Similar to clinical and support services, complementary therapies should be structured based on the market a health care facility serves. Health care administrators should consider the mission, vision, and values that govern their organization, and determine how the AAI program may support the overall strategy of the organization. For example, if a health care organization distinguishes itself in areas such as physician satisfaction, AAI may be targeted to providers as well as their patients. Health care administrators must determine who is responsible for the service, which populations to serve, and how the service will be financed. In this chapter we will examine key considerations in structuring animal-assisted intervention (AAI) programming.
The target population refers to the group of individuals that the AAI program seeks to serve. Identifying the AAI program’s target population will influence program structure, policies and procedures, and activities, so it is important to define the target population from the beginning in the development of the AAI program. Your target population may include pediatric, adult, geriatric, psychiatric, military veterans, and/or your own employees. You should determine the setting where your target population seeks care such as inpatient units, outpatient clinics, or even in their own homes. Patient volume and population census data may be used to estimate the number of patients your program wishes to serve. These estimates (along with frequency of visitation discussed in this chapter under 2.4: Defining the Intervention) will determine how many AAI teams are needed to provide services, and will also inform program administrators in making decisions on staffing as well as possibly expanding to other populations and facilities. For instance, if needs are being adequately addressed for your target population, the program may consider expansion to another facility or target population.
Within your health care environment, there may be populations with differing needs and characteristics. Below are six special populations an AAI program may serve, and some specific considerations for each population. Please note that policies and suggested interactions for all patients can be clearly communicated to AAI teams in a manual (see Chapter 5, Section 5.4: Manuals for AAI Teams) and are included in the downloadable manual template (docs.lib.purdue.edu/AAI).
Pediatric settings can be complex and dynamic, and many factors should be considered in developing an AAI program for pediatric patients. Consultation with a child life specialist or other designated professional is essential on a pediatric unit, as different sets of familial and social circumstances may be involved in the care of each pediatric patient. Pediatric units are highly stimulating for dogs, and additional temperament and training requirements are advised to ensure all therapy dogs participating on pediatric units are comfortable and appropriate in such environments (see Figure 2).
Figure 2 This therapy dog reacts to a child’s touch by closing her eyes and relaxing her mouth. Her body language indicates she is comfortable visiting with this pediatric patient. (Photo by Jordan Vance.)
Similarly, not all therapy dog owner/handlers will be comfortable visiting very sick children or those with terminal illnesses. AAI programs should ensure that the child life specialist or other designated liaison is involved in approving, orienting, and providing support for each AAI team that serves on the unit. While one orientation may prepare AAI teams to visit with a general patient population at a health care facility, an additional orientation should take place on the pediatrics unit with a designated pediatric liaison in order to familiarize the AAI team with the unique environment and expectations in pediatrics.
Pediatric patients may differ from other populations in how they interact with AAI teams. First, it should be noted that children at different ages vary in their physical and cognitive stages of development, and therefore may react differently to therapy dogs than adult patients. For example, while normal dog behavior like sniffing a person’s hand may be perfectly acceptable to an adult or an older child, a young child may find this proximity to an animal’s face and mouth alarming. A child may cry or have a similar outburst unexpectedly, or a child might have difficulty petting and handling an animal appropriately. Additionally, a four-year-old child may have limited control over the force with which she pets a dog on the head, or the strength of her embrace, and pet a dog very roughly. AAI teams should be adequately prepared for these types of common behaviors while serving in a pediatrics unit, and dogs should be temperament tested with simulated circumstances commonly found in pediatric settings in order to safely interact with young children. Appraisal of a dog’s comfort interacting with pediatric patients should be conducted by an appropriate AAI staff member. An AAI program should consider conducting recurrent reviews of a therapy dog’s temperament in order to continue service on a pediatric unit, as a dog’s tolerance may change with age.
Pediatric patients also may be limited in their ability to verbalize important information about their conditions. This can lead to circumstances that put patients at risk. For example, if a child is lying in a bed and is covered by sheets, the AAI team may not know that they have an injured leg. The child may not be able to tell them, or understand information about their condition that is important to relay to an AAI team. It is therefore vital that AAI teams communicate with adults responsible for a pediatric patient and the health care team before any interactions.
Hand sanitation by anyone interacting with the dog, both before and after the interaction, is mandatory. This includes the dog handler. If sanitizer is used on a child’s hands, there is a risk that it may be ingested if the child is not properly supervised. Hand sanitation procedures should be discussed with a child life specialist in advance of interactions as well. It may be advisable to leave sanitation procedures pre- and postvisit at the discretion of the guardian or care team member present with the child. Again, it is important to keep communication open between child life specialists or designated pediatric liaisons, AAI program staff, and AAI teams in order to maintain the safety and enjoyment of AAI for pediatric patients and their families.
Geriatric patients with a variety of medical needs can make up a large portion of the overall patient population in a health care facility. It is important for AAI programs to educate their teams to appropriately serve geriatric patients in these facilities.
First, sensory perception may be limited for a geriatric patient, and an AAI team must make sure that the patient has agreed to a visit before interacting. For example, if the geriatric patient is an inpatient on a psychiatric unit, it is important that a designated staff member from that unit serves as a liaison for the AAI team and obtains consent for the visit from the patient. If a geriatric patient is experiencing sensory limitations (for example, partial hearing loss), it may be sufficient for an AAI team to simply take extra care announcing the team’s presence on the unit.
Second, when interacting with a geriatric patient, special care must be taken to prevent accident or injury from falls due to changes in balance, motor skills, and perception. Interacting with a therapy dog should be carefully monitored, with special attention paid to the position of the dog, position of harnesses and leash, and any other tripping hazards in the immediate environment. AAI program staff may choose to work with the staff on a unit in order to ensure that a safe area (with ample room to maneuver the therapy dog and area for patients to be seated) is available for interaction with geriatric patients. When a geriatric patient is less mobile, a visit to the patient’s bedside may be preferable. In this instance, AAI program procedures need to include guidelines regarding any weight or size limitations for dogs permitted onto beds to lie with patients. It is advisable to include handler recommendations for dogs to sit or lie down while interacting with an ambulatory geriatric patient. As with anyone interacting with a dog, hand sanitation procedures must be followed before and after contact with the therapy dog.
Third, geriatric patients may also have limited dexterity, making petting either difficult or potentially less comfortable for the animal. Therefore, it is important for AAI program guidelines to remind handlers to carefully monitor their dogs for any signs of stress or discomfort, removing them from the interaction if these signs are shown.
Many patients who are pregnant will be encountered on labor and delivery units, and while some facilities may choose to prohibit visitation, AAI can be of value to these patients. As with all areas receiving AAI, consulting with staff of the labor and delivery unit should take place prior to AAI visitation.
When interacting with pregnant patients, the health and safety of the mother and her unborn child must be considered. Pregnant women, particularly those in the third trimester, may be at increased risk for a fall. AAI program guidelines must educate handlers about these risks and the need to carefully monitor therapy dog interactions with these patients, with special attention paid to the position of the dog, position of harness and leash, and any other tripping hazards in the immediate environment. Therefore it may be advisable for handlers to instruct their dogs to sit or lie down while interacting with pregnant patients. It is also important to carefully observe hand sanitation practices before and after contact with AAI team, as any infection could prove dangerous to both mother and unborn child.
Patients With Psychiatric Disorders
Psychiatric patients have been found to benefit greatly from AAI, and it is important to provide access to AAI while maintaining the comfort and safety of volunteers, patients, and unit staff. AAI can be structured in a one-on-one visitation, or in a group setting that may encourage participation and social support. AAI program staff should consult with staff on the inpatient psychiatric unit to determine the most effective and safe procedures for patients and staff. Program staff should also identify at least one staff member willing to serve as a liaison for AAI teams when they are present on the unit.
Psychiatric disorders range in presentation and in severity, and special sensitivity and care must be used by any volunteer in an inpatient psychiatric setting. AAI teams visiting acute psychiatric services will benefit from an orientation to psychiatric patients to prepare them for visiting the type of patients treated in the setting; that is, patients who may be experiencing hallucinations, delusions, cognitive decline, and/or impulsivity. All AAI teams should be accompanied by an appropriate liaison (for example, a psychiatric nurse or social worker) who can screen psychiatric patients for appropriateness for AAI). On some units, security measures must be taken for the safety of patients and staff and these extend to the AAI team. These measures may include security checkpoints and panic or alert buttons carried by the AAI team while visiting on an inpatient psychiatric unit. As with all patients, hand sanitation must be performed before and after contact with the AAI team. If psychiatric patients are unable or have difficulty sanitizing their own hands, the handler may aid them in using the hand sanitizer, or may turn to the staff liaison accompanying them to ask for assistance sanitizing the hands of patients.
Secure Care Patients
Secure care units (SCU) treat patients who are incarcerated and present an alternative to a prison hospital unit. These patients often have received no visitors for an extended period of time and welcome the opportunity to interact with a therapy dog. It is important for AAI programs to set guidelines that prioritize the safety of patients, staff, and volunteers by working closely with SCU staff and security professionals assigned to the unit. SCUs often operate under a collaborative agreement between state corrections departments and the hospital and will have officers present at all times. The appropriate administrative personnel should be consulted and involved when initiating AAI for SCU patients.
Rules for interacting with patients on this unit should be clear and well known to any visiting AAI team. AAI teams may be asked to stow personal belongings elsewhere before visiting in an SCU. Cell phones are generally prohibited as these patients are prohibited from accessing telephones. Patients in the SCU should be encouraged by the handler to use hand sanitizer before and after visiting with the therapy dog. If an SCU patient is unable or has difficulty sanitizing their own hands, the handler may aid them in using the hand sanitizer, or may turn to SCU staff for assistance sanitizing the hands of the patient.
Other Special Patient Populations
If other special populations are included in your target population for AAI program services, policies and procedures will need to address any unique needs of these populations. Consulting with a designated liaison for the special population (child life specialist for pediatric patients, nurse or social worker for psychiatric patients) in creating these specific policies and procedures is advisable. Additional orientations and training of AAI teams may be required for safe interaction with special populations and for the comfort of the AAI teams. While sanitation should always take place before and after contact with a therapy dog, practices may need to be adjusted in consideration of each patient populations’ potential cognitive or physical state.
While a dedicated physical presence in the facility served by the AAI program is preferable, available space in health care facilities is often limited and the sharing of existing administrative space may need to be arranged to provide an appropriate location for oversight of the program. At a minimum, adequate administrative space is needed to store AAI team records (documentation of therapy dog registration, completion of facility volunteer requirements, annual animal health screening, etc.), team identification apparel (volunteer shirts, dog vests, leashes, etc.), as well as informational program materials (procedural manual, brochures, etc.). Computer access is needed for electronic communication, database management, and record storage.
Ideally, AAI programs will be housed in their own separate room(s). A shared workspace for program staff with separate desks for each staff member allows for collaboration and independent work. A separate office for the program director or coordinator allows for discretion and privacy when appropriate. Two additional considerations for space include access to a conference room to allow for larger group meetings and educational/informational presentations, and separate storage space to house materials necessary for the operations of the AAI program.
AAI services may be provided in individual patient rooms, group activity rooms, and/or common areas depending on the facility and target population. Designated outdoor space in close proximity to the health care facility must be identified for exercising dogs and for sanitary elimination away from patient areas. Designated areas for AAI team parking may be needed, depending on the facility.
2.4Defining the Intervention
Once the target population and space requirements have been defined, consideration of the type of AAI (group or individual) most appropriate for the facility should be addressed. Some health care facilities benefit most from AAI at designated times by small groups of AAI teams. Such group visits typically take place with interested patients brought to a large common room and are monitored by staff. The activity may take place with several AAI teams present at once, or one AAI team visiting all of the patients in the group. This type of group activity may work well in a lower acuity setting such as a partial hospitalization program or a skilled nursing facility. This type of group AAI may also support the goals of treatment in ways that private visitation would not. For example, a psychiatrist may ask an AAI team to be present prior (or during if the therapy dog handler happens to be employed on psychiatry services) to group therapy sessions in order to encourage attendance by patients on an inpatient psychiatric unit and increase interaction among patients.
Other facilities may choose to structure AAI individually with one AAI team visiting one patient room at a time. The latter option allows for more personalized interactions with the AAI team for patients, families, and staff, but requires more planning and AAI team orientation and preparation. Additional aid from staff in the form of escorts may be needed for individual visitation in some areas, or AAI teams may need additional materials such as linens, sanitizers, maps, and unit guides in order to safely visit if unaccompanied by staff. Generally, individual visitation is preferable in acute inpatient settings, not only to reach more patients, but also to minimize risk of cross contamination between patients in group settings. Additionally, there is less risk of inappropriate interactions or distractions between dogs when AAI teams visit alone as opposed to as a group.
2.5AAI Program Staffing
Staffing for an AAI program varies according to the program size, structure of interventions, and the resources available in the community and facility. Administrators should consult with human resources team members in order to determine appropriate design, recruitment, and onboarding for any positions associated with the AAI program. Additionally, the U.S. Office of Personnel Management and the U.S. Department of Labor provide online resources for job analysis, job design, and employee assessment and selection (please see Additional Resources). Ideally, a dedicated administrative staff person (program director/administrator) with a background in AAI practice, program administration skills, and expertise in coordinating volunteers is hired to direct the program. This individual works closely with the volunteer office of the health care facility, and should report to appropriate health care administrators (see Figure 3). Other staff members may be external or internal hires, internal transfers, or employees who may benefit from job redesign.
Figure 3 Sample basic AAI program organizational chart. The AAI coordinator/director should have a clear reporting line to a hospital administrator and maintain regular communication with the volunteer coordinator of the facility. In this instance, AAI teams at the facility have dual reporting to both the AAI program leader and the volunteer manager.