This powerful experience inspired my special study Objectives To explore and evaluate occupational therapy staff experiences and understanding of Animal-Assisted Interventions To debate the feasibility of integrating Animal-Assisted Interventions into occupational therapy practice with a range of patients at Harrogate District Hospital To recommend the opportunities and implications of incorporating Animal-Assisted Interventions into occupational therapy practice
The literature search I carried out following this experience highlighted that positive benefits such as these are common. Roenke and Mulligan (1998) found similar effects when they studied older people’s behaviour when visited by a pet at a long-term facility. The study concluded that pet visitations seemed to contribute to the cognitive, physical and social-emotional benefits experienced by participants.
This key article written by Casey (1996) has the most relevance to the research question and formation of the research proposal as a whole. It is acknowledged by the author that this particular article is dated, however it was the sole published study that explored occupational therapist’s views of this type of therapy. There is a gap in the knowledge base of occupational therapists’ use of PFT which my study sought to address. Critical appraisal tool used: Generic tool developed by the Department of Health NHS Executive (leaflet 4, 1998).
Application of Findings The findings and conclusions of this study could apply to current occupational therapy service users. It is apparent that the benefits of PFT outweigh the drawbacks highlighted. However, these drawbacks would need to be taken into consideration when planning to use animals in occupational therapy interventions and full risk assessment must take place for any activity.
Risks associated with Animal-Assisted Activity/Therapy are: Cleanliness Animals in clinical areas pose significant risks to patients who are immuno-compromised or have had a splenectomy Allergies Risk of infection Animals can become carriers of potentially infectious human pathogens and may be responsible for cross infection Contact should not take place with patients who are heavily colonised with MRSA, or patients with indwelling catheters. In exceptional circumstances, and with agreement with Infection, Prevention and Control patients with MRSA who wish pet visits should be seen in the last session. The animal must be bathed after the visit, before further patient contact. Diseases carried by animals Bacterial diarrohoea Giardia Rabies Toxocariasis Scabies Ringworm Leptospirosis Cat scratch disease Toxoplasmosis Cryptospiridiosis Diseases carried by reptiles: Salmonella rubislaw, S.enteritica, S.chamelion, S. poona, Arena viruses, Rickettsial diseases, Chlamydia pneumoniae Diseases carried by rodents: Leptospirosis, Tapeworms, Salmonella, Eosinophilic meningitis, Hanta virus, Yersinia pestis Diseases carried by birds: Psittaccosis, Campylobacter, Cryptococcus neoformans, Q fever People who are physically and mentally vulnerable
Pets in healthcare settings may be unacceptably hazardous for patients who are immuno-compromised, allergic or accident prone and some patients may not wish to have contact with a pet Procedure It is the responsibility of the clinical leader in conjunction with the Infection Control Team, to take the decision whether or not to have therapeutic pets on site. Assisting dogs (e.g. guide dogs) may be permitted at ward/department level when they are working. Infection control is to be advised of the risk assessment prior to entry on to the site Responsibility of Ward/Department manager Ensure patients involved are not put at risk and are in full agreement Ensure any patients are not allergic to or have phobias about animals Ensure that the owner is compliant with vaccination and infection control guidance To seek evidence that animals are insured for public liability as appropriate Ensure anyone handling animals wash their hands before and immediately after contact Do not allow pets to lick patients skin, wounds or any open lesions
THE NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE & THE SOCIAL CARE INSTITUTE FOR EXCELLENCE These interventions may be delivered by a range of health and social care staff and volunteers, with appropriate training and supervision. The voluntary sector has a particular role to play in delivering these approaches. Health and social care staff in the NHS and social care, including care homes, should work together to ensure that some of these options are available, because there is some evidence of their clinical effectiveness. More research is needed into their cost effectiveness. 3 studies – dated!
Animal assisted therapy Cheshire design and deliver a bespoke Animal Assisted Therapy programme for service users. This includes individual assessment, goal setting, treatment planning, intervention and evaluation. Programmes can be delivered on an individual or group basis and are essentially occupational therapy based and delivered by occupational therapists. Services are available for: individuals in their own homes, mental health services – adult, CAMHS, older persons, learning difficulties, charities, hospitals, schools, hospices, residential and nursing homes, sheltered accommodation, ABI/neur rehab services, day centres BSY – Animal Assisted Therapy Diploma - Practitioner Level 3. £380 You Tube: Caleb’s story; Pet Therapy; Therapy dogs help wounded warriors heal
Learning Outcomes• How do animals make us feel?• Definitions• Case study – Dorothy – Pets as therapy• Evidence-base• Implications• Local and National Guidelines• Summary• Day Hospital – Meet Tia and Eunice• Questions• References
‘Those of you who know the power of a wet, cold nose, a loving lookthat melts your heart, or a wagging tail that makes you smile, you canreadily imagine the potential of uncovering that power to heal thepain that often floods our clients’ (Pichot and Coulter, 2007 p6)
‘He makes me feel relaxed and unconditionallyloved when he curls up on my lap; he makes mefeel invigorated when I take him out for a longwalk on a fresh day; he makes me feel safe whenIm home alone; he exasperates me when he moltsall over my clothes and furniture! The list isendless! But I wouldnt change him for the worldcos the pros outweigh the cons! ‘ :-)‘My pets make me feel happy and wanted,especially after a bad day, coming home to theaffection (purring) of my cat and my dogswagging tail being excited to see me gives me abuzz!!! But in a phrase probably "happy andcontent"!!’ :)‘Accepted and always have someoneto talk to. Company and externalfocus - you cant let your animals gethungry just because you feel downor fatigued’‘Awww, well I would not be withoutmy boys, they are good company,know when I am unhappy or poorly,they are loving, faithful and justlove their mum lol (Simba &Sweetie)’
Animal-AssistedInterventions (AAI)‘A broad term that includes what is traditionallyknown as Animal-Assisted Therapy or Animal-Assisted Activities’Society for Companion Animal Studies (2010)
Animal-Assisted Activities(AAA)‘The casual meet and greet activities that involvepets visiting people. The same activity can berepeated with many people, unlike a therapyprogramme that is tailored to a particular person ormedical condition’Delta Society (2009a p1)
Animal-Assisted Therapy(AAT)‘A goal-directed intervention directed and/ordelivered by a health/human service or professionalwith specialised expertise, and within the scope ofpractice of his/her profession. AAT is designed topromote improvement in human physical, social,emotional, and/or cognitive functioning’
Meet Dorothy• Recovering from a stroke on the rehabilitationward (Left-sided weakness)• Lived alone but had a supportive family• Difficult to engage in traditional occupationaltherapy interventions (e.g. personal care) despiteencouragement . Nurses bed-bathing• Had remained in bed recently, hoist transfersonto the commode/wheelchair. Not participating
Thinking Outside the Box• What could I do differently tomotivate Dorothy?• What was meaningful to her?• What did her loved-ones think?• Policy/procedures/team thoughts?• How? When? Where?
Meet Holly• Photograph of Holly on the windowsill• Smiled when she talked about Holly and missed her• Initially didn’t want to see her, ‘it will be too painful’,‘she might jump up on me’, ‘it wouldn’t be fair to Holly’• Family on board and staff – gentle encouragement• Meetings arranged with Holly and Dorothy’s daughterin the hospital grounds• Dorothy reported feeling happy during these emotionalinteractions with Holly and her mood appeared to lift
Special StudyThinking Outside theBoxAn Exploratory Study intoOccupational Therapy Staff Views ofAnimal-Assisted Interventions:Opportunities and Implications forOccupational Therapy Practice withResearch QuestionWhat do occupational therapists andoccupational therapy assistantsunderstand about Animal-AssistedInterventions, and how do they considerthis service can be integrated into theirpractice with patients in a hospitalsetting?
Recent StudiesAnimal-assisted interventions for elderly patientsaffected by dementia or psychiatric disorders: A review(Bernabei et al 2013)•Literature review: 18 articles on dementia, 5 on psychiatric disorders•AAI were found to have positive influences on demented patients byreducing the degree of agitation and improving quality and degree ofsocial interaction•Positive effect on coping ability and communication•No results on cognitive performance•Suggested more research examining the frequency of sessions, suitabletarget groups and optimal AAI duration
Recent Studies cont.Impact of animal-assisted therapy for outpatients withfibromyalgia (Marcus et al 2013)•Evaluation of the effects of brief therapy dog visits compared to timespent in a waiting room (patients attending a tertiary outpatient painmanagement facility)•Self-reported pain, fatigue and emotional distress•Data evaluated from 106 therapy dog visits and 49 waiting room controls•Average intervention duration 12 minutes•Significant improvements were reported for mood, pain and othermeasures of distress after the therapy dog visit•Concluded that brief therapy dog visits may provide a valuablecomplementary therapy for fibromyalgia outpatients
Recent Studies cont.Developing effective animal-assisted intervention programmesinvolving visiting dogs for institutionalised geriatric patients: Apilot study (Berry et al 2012)•19 patients (men and women), mean age of 85•Interactions between patients and visiting dogs occurred either in atherapeutic context (physical therapy sessions) or in a social situation(socialisation sessions)•Measured mood, depressive state, social interactions, apathy, cortisol levelswere measured in the saliva•Dog-mediated interactions affected the daily increase in cortisol levels, havingan ‘activational effect’ in contrast to the apathetic state of theinstitutionalised older people, concluding that they appear to be promising
Recent Studies cont.An evaluation of an Animal-Assisted Therapy programin an adult inpatient rehabilitation unit (Markovich andKristen 2012)•Qualitative analysis of patient feedback surveys and an analysis of datafrom a measurement log used to assess changes in mobility and ambulationgoals in traditional therapy versus AAT sessions•Themes included enjoyable emotional and physical interaction with thedog, distraction from pain and discomfort and dog’s assistance in therapygoals•85% had improved standing tolerance with AAT, 42% mobility improved•Suggested future studies to examine differences between effectiveness
American StudyCasey (1996)• Surveyed American occupational therapists who hadexperience of using Pet-Facilitated Therapy (PFT) in theirpractice• Concluded that PFT has the potential of becoming a morerecognised modality in occupational therapy and could beused in practice in both health care and service user’s homeswith ease• Identified drawbacks and highlighted the need for standards
American Study cont.Casey (1996)• Risks are addressed and acknowledged, such as exposure toallergens and possible injury to service users• Pointed out that the issue of potential injury or abuse of theanimals themselves is not raised by any of the participants• Stated that the need for further research due to the diversenature of PFT and suggested people’s own pets potentiallybeing used to promote mobility and motivation
American Study cont.Casey (1996)• Increased attention andmotivation during treatment• Increased eye contact• Followed directions better• Demonstrated increasedverbalisation during thePFT sessions
Norwegian StudyBerget et al (2009)• Measured therapists’ and farmers’ attitudes, knowledge andexperiences of Animal-Assisted Therapy (AAT) with farmanimals for clients with psychiatric disorders• Delivered as part of Green Care (a concept that involvesthe use of farm animals, landscape, gardens and plants in co-operation with health institutes for different groups ofclients)
Norwegian Study cont.Berget et al (2009)• Most therapists confirmed the evident potential of offeringAAT services with farm animals, believing that it hadcontributed to clients increased interaction skills with otherhumans• The study concluded that AAT using farm animals was wasbelieved to contribute more successfully to clients withmental health problems than any other occupational therapy
American StudyVelde et al (2005)• Analysed three qualitative casestudies, including Ferrese et al(1998)- Described the perceptions ofoccupational therapist and clientsregarding AAT- American occupational therapistsworking with older people in long-termcare settings (psychiatric, skillednursing facilities, facility for people
American Study cont.Velde et al (2005)• Positive themes were reported including:- Resident’s motivation, range of motion,tolerance levels from physical activity whenpain is present- Sensory interpretation and modulationincreased with animal interactions- Emotional well-being was enhanced- Social interactions improved- Opportunities for nurturing were provided- A home-like environment seemed to becreated by AAT
Texas StudyHinman and Heyl (2002)• Case study of a nursing home assessed the impact of theEden Alternative on the functional behaviours of theresidents• The Eden Alternative was developed to reduce resident’sfeelings of boredom, loneliness and helplessness throughinteractions with animals (e.g. dogs and cats), children and
Texas Study cont.Hinman and Heyl (2002)• Interactions with animals were most commonly observed andbehaviours involving animals occurred more frequently thanthose with children did or plants did• Residents mobility increased• Motivation improved• Anxiety and stress decreased when petting animals• Observations of interactions with the animals elicited avariety of positive social and physical responses including adesire to assume a care-giving role, smiling, laughing andtalking
Infection Prevention and Control Guideline No19Animals in the Healthcare Setting (January 2012 –2015)Policy StatementA key function of infection control is balancing theindividual needs of patients with the needs of others in a
Key Points• Animals used as therapy (e.g. Pets As Therapy, CaringCanines), may have access to the rehabilitation wards atChristchurch hospital• Royal Bournemouth visitations must be individually riskassessed in liaison with infection control policy• Animals must not be permitted into or pass through the followingareas:- Surgical, Orthopaedic wards, Acute Medical wards, Theatres,Intensive Care Unit/ Coronary Care Unit/ High DependencyUnit, Haematology/ Oncology, Isolation rooms or in contactwith patients with known transmissible infections/ disease,
Key Points• Responsibility of ward/ department manager to ensurecompliance with guidelines• Ensure Animal-Assisted Activity/Therapy form iscompleted and placed in patients notes prior to any visit• Responsibility of the animal keeper to ensure requireddocumentation is up to date and available• Animal keeper must remain with the animal at all times andkept on a lead• All staff on duty must be familiar with infection controlguidelines
Patients own Pet Visiting• Pets must be on a lead at all times orappropriately caged/contained• No young animals prior to primaryinoculations• Pet to have contact with patient only• Pet must be housetrained and exercisedprior to visit• Pet must not enter hospital premises if ill• Contact may need to be reviewed if thepatient is immuno-compromised
NICE Guideline -DementiaThe NICE-SCIE Guideline on Supporting People with Dementia and theirCarers in Health and Social Care(National Collaborating Centre for Mental Health 2007)188.8.131.52: A range of tailored interventions, such as reminiscence therapy,multi sensory stimulation, animal-assisted therapy and exercise, should beavailable for people with dementia who have depression and/or anxiety’(p33)184.108.40.206: For all people with all types and severities of dementia who havecomorbid agitation, consideration should be given to providing access tointerventions tailored to the person’s preferences, skills and abilities.
Summary• There is huge potential for animals to be usedin practice, with people of all ages whoexperience problems effecting both theirphysical and mental health and well-being• It is evident that further research is needed inthis field, including issues such as infectioncontrol and consideration of the effects onthe animals themselves
References• Berget B, Ekeberg O, Braastad BO (2008) Attitudes to Animal-AssistedTherapy with Farm Animals Among Health Staff and Farmers Journal ofPsychiatric and Mental Health Nursing 15, 576-581• Bernabei V, De Ronchi D, La Ferla T, Moretti F, Tonelli L, Ferrari B, Forlani M,Atti AR (2013) Animal-Assisted Interventions for Elderly Patients affected byDementia or Psychiatric Disorders: A Review Journal of Psychiatric Research 47/6762 – 763• Berry, Alessandra, Borgi, Marta, Terranova, Livia, Chiarotti, Flavia, Alleva,Enrico, Cirulli, Francesca (2012) Developing Effective Animal-AssistedIntervention Programs involving Visiting Dogs for Institutionalised GeriatricPatients: A Pilot Study Psychogeriatrics 12/3, 143 - 150• Casey HM (1996) A Survey of Occupational Therapists Using Pet-FacilitatedTherapy Home Health Care Management and Practice 8 (4), 10 - 17
References• Delta Society: The Human-Animal Health Connection (2009a) What are Animal-Assisted Activities/Therapy? Bellevue: Delta Society [Online] Available from:http://www.deltasociety.org/Document.Doc?id=10 [Accessed 6hApril 2013]• Ferrese L, Forster B, Kowalski R, Wasilewski L (1998) Occupational Therapists:Perspectives on Using Animal-Assisted Therapy with an Elderly Population.Unpublished Masters Project. Dallas: College Misericordia. In: Velde BP, CiprianiJ, Fisher G (2005) Resident and Therapist Views of Animal-Assisted Therapy:Implications for Occupational Therapy Practice Australian Occupational TherapyJournal 52, 43 – 50• Marcus DA, Bernstein CD, Constantin JM, Kunkel FA, Breuer P, Hanlon RB(2013) Impact of Animal-Assisted Therapy for Outpatients with Fibromyalgia PainMedicine 14/1, 43 – 51• Markovich, Kristen M (2012) An evaluation of an Animal-Assisted Therapyprogram in an adult inpatient hospital rehabilitation unit Dissertation AbstractsInternational: Section B: The Sciences and Engineering 73/2-B, 1258
References•National Collaborating Centre for Mental Health (2007) Dementia: The NICE-SCIE Guideline on Supporting People with Dementia and their Carers in Healthand Social Care London: The British Psychological Society & The RoyalCollege of Psychiatrists [Online] Available from:http://www.nice.org.uk/nicemedia/live/10998/30320/30320.pdf [Accessed 13thApril 2013]•Pichot T, Coulter M (2007) Animal-Assisted Brief Therapy: A Solution-Focused Approach New York: The Haworth Press•Roenke L, Mulligan S (1998) The Therapeutic Value of the Human-AnimalConnection Occupational Therapy in Health Care 11 (2), 27 - 43•The Society for Companion Animal Studies (2010) Animal-Assisted Activityand Therapy Burford: The Society for Companion Animal Studies (SCAS) inpartnership with The Blue Cross [Online] Available from:http://www.scas.org.uk/Human-companionanimalbond/Animal-assisted_activity_and_therapy.aspx? [Accessed 14thMarch 2010]•Velde BP, Cipriani J, Fisher G (2005) Resident and Therapist Views of Animal-Assisted Therapy: Implications for Occupational Therapy Practice Australian