that patients can infect dogs who visit healthcare facilities with both methicillin-resistant Staphylococcus aureus and Clostridium difficile. Dogs that either licked patients or accepted treats from patients had higher incidents of both infections. However, no incidence of dogs passing either bacterium to humans has been reported.
In 2008, the article "Guidelines for Animal-Assisted Interventions in Healthcare Facilities" was published by an interdisciplinary group of veterinarians and nurses from the United States and Canada. These guidelines address visitation by both therapy animals and family pets. See AAI guidelines for an overview. The full article can be downloaded free of charge from the Delta Society website at http://www.deltasociety.org/Document.Doc?id=659.
Establishing an AAI program
How do you bring AAI to your facility? Your first step should be to find out if there's an AAI group in your area. The Delta Society website has a list of its state and local chapters. Other local, state, regional, or national organizations may also provide AAI in your area.
After you've located an AAI organization, your next step is to decide how you wish to be involved. Do you have a pet that you believe would be a good therapy animal? If so, you may wish to become a Pet Partners team. Therapy animals must be adult, calm, and well socialized; have a gentle disposition; and welcome the touch of strangers. Dogs should have completed a course in basic obedience, at a minimum. There are no specific breed recommendations; mixed breeds are acceptable. The key determinant is the disposition and suitability of the individual dog.
After you and your dog become a team, you should closely evaluate your first AAI visit. You must be prepared for your dog to perform well, but also for your dog to show you that AAI, isn't for him or her. Any dog that doesn't enjoy AAI shouldn't be forced to participate.
During my Pet Partners training, another team had a well-behaved golden retriever, usually an excellent breed for AAI, that had been adopted from a shelter and excelled in the training program. However, she suffered a complete meltdown during her first AAI visit to a healthcare facility and could no longer continue to visit. Usually the signs aren't this dramatic, but you should stop your visit immediately if your dog shows signs of stress. If the behavior continues or gets worse on a subsequent visit, you should reevaluate your dog's suitability for AAI.
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Your therapy dog will tell you when he or she is ready to stop providing AAI. As therapy dogs age, they may also begin to show signs that they no longer wish to participate in therapy. As with humans, dogs should be allowed to retire from their work when it's no longer rewarding to them. My therapy dog let me know when he was about 4 years old that he no longer wished to work. I was disappointed, but allowed him to stop. It wasn't until about a year later that we found he had an untreatable, hereditary disease that would end his life at age 6. He was beginning to show signs of it when we stopped providing AAI, but the symptoms were nonspecific, so it was too early to correctly diagnose his problem.
If you don't wish to be part of a Pet Partners team or are unable to, you may wish to set up an AAI program at your facility and serve as the animal visitation liaison. The first obstacle to developing the program is usually administrative approval. Be prepared to present a strong argument about the benefits of AAI. Obtain copies of pertinent articles and website information as a starting place for developing your presentation. Contact your local animal therapy organization or Delta Society for pointers on resources to support the development of a program. If you don't succeed at first, keep trying. Continue to collect evidence that AAI is safe and effective. Address administrative concerns with evidence. Suggest a pilot study to test the applicability of AAI at your facility.
After you gain administrative approval, you'll need to develop a visitation policy and procedure. You should then choose one unit at your facility to pilot your therapy intervention. You may wish to start with a unit on which patients aren't acutely or critically ill. A rehabilitation unit, psychiatric/behavioral unit, or the physical therapy department is a good place to start AAI. During the pilot, you'll want to closely evaluate implementation to discover if there are areas for improvement.
When you have a successful program in place, it will be time to branch out to other hospital units. Again, you may want your first expansion to be to a unit with lower acuity. As the success of the program grows, slowly branch out to other units with sicker patients. Implementing AAI in ICUs may be your biggest hurdle. You'll be able to find many healthcare facilities that use AAI in all hospital units, including ICUs, by performing an Internet search. Some of these healthcare facilities have AAI programs that have been recognized as "best practices" by The Joint Commission.
And don't forget the use of family pets. Research shows that humans and companion animals have a strong relationship, known as the human-animal bond. Current estimates are that 62% of American households have pets. Owners report that they consider their pets to be part of the family. Yet healthcare providers have been slow to realize that visits by family pets can impact a patient's recovery. Family pets aren't held to the same rigorous standards of behavior as therapy animals, but should be clean and well-behaved. They should only visit the patient who owns them and should be removed from the facility promptly after the visit.
A helping paw
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Pets provide a similar level of social support to individuals as humans do. The Delta Society has identified several benefits of patient interaction with animals, including:
* lower BP
* decreased anxiety and stress, particularly in children
* minimized disruptive behavior and improved eating habits in patients with Alzheimer disease
* reduced loneliness and increased socialization in patients in long-term care
* lower triglyceride and cholesterol levels
* improved adjustment to serious illness
* improved well-being.
There's anecdotal evidence and descriptive research that show therapy animals improve patient care interventions and healing. In a 2007 meta-analysis of articles on AAT, authors stated that research studies showed AAT was a promising addition to existing interventions for many patients. But both types of AAI are underdeveloped interventions, according to recent research. Better research is needed to show how beneficial AAI is to patients on all hospital units. If you start an AAI program at your facility, plan to study its effectiveness and report your findings.
Our furry friends
AAI is a useful adjunct to patient care for many patients. Whether family pets or therapy animals are used, patients can benefit from these visits. When you advocate for animal visitation, you're also advocating for your patients.
On the web
* American Humane Association: http://www.americanhumane.org/interaction/programs/animal-assisted-therapy/about/
* American Kennel Club: http://www.akc.org/akctherapydog/
* Delta Society: http://www.deltasociety.org/
* Love on 4 Paws: http://www.loveon4paws.org/
* Paws for People: http://www.pawsforpeople.org/
* Therapet: http://www.therapet.com/
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