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Animal-assistedTherapyintheworkenvironment.pdf

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By Morgan Yordy, DNP, RN-BC, ACNS-BC; Amy Brandon, MSN, RN, CCRN-K, ACNS-BC, NEA-BC; and Lisa Harmon, BSN, RN, NE-BC, PCCN

Animal-assisted therapy:

Animal-assisted therapy (AAT) has the potential to benefit employees, as well as patients, in the healthcare environment; however, there can be misconceptions about AAT that may create barriers to implementing this strategy. Negative stereotypes include perceptions that animals in the healthcare environment cause disruptions, such as barking, biting, or infection risk. This may lead to a mismatch between beliefs about the effectiveness of AAT and using it to provide support for the healthcare teams who work in high-stress environments. The primary purpose of this study was to gauge the care team’s perceptions of AAT in the inpatient and outpatient healthcare setting before and after exposure to AAT experiences to provide nurse leaders with evidence to support AAT as a coping strategy to address staff stress and burnout.

National Therapy Animal Day

Promoting a healthy work environment

www.nursingmanagement.com Nursing Management • April 2020 25

April 30

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Animal-assisted therapy

26 April 2020 • Nursing Management www.nursingmanagement.com

Background and significance Stress is a commonly cited fac- tor associated with job reten- tion, with many nurses willing to leave the profession due to workplace stress.1-3 In addition, nurses may have an increased risk of obesity, anxiety, and depression and may even exhibit symptoms of posttrau- matic stress disorder.4-7 This heightened level of stress links nurses to declining health, dependence on medications and caffeine, and injuries related to overexertion and burnout.8-10 Nursing is a high- stress profession that may lead to negative psychological

effects. Nurse managers and administration need to focus on affordable and attainable meth- ods to decrease workplace stress to retain a resilient work- force.

Animal-assisted intervention (AAI) is a broad term used to describe the goal-oriented use of animals in settings such as health, education, and therapy. AAT is a type of AAI in which health service professionals use licensed animals to assist indi- viduals to reach their specific goals.11 Current evidence has demonstrated the positive effects of AAT for patients and health- care personnel in a multitude of settings, such as clinics, hospital units, schools, and behavioral health programs.

Healthy work environment tactics using pets can minimize absenteeism, decrease staff turnover, and promote moral resilience.12 This can lead to improved care delivery, fewer medical errors, and increased patient satisfaction scores.6 One qualitative study noted that more relaxation and happiness was experienced by hospital staff when interacting with dogs on the unit.13 In another study, staff members reported higher job sat- isfaction and enrichment when dogs were present. Dogs allowed a break in the daily serious and stressful events occurring on the unit.14

Specific characteristics, such as gender and pet ownership, impact attitudes toward AAI. More positive perceptions of AAI were seen in women and pet owners.15,16 Even if a dog isn’t owned by the person, individu- als who are pet owners are more favorable toward programs with animals incorporated into the therapy.17

Methods Design. Research provides evidence on the effect of ani- mal interactions with patients, yet there are limited studies relating to the benefits of ani- mals used in other ways in a hospital or clinic setting.13 Medical staff members have indicated positive effects on

individuals/patients (physical and psychological) in various organizations and mentioned staff involvement, but only as a participant facilitating the intervention with patients.13 Research has also focused on concerns about AAI and accepting the animal assistance program, but little is available regarding staff perceptions and feelings of comfort gained from working with animals on the nursing unit.14 We hypothesized that clinical staff members would be more accepting and receptive to therapy dogs on the unit after exposure to an AAT experience.

The research pilot study con- sisted of cross-sectional surveys of staff members either working on a cardiovascular step-down unit (CVSU) in an inpatient hospital setting or at a medical clinic located on a university campus in the Southeastern US to include a representation of the organization’s workforce. Insti- tutional Review Board approval was granted by both the univer- sity and the medical center (the medical center owns both the hospital and medical clinic where the intervention took place). Institutional Animal Care and Use Committee approval was also obtained from the university for the research project. The first survey took place 2 weeks before program implementation. The

The results of this study reveal that AAT can serve as a source of energy and positivity for staff members.

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second survey was administered at the conclusion of the 5-week program intervention.

Survey instrument. A modi- fied Brisbane AAT Acceptability Test (BAATA Test) was used to measure the perceptions and attitudes of staff members toward AAT on nursing units in the hospital or clinic setting.18 The BAATA Test is a 21-item Likert-scale survey. Staff mem- bers who participated in the survey chose a response to each question based on agreement or disagreement with the ques- tion asked, with the score of 1 being strongly agree and 4 being strongly disagree.18 Participants in the first survey were asked to mark items regarding their expectations of the program; in the second survey, partici- pants responded based on their experience with the program. A confirmatory factor analysis conducted by the BAATA Test authors indicated high reliability with factor one (alpha = 0.87) and acceptable reliability with factors 2 (alpha = 0.70) and 3 (alpha = 0.78).18

The principal investigator and coinvestigators modified the survey verbiage to be in line with terms often used in the Southeastern US. For example, the term “ward” in the origi- nal tool was changed to “unit/ clinic.” In addition, the BAATA Test was used to evaluate staff members and not children as the original authors intended; therefore, questions 6, 8, 9, 10, and 17 were altered by replacing the term “children” with “staff.” Lastly, the term “illness” from the original tool was replaced with “stress” in question 8. The word- ing change didn’t alter the intent

and purpose of the questions or the scoring method.

Sample. All clinical staff employed full time, part time, or per diem by the CVSU (n = 29) or medical clinic (n = 50) were invited to participate in the pilot study. (See Table 1.) The organiza- tion’s management information system sent an intranet email with study information, a demo- graphic sheet, and a link to the electronic survey to all employ- ees. Completion of the pre- and postintervention surveys and demographic sheet indicated consent to participate. There were 27 completed responses to the preintervention survey and 30 completed responses to the postintervention survey. Results were reported as deidentified aggregated data. For both sur- veys, most respondents were female (89%, 90%), Caucasian (78%, 77%), and current or previ- ous dog owners (96%, 87%).

Program implementation A meeting took place between the hospital’s director of critical care, the university medical clin- ic’s nurse manager, and a faculty member of the university’s school of nursing trained in AAT. This collaboration resulted in

identifying a need to support staff members with stress relief and comfort measures by bring- ing a trained AAT dog to the unit during working hours. This would also provide valuable data to inform hospital administrators regarding future staff support programs. Hospital and medical clinic administrators supported the pilot program.

A visitation schedule was developed for a 5-week period and approved by hospital man- agers, nurse leaders, and the dog-handler team. Visits were set at normal low patient-need times during the shift. The dog-handler team consisted of a faculty member with over 8 years of AAT experience and a 2-year- old Goldendoodle named Daisy who had been tested for tempera- ment and was free from diseases, up-to-date with vaccinations, cleared by a veterinarian, and groomed before each visit.

Over the course of 5 weeks, the dog-handler team conducted seven visits to the inpatient CVSU unit on the day shift (beginning at 2 p.m.), six visits on the night shift (beginning around 3 a.m.), and six visits to the uni- versity medical clinic (beginning at 11 a.m.). The scheduled visits

Table 1: Survey responses by profession Preintervention Postintervention

Clinical nurse 10 15

Nurse assistant 4 7

Nurse practitioner 2 0

Unit secretary 4 5

Physician assistant 1 1

Other* 6 2

*Those selecting “other” could serve in the role of phlebotomist, lab technician, or radiology technician or in the financial department at the university medical clinic.

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occurred on all days of the week and, depending on staff need, patient acuity, and Daisy’s disposi- tion, lasted anywhere from 30 minutes to 2 hours (the average visit lasting around 1 hour). Daisy remained leashed at all times during the scheduled visits and was allowed access on the unit and in the breakroom of the CVSU and into all parts of the

nurses’ station at the medical clinic. The handler didn’t interact with staff unless the staff members asked questions or engaged the handler in conver- sation. All staff members were encouraged to fully interact with Daisy if desired regardless of whether they agreed to participate in the research study and have their data recorded.

Results The data were compiled and analyzed using statis- tical software. Items were analyzed by item and subscale: factor 1 (adverse impact), factor 2 (unit/ clinic climate), and factor 3 (dog acceptability). (See Tables 2 and 3.) An independent t-test was conducted for each of the subscales to determine pre-/post-

Table 2: Item analysis

Item Mean Standard deviation t P

The staff work- load will be decreased

Pre

Post

3.15

2.82

.46

.79

1.91 .062

Visiting dogs will benefit the medi- cal center’s image

Pre

Post

2.06

1.53

.81

.82

2.41 .019

Visiting dogs will take staff members’ minds off stress

Pre

Post

2.24

1.55

.76

.74

3.47 .001

Visiting dogs will help staff members relax

Pre

Post

2.33

1.48

.78

.75

4.19 .000

Hospital admin- istrators will accept the dog visiting program

Pre

Post

2.44

2.1

.64

.55

2.19 .033

Visiting dogs will make the unit/ clinic a happier place

Pre

Post

2.07

1.05

.87

.68

2.78 .007

The unit/clinic will be a more interesting place to work

Pre

Post

2.3

1.67

.82

.76

3.01 .004

Visiting dogs will help make the staff members more relaxed

Pre

Post

2.26

1.53

.86

.73

3.45 .001

The new program is a worthwhile activity for the hospital to pursue

Pre

Post

2.15

1.45

.91

.65

3.37 .001

Nurses will accept the dog visitation program

Pre

Post

2.11

1.53

.75

.57

3.29 .002

Visitors will accept the dog visitation program

Pre

Post

2.3

1.77

.78

.68

2.75 .008

Item Mean Standard deviation t P

Dogs are likely to bark in the unit/ clinic

Pre

Post

2.59

3.23

.89

.63

3.17 .002

Dogs are likely to urinate or defecate in the unit/clinic

Pre

Post

2.7

3.37

.82

.67

3.35 .001

A hospital or clinic is no place for visiting dogs

Pre

Post

2.89

3.37

.89

.67

2.3 .025

Dogs are likely to increase staff members’ stress levels

Pre

Post

2.93

3.45

.92

.70

2.44 .018

Allergies to dogs will be a problem

Pre

Post

2.37

2.88

.69

.76

2.66 .010

Dogs are likely to bite staff

Pre

Post

3.13

3.4

.74

.66

1.46 .151

Visiting dogs will bring fleas and/ or ticks

Pre

Post

2.89

3.37

.85

.67

2.38 .021

Dogs will spread infection, such as worms, bacteria, and fungi

Pre

Post

3.04

3.4

.71

.68

1.98 .052

Dogs are likely to damage hospital/ clinic equipment

Pre

Post

3.04

3.57

.71

.50

3.28 .002

Dogs are likely to scratch staff

Pre

Post

2.94

3.47

.71

.57

3.07 .003

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www.nursingmanagement.com Nursing Management • April 2020 29

changes. All three factors showed significant changes, with unit/ clinic climate and dog acceptabil- ity significantly improved.

Discussion Results indicated that most staff members noted an overall posi- tive impact of the AAT program within the hospital and clinic set- ting. The results and experiences of this pilot program will help guide further discussion about whether to implement the ther- apy dog program hospital- and clinic-wide.

Factor 1 (adverse impact). Fac- tor one was concerned with the adverse characteristics of dog behavior, such as barking, flea and tick infestation, biting, and scratching, potentially occur- ring on the unit. Staff members anticipated few negative impacts before program implementation, which was in line with other research regarding staff views.14,18 After program implementation, staff members indicated that the experience was positive and there was a significant reduction in adverse attitudes, consistent with published research.14

Factor 2 (unit/clinic climate). Similar to other research find- ings, unit/clinic climate demon- strated significant improvement after program implementation.18 AAT has been shown to reduce stress and enhance overall well- being.19,20 Staff members were receptive to the program due to the sense of well-being that the dogs provided.

Factor 3 (dog acceptability). Previous research findings sug- gested improved dog accept- ability among allied health staff and nonclinical staff as compared with nurses.18 However, in our

study, all staff members regard- less of role were more positive about the program following implementation. In addition, research indicates that women and pet owners are more recep- tive to AAI.15,16 Our results are consistent with these reports as our sample consisted primarily of women and current or previ- ous pet owners, which could help explain the positive accept- ability of dogs on the unit and in the clinic.

Limitations Limitations are acknowledged in this pilot study, which relied on self-report responses with no objective measures. We also had a relatively low response rate. In addition, the data for pre-/post- surveys weren’t linked. Therefore, we can’t assume that the results are comparable. Another possible limitation is the use of only one breed of therapy dog. Participants may feel differently if presented with a different breed. Lastly, han- dler interaction could’ve influ- enced study results.

Energy and positivity Evaluating staff perceptions of AAT can be useful for organiza- tions interested in implement-

ing an AAT program. It’s imper- ative that nurse leaders inten- tionally create and sustain work environments that promote wellness for the healthcare team providing care, as well as the patients and families receiving care. The results of this study reveal that AAT can serve as a source of energy and positivity for staff members. In addition to the positive staff impact, the therapy dog encounters also significantly improved miscon- ceptions associated with AAT, such as negative animal behav- ior and infection risk. Further research to correlate AAT’s impact on decreasing anxiety, depression, and burnout among the nursing workforce would be beneficial for hospitals and clinics that are focused on pro- moting the health of employ- ees working in high-stress environments. NM

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Table 3: Subscale analysis Item Mean Standard deviation t Sig.

Adverse impact Pre

Post

17.3

20.2

3.9

3.3

3.05 .002

Unit/clinic climate Pre

Post

15.4

10.7

5.2

4.5

3.64 .001

Dog acceptability Pre

Post

6.9

5.4

1.8

1.4

3.38 .001

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30 April 2020 • Nursing Management www.nursingmanagement.com

4. Fang L, Hsiao LP, Fang SH, Chen BC. The associations with work stress, social support and overweight/ obesity among hospital nurses: a cross-sectional study. Contemp Nurse. 2018;54(2):182-194.

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In Ala., Morgan Yordy is an assistant pro- fessor at the Auburn University School of Nursing, Amy Brandon is the director of critical care services at East Alabama Medical Center in Opelika, and Lisa Har- mon is a nurse manager at the Auburn University Medical Clinic.

The authors have disclosed no financial relationships related to this article.

DOI-10.1097/01.NUMA.0000657248.63754.fc

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