Animal-Assisted Therapy and Quality of Life in Nursing Home Residents - Research Proposal Example

 Animal-Assisted Therapy and Quality of Life in Nursing Home Residents INTRODUCTION Over the past 30 years, human-animal interaction research has slowly progressed across a variety of disciplines such as anthropology, psychology, nursing, sociology, and education (Podberscek, Paul, & Serpell, 2000). Recent animal-assisted therapy (AAT) research reveals that therapeutic animals can improve socialisation, reduce anxiety and arousal, and assist with cognitive and behavioral modification for children, adults, and especially the elderly. Approaches include both individual and group therapy models across settings such as nursing homes, inpatient/rehabilitation units, private practices, and hospitals. Studies have demonstrated improvements for individuals suffering from an array of psychological disorders and associated symptoms and behaviours (Bizub, Joy, & Davidson, 2003). More recently, clinicians, nursing professionals and therapists are implementing animal-assisted interventions in working with geriatric population. STATEMENT OF THE PROBLEM The increase in numbers of elders living in nursing homes and exhibiting various symptoms and behaviors, such as depression, apathy and anxiety, which decrease their quality of life, is anticipated to demonstrate a corresponding growth within the long-term care setting. Nursing homes and similar institutions can expect to house more and more individuals who could benefit from an improved quality of life if therapeutic interventions were implemented to change these behaviours and consequently improve residents’ quality of life. Current research indicates that the need for therapeutic interventions to improve quality of life for elders is readily recognised, and alternatives and options for implementation are often suggested with solid empirical evidence to support their effectiveness. Animal assisted therapy is cited in the literature as a therapeutic intervention that holds promise as one such modality. Although much popular and scientific literature extols the benefits of animal assisted therapy, more research is needed which empirically evaluates the results of this therapeutic intervention. STUDY OBJECTIVES This study is empirically based and allowed for the investigation of effects within individual subjects. The study is designed with a philosophy that animal assisted therapy is an adjunct to an already established therapeutic discipline with its own standards of practice and methods, and acknowledged that the therapist is an integral aspect to the therapeutic intervention. The study acknowledges that while animals may be therapeutic, they are not therapists, and that animal assisted therapy cannot be implemented without a therapist specifically trained in a particular discipline, such as recreation therapy or psychology. Additionally, the design allowed for the application of nursing reasoning, a clinical assessment, a deliberately developed and implemented therapeutic intervention, and exploration of the effects of individualised animal assisted therapy on elders residing in nursing homes and its impact on their quality of life. Particularly, the goal is to examine the effect AAT has on self-reported quality of life in nursing home residents. Research studies in AAT have been conducted by various disciplines such as anthropology, psychology, gerontology, and veterinary medicine. To date, academic nursing has devoted limited effort to gathering information on the role of nurses in providing AAT. Currently, there is no nursing theory, and there is limited research on the benefits of animals to the elderly. The problem of quality of life among the elderly in long-term care facilities and nursing homes is common and is a problem that falls into the realm of nursing to monitor and address. It is also within the realm of nursing to determine if AAT has beneficial effects on quality of life improvements in the elderly residing either in nursing homes or in long-term care facilities. Furthermore, it is appropriate for nursing to identify the characteristics of individuals for whom this intervention of AAT is appropriate and the reasons for its effectiveness. HYPOTHESIS Participants in AAT score higher on measures of improved quality of life following the intervention of AAT as indicated and measured by pre-test and post-test self-report questionnaires. LITERATURE REVIEW During last three decades the nursing profession made significant contributions to the study of therapeutic animal benefits. In the 1980s, professional nursing practice journals began to publish on the area of animal-assisted therapy (Hooker et al., 2002). The research work was primarily descriptive, discussing how animals fulfilled the desire of patients to feel needed and also reduced the stress levels of patients, visiting family members, and staff (Chandler, 2005). Over the next few years, scientific studies began to surface in nursing and other health care journals (Chandler, 2005). Physiological benefits of animal-assisted therapy were documented, such as lowered blood pressure in child patients (Chandler). A seminal study published by Friedmann, Katcher, Lynch, and Thomas (cited in Chandler, 2005) reported greater oneyear survival rates following myocardial infarction for pet owners as compared to non-pet owners. The findings launched a myriad of studies examining the health benefits of companion animals, thus directing researchers to take a closer look at the benefits of animal-assisted interventions. Literature indicates a number of studies demonstrating the benefits of animal-assisted therapy interventions among elderly and its impact on their quality of life. More specifically three research areas receiving significant attention include investigating therapeutic animals as social facilitators and/or support, as agents to reduce anxiety and arousal, and in assisting with cognitive and behavioral modification. There are a number of research studies that demonstrate how therapeutic animals serve as social facilitators with adults and the elderly. Nathans-Barel, Feldman, Berger, Modai, and Silver (2005) conducted a study to examine the beneficial effects of AAT on anhedonia in adult patients diagnosed with schizophrenia. The participants consisted of 20 male and female individuals who were assigned to 10 weekly, one hour psychosocial therapy sessions that either included or excluded an AAT component. Among various outcome measures researchers included the Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ) and the Subjective Quality of Life Scale (SQLS). After receiving the treatment, the AAT group demonstrated significant improvement on the utilisation of leisure factor on the QLESQ; a similar trend in improvement was also found for the motivation factor on the SQLS. Nathans-Barel et al. (2005) also noted other important findings related to the patients’ experiences, particularly, that the patients identified as previously socially detached and withdrawn were able to form close bonds with the therapy dog. Interestingly, the patients were also observed making socially appropriate preparations for the AAT sessions (e.g., bathing, improving physical appearance) and spoke to the staff regarding a desire to present themselves appropriately. Research has also demonstrated the potential benefits of AAT in working with elders experiencing communication problems. LaFrance, Garcia, and Labreche (2007) conducted a study to investigate the impact of a dog’s presence and handler on overt social-verbal and social nonverbal communication skills on a 61 year-old male participant suffering from nonfluent aphasia. One hour AAT sessions were conducted weekly at an inpatient rehabilitation setting over a period of 11 weeks. This study demonstrated that therapy dogs can serve as human communication catalysts (LaFrance et al., 2007). While walking the dog, the shy, quiet participant became more outgoing with others, for example introducing the animal to strangers and behaving less passive in his approach to communication. In addition, his general sense of cheerfulness and well-being appeared to improve in the presence of the dog. A study conducted by Bernstein, Friedmann, and Malaspina (2000) compared the effectiveness of AAT to Non-Animal Therapy (NAT) in providing social stimulation to a geriatric population (n = 33) residing in a long-term care facility. Subjects were more likely to initiate and participate in longer conversations with each other during AAT as compared to NAT. Touching the animals during AAT added significantly to resident engagement in, and initiation of, this behavior. The findings suggest that, since touch is an integral part of social stimulation and therapy, enhancing such social behaviors via AAT is an intervention worthy of further consideration (Bernstein et al., 2000). Barak, Savorai, Mavashev, and Beni (2001) evaluated the effects of AAT on long-stay geriatric schizophrenic patients in a controlled one year study. Twenty chronic schizophrenic patients served as subjects in either a treatment group receiving AAT or a control group participating in a reading and current events discussion, which was facilitated by the nursing staff. The most significant effect was found for the social functioning domain, which includes conversational skills, instrumental social skills, social appropriateness/politeness, social engagement, friendships, recreation/leisure, communication skills, and participation in hospital programmes (Barak et al., 2001). Richeson (2003) examined the effects of AAT on agitated behaviors and social interactions of elderly adults with dementia. Participants were 15 nursing home residents who engaged in a daily AAT intervention for three weeks. Pre-test and post-test data revealed a statistically significant decrease in agitated behaviors and a statistically significant increase in social interactions. In terms of other observations, staff and family visitors reported how alert and responsive some of the residents were, for example, talking endlessly about the dogs. The staff appeared motivated to implement the intervention, engaging the residents in conversation about the dogs and sharing stories about their own pets. As such, the AAT intervention appeared to facilitate a pleasurable experience for both the residents and staff (Richeson, 2003). AAT studies have also investigated its impact on the mood of elder patients with dementia. In a study conducted by Motomura, Yagi, and Ohyama (2004), the effects of AAT on eight patients with dementia residing in a nursing home were assessed via pre and post mental state batteries. AAT with two dogs occurred for one hour over four consecutive days. The results indicated no significant difference in the irritability scale, depression scale, activity of daily living and mini-mental state examination. However, there was a significant difference on the apathy scale, which may indicate that AAT has the power to influence the mental state of patients with dementia. In addition, 75% of the patients stated that it was fun to attend dog therapy; 63% of the participants mentioned that they would like to attend this activity again (Motomura et al., 2004). A study conducted by Kanamori et al. (2001) implemented six biweekly AAT sessions at an elder dementia day care center. Data was collected at baseline and three months later for both a treatment and a control group. Collected data included: Mini-Mental Status Exam (MMSE), Nishimura's Activities of Daily Living (N-ADL), behavioral pathology of Alzheimer's disease (Behave-AD), and salivary chromogranin A (Cg A) as a mental stress index. The findings revealed that the treatment group's MMSE average score and N-ADL score increased, as compared to the control group. The Behave-AD score significantly improved for the treatment group as opposed to the control group's score. The AAT group experienced a decrease in Cg A, indicating decreased mental stress, as compared to the control group (Kanamori et al., 2001). A study conducted by Colombo et al. (2006) assessed whether a pet therapy programme had a positive effect on the psychopathological status and perceived quality of life for cognitively unimpaired institutionalised elderly adults in Italy. Seven nursing homes and 144 male and female residents participated in this study. Divided into three groups, the subjects were given either a plant, a canary or nothing to care for over a three month period of time. Results indicated that participants given a canary to care for experienced overall improvement on the LEIPAD-SV (designed to assess subjective perception of quality of life in the elderly), with statistically significant improvements for the perceived physical health subscale (Colombo et al., 2006). A significantly higher number of the animal group members rated their own autonomy more positively than members of the other two groups, especially in comparison to the plant group. The animal group also demonstrated significant improvements on the Somatization, Obsession-Compulsion, Depression, and Phobic Anxiety BSI subscales as compared to both other groups. Overall, the findings supported that the canary's presence seemed to facilitate improved BSI mood outcomes, which may protect participants from depressive and obsessive compulsive symptoms, and to some extent, anxiety and paranoid ideation (Colombo et al., 2006). Edwards and Beck (2002) utilised fish aquariums to examine the influence of AAT on the nutritional intake for elderly diagnosed with Alzheimer’s disease. Participants in either a treatment or a control group were residents in one of three dementia-specific units in extended day care facilities. Fish aquariums were introduced into the activity/dining areas for the treatment groups. Across all three facilities, the experimental group demonstrated a significant increase in nutritional intake, which resulted in a significant increase in weight for the month that the aquarium was introduced. Interestingly, the staff observed that patients with a history of pacing and wandering sat for longer periods observing the aquarium. Thus, the patients spent more time at the dining tables which resulted in increased nutritional intake. The staff also reported that patients who tended to be lethargic were more attentive and awake in the presence of the aquarium, which also may have contributed to increased nutritional intake (Edwards & Beck, 2002). METHODOLOGY AND RESEARCH DESIGN This study takes place in three different nursing home facilities during five weeks. The subjects selected from the current residents at the facility. There is no attempt to select an even number of male and female subjects, however, there are restrictions as to the age, psychological and social abilities of the subjects as a requirement for participation in the AAT programme (see sample population section for detailed restrictions). This nonexperimental study utilises pre-test and post-test methodological approach. The researcher is to administer self-report questionnaires to each of the residents who decides to participate in the study (see Appendix A for a sample questionnaire). The pre-test self-report questionnaires are to be administered one week before the scheduled start of the AAT programme. A follow-up post-test questionnaires are to be administered one week after the five week study has been completed. The same questionnaire is used in both instances in an attempt to measure any changes occurring in residents’ quality of life or their perceptions of occurred changes in quality of life. During five week study, selected residents of nursing home facilities are to be exposed to live animals brought into facilities in conjunction with the establishment of an AAT programme. The Animal Assisted Therapy Programme is considered to be the independent variable (IV). The dependent variables (DV) considered and measured are quality of life categories and perceptions of programme participants. Extraneous variables (EV) are considered to be the staff of the facilities, the AAT therapists who bring the animals and the particular animals that are visiting. Any occurrence, either physically, psychologically or socially, that affects the resident and, thereby, impacts the results of the visit with the animals on any given day is also considered an extraneous variable. The AAT programme consists of one hour visits occurring five times a week for five weeks (25 hours in total) occurring in a controlled setting within the nursing home facilities. The typical visits consist of the participants interacting with the animals by petting, stroking, brushing, walking, and holding them, or throwing the ball for the animals, or just sitting and watching the animals. Communication with the animal, such as talking to the animal, or talking with the other people in the room about the animal, is considered to be important and is to be encouraged. Specific behaviours that are looked for are: proximity to the animals, talking to the animals or other people in the room, smiling or laughing at the pet, remembering a pet’s name from a previous visit, participating in play activity with the animals (throwing tennis balls) and physically interacting with the animals (stroking, brushing and petting.) SAMPLE POPULATION Based on research requirements, 30 subjects (n=30), both males and females, were subjects selected to participate in this study. The subjects were recruited from three nursing home facilities. Subjects were recruited based on 1) their age; 2) their length of stay in the long-term care facility; 3) their educational level; 4) their ability to speak, read, and write English; 5) freedom from any cognitive impairments; 6) freedom from any psychiatric diseases, 7) a lack of known allergies to animals; 8) a score equal to or greater than 30 on the Mini-Mental Status Examination. From methodological perspective, the criteria for subject selection were based on the criteria for subject recruitment. The subject: (1) Is between the ages of 62-90. (2) Lives at the long-term care facility for at least 1 year. (3) Has a minimum of a sixth-grade education. (4) Is able to speak, read, and write English. (5) Is free from any cognitive impairment as stated by the physician in the history and physical examination. (6) Has no known history of psychiatric disorders or diseases. (7) Verbally states no known allergies to animals. (8) Scores equal to or greater than 30 on the Mini-Mental Status Examination in the screening phase of the study, a score demonstrating mental competence. ETHICAL CONSIDERATIONS AND LIMITATIONS One possible ethical concern is the withdrawal of an effective therapeutic intervention on a participant’s undesirable behavior. In this particular study, withdrawal means no gain in quality of life through AAT interventions. However, in terms of this study, it was anticipated that the withdrawal or absence of the intervention was not harmful to the participant, while its presence may have been beneficial. The risks associated with AAT have been demonstrated as minimal. Particularly of note in this study was the working relationship of the animal, animal therapist and nursing home resident. The animals were fully certified assistance animals that carried public access certification and were bred and trained by an organisation that was a pioneer in the provision of service animals to people with disabilities or special needs. Gorczyca, Fine, and Spain (2000) noted that education about the benefit/risk ratio needs to take place before attempting to implement an AAT programme: “the first hurdle was to educate physicians…about the benefits of animal companionship, the small risk of zoonoses, and how to make pets even safer…” (p. 271). The three most commonly feared risks in AAT are the transmission of disease, dangers related to allergies, and potential for bites from the animal. An analysis of the risks and ethical considerations associated with each of these areas of concern leads to the conclusion that risks are negligible when compared to the benefits. As Fredrickson and Howie (2000) stated that studies indicate “properly cared for animals do not pose additional health risks and that the benefits outweigh the small, easily preventable risks involved” (p. 113). The results of this study may be generalised only to the elderly with the same characteristics as those in the study sample. REFERENCES Barak, Y., Savorai, O., Mavashev, S., & Beni, A. (2001) Animal-assisted therapy for elderly schizophrenic patients: A one-year controlled trial. American Journalof Geriatric Psychiatry, 9(4), 439-442. Bernstein, P. L., Friedmann, E., & Malaspina, A. (2000). Animal-assisted therapy enhances resident social interaction and initiation in long-term care facilities. Anthrozoos, 13(A), 213-224. Bizub, A. L., Joy, A., & Davidson, L. (2003). "It's like being in another world": Demonstrating the benefits of therapeutic horseback riding for individuals with psychiatric disability. Psychiatric Rehabilitation Journal, 26(4), 377-384. Colombo, G., Dello Buono, M., Smania, K., Raviola, R., & De Leo, D. (2006). Pet therapy and institutionalized elderly: A study on 144 cognitively unimpaired subjects. Archives of Gerontology and Geriatrics, 42, 207-216. Chandler, C. K. (2005). Animal assisted therapy in counseling. New York: Taylor & Francis Group. Edwards, N. E., & Beck, A. M. (2002). Animal-assisted therapy and nutrition in Alzheimer's disease. Western Journal of Nursing Research, 24(6), 697-712. Fredrickson, M., & Howie, A. R. (2000). Guidelines and standards for animal selection in animal assisted activity and therapy programmes. In A. Fine (Ed.), Handbook on animal assisted therapy: Theoretical foundations and guidelines for practice (pp. 100-114). San Diego, CA: Academic Press Gorczyca, K„ Fine, A. H., and Spain, C. V. (2000). History, theory, and development of human-animal support services for people with AIDS and other chronic/terminal illnesses. In A. Fine (Ed.), Handbook on animal assisted therapy: Theoretical foundations and guidelines for practice (pp. 254-302). San Diego, CA: Academic Press. Hooker, S., Freeman, L., & Stewart, P. (2002). Pet therapy research: A historical review. Holistic Nursing Practice, 16, 17-23. Kanamori, M., Suzuki, M., Yamamoto, K., Kanda, M., Matsui, Y., Kojima, E. Oshiro, H. (2001). A day care programme and evaluation of animal-assisted therapy (AAT) for the elderly with senile dementia. American Journal of Alzheimer's Disease and Other Dementias, 16(4), 234-239. LaFrance, C, Garcia, L. J., & Labreche, J. (2007). The effect of a therapy dog on the communication skills of an adult with aphasia. Journal of Communication Disorders, 40, 215-224. Motomura, N., Yagi, T., & Ohyama, H. (2004). Animal assisted therapy for people with dementia. Psychogeriatrics, 4, 40-42. Nathans-Barel, I., Feldman, P., Berger, B., Modai, I., & Silver, H. (2005). Animalassisted therapy ameliorates anhedonia in schizophrenia patients: A controlled pilot study. Psychotherapy and Psychosomatics, 74, 31-35. Podberscek, A. L., Paul, E. S., & Serpell, J. A. (2000). Introduction. In A. L. Podberscek, E. S. Paul, & J. A. Serpell (Eds.), Companion animals & us: Exploring the relationships between people & pets (pp. 1-4). New York: Cambridge University Press. Richeson, N. E. (2003). Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia. American Journal of Alzheimer's Disease and Other Dementias, 18(6), 353-358. APPENDIX A QUALITY OF LIFE SELF-REPORT QUESTIONAIRE These questions help us to identify how you have been feeling emotionally and physically in the past two weeks. Question 1. In the past five weeks, how often have you been unable to relax and felt restless? All the time __4 Often __3 Several times __2 None of the time __1 Question 2. In the past five weeks, how often have you truly enjoyed free evenings and weekends? All the time __4 Often __3 Several times __2 None of the time __1 Question 3. In the past five weeks, how often have you been overwhelmed with some problems that you could not concentrate on anything else? All the time __4 Often __3 Several times __2 None of the time __1 Question 4. In the past five weeks, how often have you been satisfied with your conduct and behaviour? All the time __4 Often __3 Several times __2 None of the time __1 Question 5. In the past five weeks, how often have you felt good because you received a compliment or appreciation? All the time __4 Often __3 Several times __2 None of the time __1 Question 6. In the past five weeks, how often have you experienced feelings of fear or anxiety? All the time __4 Often __3 Several times __2 None of the time __1 Question 7. In the past five weeks, how often have you been preoccupied with feelings of sadness or depression? All the time __4 Often __3 Several times __2 None of the time __1 Question 8. In the past five weeks, how often has something or someone interested you? All the time __4 Often __3 Several times __2 None of the time __1 Question 9. In the past five weeks, how often have you felt completely satisfied with your life? All the time __4 Often __3 Several times __2 None of the time __1 Question 10. In the past five weeks, how often have you been satisfied with decisions you’ve made? All the time __4 Often __3 Several times __2 None of the time __1 Question 11. In the past five weeks, how often have you experienced difficulties with sleeping? All the time __4 Often __3 Several times __2 None of the time __1 Question 12. In the past five weeks, how often have you been overwhelmed with fatigue? All the time __4 Often __3 Several times __2 None if the time __1 Question 13. How satisfied are you with your room, its repair conditions, bed, air conditioning, lighting, etc? Very satisfied __4 Satisfied __3 Dissatisfied __2 Very dissatisfied __1 Question 14. In the last five weeks, have you seen a doctor or requested medical care? Yes __2 No __1 Question 15. In the last five weeks, how often did you engage in social conversation with you mates, relatives or neighbours of nursing home? More than 3 times __4 2 or 3 times __3 Once __2 Never __1 Question 16. In the last five weeks, how many times you felt satisfaction regarding yourself as a person? More than 3 times __4 2 or 3 times __3 Once __2 Never _ __1 Question 17. In the last five weeks, how many times you felt supported? More than 3 times __4 2 or 3 times __3 Once __2 Never __1 Read More