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Perioperative Nursing and Animal- Assisted Therapy

t is well understood that interacting with animals can reduce anxiety, blood pressure, and heart rate and improve one’s sense of well being. Where else in the health care setting are people more I stressed and less able to focus on the work of heal-

ing then in the perioperative arena? Animal-assisted therapy (AAT) is a goal-oriented intervention designed to improve physical and psychosocial func- tioning, and it is a natural adjunctive treatment that perioperative nurses can use.’ This article reviews potential uses for AAT, infection control issues, sug- gestions for starting an AAT program, and current and proposed research.

COMFORTING PAnENTS Preoperative patients are under an enormous

strain, which diverts their attention away from such nursing interventions as preoperative teaching and informed consent. In addition, many patients may focus only on the possibility of death and are unable to divert their attention beyond this possibility. Providing interaction with a trained and certified ther- apy animal may help alleviate fears and promote a sense of well-being (Figure 1).

A B S T R A C T

For example, Ms S is a 68-year-old female diag- nosed with three-vessel coronary artery disease. She is emergently scheduled for coronary artery bypass graft (CABG) surgery and is spending the night before the procedure in the intensive care unit (ICU) receiving nitroglycerin and heparin intravenously. She is visit- ing with family members, who tell the nurses that Ms S does not think she is going to survive the procedure.

The nurses encourage Ms S to express her con- cerns, but this does not alleviate her fear. A nurse sug- gests using AAT as a method of relaxation; the patient agrees, as she loves animals and has several dogs at home. Harley and Splotch, certified therapy dogs, are brought to the bedside to interact one-on- one with Ms S. She is overjoyed by the visit and spends approximately 20 minutes stroking the dogs and whispering to them. Ms S spends a restful night in the ICU and has an uneventful surgical procedure the next day. She is transferred to the step down unit on the first postoperative day, and on postoperative day three, she asks to see the therapy dogs again. As she is visiting with the therapy animals, she relates what she believes is the reason she survived surgery. “Visiting with the therapy dogs the night before sur-

gery reminded me that I needed to get better to get home to take care of my own animals.” Animal-

Interacting with animals has been shown to reduce blood pres- sure and cholesterol, decrease anxiety, and improve a person‘s sense of well being. Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients. Some of the goals that can be met by using trained and certified therapy animals are reducing stress preoperatively, motivating patients to have a positive attitude, pro- moting postoperative activity, and reducing the need for pain med- ication. Infection control, immunosuppressed patients, and research are issues regarding AAT in the hospital setting that must be covered by policy and procedure. Suggestions for setting up an AAT program are discussed. AORN J (Sept 2000) 477-483

assisted therapy made a difference in this woman’s attitude toward surviving her surgical procedure and helped relieve her anxiety so she could sleep the night before the procedure.

Certification for therapy ani- mals varies by organization. Therapet is one nonprofit organi- zation that requires screened ani- mals to be one year old, pass a

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class for and demonstrate basic obedience, and undergo veterinary screening. The screening process evaluates an animal’s ability to follow basic obedi- ence commands, response to stress, and relationship with its handler. After an animal and handler team passes the temperament evaluation, they must attend a training session and successfully complete three visits or therapy sessions before being issued identifi- cation badges, collar, and leash (Figure 2) . Ongoing training for the therapy team includes volunteering four times per year and completing an annual training session. The annual training session covers updates on new equipment, techniques for working with patients, and hospital policy changes (Table 1).

Some hospitals allow personal pets to visit patients. Personal pet visits can be comforting to the patient, but many pets cannot tolerate the stress involved in visiting a hospital. Personal pet visits require the same stringent guidelines as the therapy animal policy. Trinity Mother Frances Health System, Tyler, Tex, has a policy on personal pet visi- tation for long-term or terminally ill patients. When allowing personal pet visits, the animal must

be bathed before the visit.

Figure 1 : A patient recovering from surgery enjoys meeting Abby, the Newfoundland.

Table 1 IMPLEMENTING AN ANIMAL-ASSISTED THERAPY (AAT) PROGRAM

Coordinate with an AAT support organization.

Write a policy and procedure for using animals In your facility.

Seek approval from administrators. Screen volunteers and evaluate animals for the correct temperament. Hold orientation and training sessions for animals and volunteers.

t Schedule AAT sessions in accordance with the number of volunteers available. Educate staff members about the potential uses of therapy animals. Reevaluate the program frequently for possible perfor- mance improvement and research potential.

have proof of current vaccinations, be escorted into and out of the facility, be brought in a carrier or on a short leash, interact only with the patient, and have a time limited visit (usually 30 minutes once per week).

Many families find it less stressful to have a therapy animal visit, rather than bringing in a personal pet.

COM#HmNC FAMILY MEMBERS The surgical waiting room is a stress-laden area

that is ripe for interaction with therapy animals. One well-known researcher of AAT has demonstrated that people petting an animal have lower blood pres- sure than those who are not petting an animal.’ Trained therapy animals offer diversion and relax- ation that reading or watching television may not accomplish.

For example, a mother and her three children, ages 12, 15, and 18, are waiting for word about their husband and father who is undergoing a thoracoto- my for lung cancer. The family is distressed by the diagnosis of cancer, and this stress is compounded by the long procedure time. Interaction with a ther- apy animal is offered to the family, and they agree to visit with one of the therapy dogs. Barney, a certi- fied therapy dog, is brought to the waiting area with his owner and handler. The family spends time stroking and playing with Barney. The interaction sparks memories of family pets, and soon laughter is

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Figure 2: Holly is a certified therapy dog, and she has the identification badge to prove it.

reverberating through the waiting area as stories are remembered and told. Several hours pass during this interaction, and soon news is brought by the perioper- ative nurses that the surgery is over and family mem- bers soon will be able to see their loved one. The fam- ily thanks Barney and his handler for spending time with them and for helping them through a very stress- ful occasion with humor and furry hugs. This interac- tion demonstrates the ability of therapy animals to decrease stress and improve family members’ sense of well-being while waiting for news about loved ones.

COMFORTING STAFF MEMBERS A special benefit of having an AAT program in

your facility is the potential for interaction between the therapy animals and staff members. Many of the staff members in our facility relate the benefits of decreased stress and moments of diversion from the strain of their jobs by interacting with the therapy animals (Figure 3). One RN first assistant (RNFA) expressed his appreciation of the therapy animals after a particularly stressful day in the open-heart sur- gery room. He met the therapy animals in the hall, as he was returning an empty blood cooler to the blood

Figure 3: Staff members enjoy visiting with the thera- py dogs and say it reduces their stress level.

bank. He set the cooler down, sat down on top of the cooler, and called Harley and Pita over to his side. He buried his head in their soft fur and spent five minutes stroking and interacting with the two dogs. He reluc- tantly returned the two dogs to us and related how helpful it was to give up all his stress to the uncondi- tional love of the therapy animals. There are numer- ous anecdotal reports of decreased stress and improved morale among staff members from inter- acting with a therapy animal3 The benefit of AAT to staff members and patients is positive and promotes a healthy healing environment.

THE POSITIVE EFFECTS OF THERAPY M \ W In 1989, researchers anecdotally reported a

decreased need for pain medication in a surgical pop- ulation when therapy animals were visiting.‘ It is not well understood why this occurred, but it may be related to the relaxation and diversion that therapy animals provide. Using therapy animals to promote relaxation in patients who have pain promotes an environment in which patients heal faster.

In addition to decreasing the need for pain med- ication, therapy animals also have a positive effect

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on motivating activity in patients. For example, Sid, a 12-year-old boy, is recovering from surgery for removal of a ruptured appendix. He has had several postoperative complications, including a pleural effusion requiring chest tube placement. He is with- drawn, reluctant to get out of bed to walk, and refus- es to perform incentive-spirometry. After investigat- ing Sid’s likes and dislikes, the nurses request a visit from the therapy dogs. Molly, an Italian Greyhound, and her owner visit Sid in his room. A game of fetch is suggested but Sid refuses. The handler points out that Molly came specifically for Sid to take her for a walk and play fetch, and if he does not play with her, Molly will feel bad. He agrees, but says it will be only for a few minutes and that he is not going to walk very far. Molly, the handler, Sid, Sid’s mother, and the nurse walk approximately 100 ft to the end of the hall. Sid is given a chair, and he proceeds to throw the ball for Molly. He is encouraged to switch arms to throw the ball, to sit for five throws, and then to stand for five throws. After 30 minutes, Sid has to be convinced that Molly is tired, and that he needs to go back to his room. You can see how moti- vating a therapy animal can be in encouraging post- operative activity. Using therapy animals to promote activity and decrease anxiety is an important tool that can be incorporated by nurses throughout a patient’s hospital stay.

The examples that have been related through- out this article are actual situations where AAT made a difference. Animal-assisted therapy is an intervention that is appropriate for all age groups, and it can be incorporated into almost any phase of a patient’s hospital stay (excluding the OR) with dramatic results.

ONE NURSE‘S STORY Lisa Ingram, RN, is a surgical staff nurse who

volunteers in the AAT program at Trinity Mother Frances Health System, Tyler, Tex. The following is her account of the value of AAT to herself and patients.

“I was introduced to AAT during one of our East Texas AORN meetings when Julie Miller, RN, and Katherine Connor, RN, were guest speakers. They showed a film and explained the role that dogs play in the AAT program. I thought to myself that my mixed breed dog, Barney, would be perfect for this program. After all, Barney and I, along with my then 4-year-old son Grant and 5-year-old daughter Kelsey, already had been visiting a local nursing

home on our own. I knew he was a natural with peo- ple, and it was obvious that he loved children of all ages. Barney had been named a “top dog” in his obedience class, so he easily passed the AAT required veterinary screening, temperament evalua- tion, and obedience tests. When the lady administer- ing the behavioral portion of the temperament test stressed Barney, he simply looked at her and licked her hand as if to say, ‘Please, you’re bothering me. . . .would you mind leaving me alone?’

“Through my volunteer work with AAT, I now know how much happiness a pet can bring to some- one who simply needs a little tender loving care. To watch the hands of an elderly person gently scratch behind my dog’s ears and show him affection, if only for a few minutes, makes me know my and my pet’s efforts are worthwhile. Many times I have watched a patient cry as my therapy pet reminds her of a pet lost in the months or even years past. I remember watch- ing a remarkable blind lady as she “saw” Barney for the first time through her sense of touch. Two weeks later, she “recognized” him and was overjoyed to “see” him again.

“Although we lost Barney in August 1999 to a sudden, still unexplained illness, I knew that I want- ed to continue my AAT work. As the search for a new family pet began, one requirement was that it must have the characteristics needed to be a therapy animal. We were fortunate to be able to adopt two- year-old Holly (another mixed breed dog) from a local animal rescue group. She quickly passed her required tests to be a Therapet and is following in Barney’s pawprints as an AAT volunteer. Like Barney and all our local Therapets, Holly has her own hospital ID badge.

“Visiting the pediatric floor at the local hospital is one of my favorite experiences. There always are squeals and hugs all around, for both the volunteers and our pets. As an extra benefit, I get the opportuni- ty to do a little nursing of my own as I visit with the children, ask them how they are doing that day, and generally, just be a friend to them.

“We also visit the oncology floor and the inten- sive care units. It is amazing to see a patient who can barely move his or her extremities put forth the effort to wiggle his or her fingers in my dog’s soft fur. These pets truly give so much love to the people they visit.

“At a local rehabilitation hospital, the occupa- tional therapists use the dogs to work with patients in 30-minute sessions at a table. The dogs are the ‘equipment’ with which the patient exercises. Some

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patients, who must stand for long periods of time to strengthen leg muscles, tell me that it is so much easier to bear if they are grooming a dog during that time as it takes their mind off the clock. For some head trauma patients, the therapist will direct them to ask me questions about my dog or to point out certain parts of the dog’s anatomy. I especially find it amazing to watch stroke patients begin the ardu- ous task of regaining the use of their fingers by mas- saging one of our pets.

“I am sure you can see why I find my volunteer work with AAT so gratifying. I am thrilled to be able to be a nurse to each of these people through my pet, and it makes me proud to share my beloved pet so that they may find a bit of joy in their day. I hearti- ly recommend this program to any nurse or anyone else who has a love for both their pet and their fel- low man.’’

Infection control is the most often discussed issue regarding AAT programs. According to cur- rent literature, there have been no documented cases of disease transmission from therapy animals, and the risk of zoonotic transmission (ie, disease trans- mitted between animals and humans) is extremely low.’ Policies and procedures for AAT should address the concern for zoonosis and infection. In addition, animals that are used for AAT should have at least annual veterinary screenings, biannual tem- perament evaluations, and should not be used if they are sick or exhibiting unusual behavior! As with any infection control program, hand washing signifi- cantly reduces the risk of disease transmission. Ad- ditionally, infection control policies should address patients who are allergic to animals or are immuno- suppressed. Controversy continues to exist among health care providers as to whether the immunosup- pressed patient population should receive AAT.’ The medical director for Therapet recommends that patients who are in the immunosuppressed stage of organ transplantation should not receive AAT, nor should they receive AAT if their absolute granulo- cytopenic count is less than 500.’ Each institution should follow its own established guidelines regard- ing visitors and the immunosuppressed patient.

CONCI” Animal-assisted therapy is a modality that has

enormous potential for research. Current documented outcomes include decreased heart rate and blood

pressure, reduced anxiety, and increased one-year survival in patients admitted for coronary artery dis- ease? Currently, the literature is laden with anecdotal reports of improved functioning, reduced stress, and miraculous recoveries in patients who interact with therapy animals. Nurses can have an effect on sup- porting AAT as a reliable modality by participating in research aimed at validating outcomes when using certified therapy animals. We currently are research- ing whether patients’ retention of material taught improves if a therapy animal is present during dis- charge teaching. Other areas where nurses could be involved in research include:

use of pain medication, improvements in postoperative functioning, preoperative and postoperative teaching, and stress reduction in waiting areas.

Animal-assisted therapy is a modality that can be incorporated by perioperative nurses to enhance the care they provide their patients. By adhering to policies and procedures, using reliable temperament- evaluated therapy animals, and training volunteers and animals, nurses can implement successful AAT programs in their facilities. When implemented care- fully, AAT can have an effect on patients that will last a lifetime. A

Julie Miller, RN, BSN, CCRN, is a critical care staff development educator at the Trinity Mother Frances Health System, Tyler, Ten.

Lisa Ingram, RN, is a surgical staff nurse at the Trinity Mother Frances Health System, Tyler, Tex.

The authors thank Katherine Connor, RN, for her help in reviewing this article. The authors also dedicate this article to all the volunteers and pets who spend count- less hours improving the lives of others.

Editofs note: Here are two sources of information about animal- ossisted therop y: Therapet Animol Assisted Therapy Foundation PO Box 1696 Whitehouse, lX 7579 1

e-mail: Therapet@juno.com; web site: http:/%vwvv, Therapet com

Delta Sociefy 289 Perimeter Road E Renton, WA 98055- 1329

web site: hitp:/W.petsforurnelsrolvm. corn/deltasociety/

(903) 842-2 15 1

(206) 226- 7357

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THE INFECTION CONTROL QUESTIONMark only one answer per question.

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NOTES 1. P Emmett, “Animal assisted

therapy: Unleashing the power of pets,” Healthweek-DallaslFort Worth

2. K M Fick, “The influence of an animal on social interactions of nursing home residents in a group setting,” The American Journal of Occupational Therapy 47 (June

3. L Cullen, M Titler, R

(Oct 20, 1997) 18-23.

1993) 529-534.

Drahozal, “Family and pet visitation in the critical care unit,” (Protocols for practice-Applying research at the bedside) Critical Care Nurse 19 (June 1999) 84-87: B J Carmack, D Fila, “Animal assisted therapy: A nursing intervention,” Nursing Management 20 (May 1989) 96-101.

4. Carmack, Fila, “Animal assist- ed therapy: a nursing intervention,” 96- 101.

5. Cullen, Titler, Drahozal, “Family and pet visitation in the crit- ical care unit,” 84-87: Emmett, “Animal assisted therapy: Unleashing the power of pets,” 18- 23.

Therapy: A Guide for Health Care Professionals and Volunteers (Whitehouse, Tex: Therapet Animal Assisted Therapy Foundation, 1995)

6. S Bernard, Animal Assisted

59-62. 7. Cullen, Titler, Drahozal,

“Family and pet visitation in the crit- ical care unit,” 84-87.

8. K Curran, personal communi- cation with the authors, Tyler, Tex, February 2000.

therapeutic, too,” Journal of the American Medical Association 274 (Dec 27,1995) 1897-1899; Fick, “The influence of an animal on

9. R Voelker, “Puppy love can be

social interactions of nursing home residents in a group setting,” 529- 534.

SUGGESTED READING Bernard, B. Healing Through

Touch: Animal Assisted Therapy in Acute Care. Therapet Animal Assisted Therapy Foundation, 1996. Video cassette.

Cole, K M, Gawlinski, A. “Animal assisted therapy in the intensive care unit: A staff nurse’s dream come true.” Nursing Clinics of North America 30 (September 1995) 529-537.

Connor, K, Miller, J. “Animal- assisted therapy: An in-depth look.” Dimensions of Critical Care Nursing 19 (May/June 2000) 20-28.

Proulx, D. “Animal assisted ther- apy.” Critical Care Nurse 18 (April 1998) 80-84.

Scientists Discover Sharks Are Susceptible to Cancer Scientists at Johns Hopkins University and George Washington University have discovered that sharks may be susceptible to cancer, according to an April 5,2000, news release from The Johns Hopkins University. For years, businesses have sold shark cartilage as a cancer cure or preventive.

At the annual meeting of the American Association for Cancer Research, scientists pre- sented findings that indicate sharks can get chon- dromas. In surveying data in the National Cancer Institute’s Registry of Tumors in Lower Animals, scientists found 40 cases of tumors in sharks and other related fishes. They do note, however, that this discovery does not rule out the possibility that one day a useful cancer treatment may be found in shark cartilage.

Currently, scientists have not studied cancer rates in sharks, and information currently is not available to allow them to determine the cause of cancer in these animals. Sharks’ isolation from humans, and therefore their reduced exposure to carcinogenic pollutants, is one reason for the myth

that sharks are not susceptible to cancer.

can have positive effects on cancer. Issues, such as the cost of cartilage pills, potential interference with proven cancer treatments, and the potentially devastating impact on the Earth’s ecosystem, have scientists deeply concerned about people using shark cartilage.

taking shark cartilage pills based on very faulty data, and no preventative studies to show that it works,” says Gary Ostmader, Hopkins professor of biology and comparative medicine. “That is not only giving desperate patients false hope based on misinterpreted data, it is also taking a top level predator out of an ecosystem, which could cause major disruptions in the ecosystem.”

No proof currently exists that shark cartilage

“People are out there slaughtering sharks and

Shark Cancers Cast More Doubt on Cartilage Pills (news release, Baltimore: Johns Hopkins Universik April 5, 2000) 1-3. Available torn http:/W.jhu.ededu‘news-info/ newsJhomeOO/aprtIO/sharks. html. Accessed 9 June 2000.

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