Animal-assisted interventions (AAIs) purposefully incorporate animals into the realm of health, education, and human services with the goal of improving personal health and wellness.1 Published scientific research on AAIs in the promotion and improvement of health began over 70 years ago, with studies on the relationships between pets and their owners, as well as the inclusion of dogs in psychotherapy treatment sessions or visits to pediatric psychiatric hospitals.2,3
The primary focus of AAI studies remains on the benefits and risks to health care clients who engage with AAIs. For instance, an increase in self-esteem, self-determination, and socialized behaviors was found among patients participating in AAIs in psychiatric settings, as was reduced aggressiveness and violent incidents.4-7 Reductions in anxiety, perceived pain, and systolic blood pressure were also shown across patients engaging with AAIs in children's hospitals, emergency departments, and long-term residential homes.2,4-6,8-10 Furthermore, AAIs can have positive impacts on immune system function, loneliness, stress,2,9 quality of life,7,10,11 and sense of belonging.9 Despite such benefits, risks have been identified in AAIs in health settings, such as zoonotic diseases (eg, salmonella, giardia, methicillin-resistant Staphylococcus aureus [MRSA]),4 which can be transferred from animals to humans; allergies; bites; and/or fear of animals.2,4,9-11 While these risks need to be considered, mitigating steps exist, including health screenings and up-to-date vaccinations for animals, clear institutional guidelines, careful selection of patient participants, avoidance of certain species of animals (eg, reptiles and primates), and the cancellation of programs if risks are perceived as too high.2,4,9,10 Such mitigating factors have allowed many studies to conclude that the benefits of AAIs outweigh the identified risks.4,9
During these early studies, health practitioners’ attitudes towards AAIs were not a primary focus; only within the past 50 years has AAI research included this perspective.12 More recent studies have explored links between a practitioner's or staff member's perception of animals and AAIs, and their willingness to accept AAIs into their facilities, noting that their perceptions play a role in the implementation of and receptivity to AAIs.12-17 This has prompted a specific call to focus on health care professionals’ (HCPs) and staff members’ experiences and perceptions with AAIs in human health.12,13,18,19 Health care professionals and staff often play a direct role in the coordination of AAIs, and can influence what, if any, AAIs are offered in a setting.13-16,18 Understanding their perceptions is fundamental to the mainstream acceptance of such programs.12,19 Today, AAIs are offered in diverse cultural contexts and health care settings in various regions across the globe, and this reflects the breadth of the related research.
A preliminary search of PROSPERO, MEDLINE (1946–present via Ovid), CINAHL Plus with Full Text (EBSCO), the Cochrane Library (Wiley Online Library), and JBI Evidence Synthesis was conducted and no current or in-progress qualitative systematic reviews on the perceptions and experiences of HCPs and staff with AAIs were identified. Thus, the primary objective of this review is to systematically examine qualitative research that reports on the perceptions and experiences of HCPs and staff engaging with AAIs in order to understand the strategies that have been used (or could be developed) by HCPs and staff to integrate well-designed interventions into health care settings to improve patient health and well-being.
While a number of systematic reviews have studied AAIs, these reviews focus on the effectiveness and benefits of AAIs and capture the perspectives of the recipients of the AAI. They do not focus solely on the perceptions and experiences of HCPs and staff while utilizing a qualitative systematic review methodology. For instance, quantitative systematic reviews have studied the effectiveness of animal-assisted therapies,7,10,11,20,21 including psychosocial outcomes,22 benefits and risks,4 and patient benefits.6 A scoping review was conducted to examine the benefits of nature-based interventions, which included both qualitative and quantitative studies involving AAIs; however, these did not include appraisal of the evidence.5 A qualitative systematic review was also conducted to further understand the lived experiences of participants and their family members with AAIs,9 but again did not focus on the HCP or staff perceptions or experience. More recently, a protocol was published for a JBI mixed methods systematic review on the impact of canine-assisted interventions on older residents in long-term care, and while the authors state they will include the views of people directly or indirectly involved in delivering canine-assisted interventions, their main goal is to provide a review of the health and well-being of those participating in the intervention. Furthermore, this review involves only canine interventions and does not address the broader scope of AAIs.23
In summary, considering that completed systematic reviews of AAIs focus on patients, not practitioners, and quantitative methods (eg, randomized controlled trials, control groups),4-7,10,20,22,23 a synthesis of qualitative research on HCPs’ and staff's perceptions could provide insights into how these individuals perceive and engage with AAIs. Only a limited number of reviews have qualitatively addressed, as a secondary consideration, the experiences and perceptions of HCPs with AAIs in health care settings, further reflecting that a qualitative systematic review on the topic is warranted.
It should be noted that while animal welfare is not the specific focus of this review, it is key to any discussion on AAIs and therefore its presence or absence in studies will be noted throughout the review.
What are the perceptions and experiences of HCPs and staff with AAIs in health care settings?
- What are the facilitators identified by the authors and/or the participants that support AAIs within their health care settings?
- What are the barriers identified by the authors and/or the participants that hinder AAIs within their health care settings?
This review will consider studies that include HCPs and staff working in health care settings. Health care professionals will include registered or certified paid professionals, including, but not limited to: physicians, nurse practitioners, registered nurses, licensed practical nurses, respiratory therapists, social workers, occupational therapists, physical therapists, psychologists, psychiatrists, and registered massage therapists. Similarly, health care staff will include paid employees, including, but not limited to: managers, medical office assistants, and administrative/clerical staff. We are including both HCPs and health care staff for two reasons: i) both groups play key roles in whether complementary and alternative medicine, such as AAIs, are implemented and used within the health setting;13-16,18 and ii) studies often include both groups as participants but do not always distinguish between the two in their analysis, results, or discussion.13,16,18 Animal handlers who hold paid health care professional or staff positions will also be included. Health care professionals and staff must be over 18 years of age, and there will be no limits on gender, ethnic origin, and/or socioeconomic status. Individuals identified as unpaid caregivers, family or friends of patients, volunteers working in the health setting, and animal handlers will be excluded. While animal handlers play a key role in AAIs, those who do not hold paid positions within health care settings do not have decision-making power as to whether AAIs are introduced. Further, the lack of research on animal handler perspectives necessitates exclusion.
Phenomena of interest
This review will consider studies that explore the perceptions and experiences of HCPs and staff, including attitudes, beliefs, expectations, and understandings arising from implementing or coordinating AAIs in health care settings. These studies may include HCP and staff perspectives on the impact AAIs have on patients, but the focus of our review will be how AAIs affect the HCPs and staff themselves. Thus, if a study does not include details of how the AAI affects HCPs and staff from their perspective, it will not be included.
Animal-assisted interventions are defined as “a goal oriented and structured intervention that intentionally includes or incorporates animals in health, education, and human services (e.g., social work) for the purpose of therapeutic gains in humans.”1(p.5) As such, AAI is an umbrella term that incorporates animal-assisted therapy (AAT), animal-assisted activities (AAA), and animal-assisted education. Animal-assisted therapy specifically refers to a “goal oriented, planned, and structured therapeutic intervention directed and/or delivered by health, education or human service professionals, including e.g. psychologists and social workers.”1(p.5) An AAA is a “planned and goal oriented informal interaction and visitation conducted by the human-animal team for motivational, educational and recreational purposes.”1(p.5) This review will include AAT, AAAs, and residential pet programs. Animal-assisted education will be excluded as these activities take place outside of the health setting and are “directed and/or delivered by educational and related service professionals”1(p.5) and the focus of the activity is on a student's progress or academic goals.
Specifically, for this review AAIs will only include in-person AAIs and include all animals (eg, dogs, cats, horses, reptiles), with the exception of robotic or plush animals. In comparative studies of AAIs, it was shown that the positive impact of engaging with plush animals was less than those of engaging with live animals.2 In addition, caring for and interacting with live animals is considered more difficult and costly.10 Interactions with robotic and plush animals is an emerging area of practice in which more research is needed. The authors believe the impact of HCPs and staff coordinating and implementing programs with robotic or plush animals would not be comparable and therefore not worthy of inclusion. Service or assistance animals (ie, guide dogs, hearing dogs) will also be excluded as they are governed by legislation that allows for them to accompany their handler into health care settings. In addition, emotional support animals will be excluded as they are very rarely granted access to health care facilities. In our review of the literature, we have found that emotional support animals are not considered service animals because they do not receive specific training. Therefore, they are not protected under the same laws or rights and can only enter facilities that are designated “pet friendly.”24,25
This review will consider studies that describe AAIs delivered within health care settings. This might include, but is not limited to, hospitals, primary care clinics, community care clinics, nursing homes, long-term or residential care homes, pediatric clinics or hospitals, treatment centers, or therapist offices. Further, cases where HCPs or staff participate in AAIs offsite with patients/clients will be included (eg, a situation in which a staff member takes a client to visit horses on a farm as an AAI). In such cases, it is anticipated that HCPs and staff may need to organize, supervise, and/or engage in the AAI, and, because of this, will have perceptions around the value and effectiveness of implementing or coordinating the intervention.
Types of studies
This review will consider qualitative studies including, but not limited to, research designs such as phenomenology, grounded theory, ethnography, exploratory, and action research. Qualitative data from mixed methods studies will be considered if there is inclusion of a robust qualitative section, and the data can be evaluated on its own. Gray (unpublished) literature that meets the inclusion criteria will also be included.
The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of qualitative evidence.26 The review title has been registered with PROSPERO (CRD42021258909).
The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE (1946–present via Ovid) and CINAHL Plus with Full Text (EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for CINAHL Plus with Full Text (EBSCO; see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each information source. The reference lists of all studies selected for critical appraisal will be screened for additional studies. The search strategy will not include any date range limiters, but will be restricted to studies published in English. This limitation is due to insufficient human and financial resources to provide proper translation.
The databases to be searched include: MEDLINE (1946–present via Ovid), CINAHL Plus with Full Text (EBSCO), PsycINFO (Ovid), Health Source: Nursing/Academic Edition (EBSCO), Academic Search Complete (EBSCO), Web of Science (this includes Web of Science Core Collection, BIOSIS Citation Index, BIOSIS Previews, CABI: CAB Abstracts, Derwent Innovations Index, KCI-Korean Journal Database, MEDLINE, Russian Science Citation Index, SciELO Citation Index, and Zoological Record), and Cochrane Library (Wiley). Sources of unpublished studies and gray literature to be searched include Dissertations and Theses Global (ProQuest) and relevant websites (eg, Centre for Human-Animal Bond, Pet Partners, Human Animal Bond Research Institute).
Following the search, all identified citations to be collated will be uploaded into the citation manager Legacy RefWorks (ProQuest LLC, Ann Arbor, USA). Collated citations will be exported to Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates removed. Remaining citations will undergo title and abstract screening by two independent reviewers against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).27 The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.28
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI critical appraisal checklist for qualitative research.26 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data for clarification, where required. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). The results of critical appraisal will be reported in narrative form and in a table.
Data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool for qualitative studies within JBI SUMARI.26,27 The data extracted will include specific details about the population, context, culture, geographical location, study methods, and the perceptions and experiences of HCPs/staff with AAIs, including identified barriers and facilitators. Findings, and their illustrations, will be extracted and assigned a level of credibility. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Qualitative research findings will, where possible, be pooled using the JBI SUMARI meta-aggregation approach.27 This will involve the aggregation or synthesis of findings by consensus of two reviewers to generate a set of statements that represent the aggregation, through assembling the findings rated according to their quality and categorizing these findings based on similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings. Where textual pooling is not possible the findings will be presented in narrative form. Only unequivocal and credible findings will be included in the synthesis.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.29 The Summary of Findings will include the major elements of the review and will detail how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest, and context. Each synthesized finding from the review will then be presented, along with the type of research informing it, a score for dependability and credibility, and the overall ConQual score.29
Appendix I: Search strategy
CINAHL Plus with Full Text (EBSCO)
Search conducted on April 6, 2021
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2. Morrison ML. Health benefits of animal-assisted interventions. Complement Health Pract Rev 2007;12 (1):51–62.
3. Academic Press, Serpell JA. Fine AH. Animal-assisted interventions in historical perspective. Handbook on animal-assisted therapy 5th ed2019; 13–22.
4. Bert F, Gualano MR, Camussi E, Pieve G, Voglino G, Siliquini R. Animal assisted intervention: a systematic review of benefits and risks. Eur J Integr Med 2016;8 (5):695–706.
5. Moeller C, King N, Burr V, Gibbs GR, Gomersall T. Nature-based interventions in institutional and organisational settings: a scoping review. Int J Environ Health Res 2018;28 (3):293–305.
6. Lundqvist M, Carlsson P, Sjödahl R, Theodorsson E, Levin L-Å. Patient benefit of dog-assisted interventions in health care: a systematic review. BMC Complement Altern Med 2017;17 (1):1–12.
7. Kamioka H, Okada S, Tsutani K, Park H, Okuizumi H, Handa S, et al. Effectiveness of animal-assisted therapy: a systematic review of randomized controlled trials. Complement Ther Med 2014;22 (2):371–390.
8. Hoffmann AOM, Lee AH, Wertenauer F, Ricken R, Jansen JJ, Gallinat J, et al. Dog-assisted intervention significantly reduces anxiety in hospitalized patients with major depression. Eur J Integr Med 2009;1 (3):145–148.
9. Shen RZZ, Xiong P, Chou UI, Hall BJ. ”We need them as much as they need us": a systematic review of the qualitative evidence for possible mechanisms of effectiveness of animal-assisted intervention (AAI). Complement Ther Med 2018;41:203–207.
10. Demiralay Ş, Keser İ, Çaynak S. The use of animal-assisted practices as a nursing intervention: a systematic review. J Psychiatr Nurs 2020;11 (3):239–250.
11. Charry-Sánchez JD, Pradilla I, Talero-Gutiérrez C. Animal-assisted therapy in adults: a systematic review. Complement Ther Clin Pract 2018;32:169–180.
12. HABRI Central Briefs, Purdue University, Trembath F. Practitioner attitudes and beliefs regarding the role animals play in human health. 2014; 7 p.
13. Bibbo J. Staff members’ perceptions of an animal-assisted activity. Oncol Nurs Forum 2013;40 (4):E320–E326.
14. Fletcher CE, Mitchinson AR, Trumble EL, Hinshaw DB, Dusek JA. Perceptions of providers and administrators in the veterans health administration regarding complementary and alternative medicine. Med Care 2014;52: (12 Suppl 5): S91–S96.
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16. Lawrence V, Fossey J, Ballard C, Moniz-Cook E, Murray J. Improving quality of life for people with dementia in care homes: making psychosocial interventions work. Br J Psychiatry 2012;201 (5):344–351.
17. Rossetti J, DeFabiis S, Belpedio C. Behavioral health staff's perceptions of pet-assisted therapy: an exploratory study. J Psychosoc Nurs Ment Health Serv 2008;46 (9):28–33.
18. Abrahamson K, Cai Y, Richards E, Cline K, O’Haire ME. Perceptions of a hospital-based animal assisted intervention program: an exploratory study. Complement Ther Clin Pract 2016;25:150–154.
19. Velde BP, Cipriani J, Fisher G. Resident and therapist views of animal-assisted therapy: implications for occupational therapy practice. Aust Occup Ther J 2005;52 (1):43–50.
20. Nimer J, Lundahl B. Animal-assisted therapy: a meta-analysis. Anthrozoos 2007;20 (3):225–238.
21. Zafra-Tanaka JH, Pacheco-Barrios K, Tellez WA, Taype-Rondan A. Effects of dog-assisted therapy in adults with dementia: a systematic review and meta-analysis. BMC Psychiatry 2019;19 (1):41.
22. Maujean A, Pepping CA, Kendall E. A systematic review of randomized controlled trials of animal-assisted therapy on psychosocial outcomes. Anthrozoos 2015;28 (1):23–36.
23. Stern C, Lizarondo L, Carrier J, Godfrey C, Rieger K, Salmond S, et al. Impact of canine-assisted interventions on the health and well-being of older people residing in long-term care: a mixed methods systematic review protocol. JBI Evid Synth 2020;18 (10):2140–2147.
24. CertaPet. Emotional support animal canada laws: what you must know [internet]. CertaPet; 2020 [updated 2020 Nov 23; cited 2021 Aug 6]. Available from: https://www.certapet.com/emotional-support-animal-canada-laws/
25. Conlon P, Therapetic. Emotional support animal canada laws [internet]. Therapetic; 2021 [cited 2021 Aug 6]. Available from: https://therapetic.org/canada-register-emotional-support-animal/
26. Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, et al. Chapter 2: Systematic reviews of qualitative evidence [internet]. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. Adelaide: JBI; 2020 [cited 2020 Jul 17]. Available from: https://synthesismanual.jbi.global
27. Munn Z, Aromataris E, Tufanaru C, Stern C, Porritt K, Farrow J, et al. The development of software to support multiple systematic review types: the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Int J Evid Based Healthc 2019;17 (1):36–43.
28. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71.
29. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol 2014;14 (1):1–7.