Historically, animals and humans have developed a special relationship with one another. The earliest relationship, as documented in cave paintings, was between wolves and cave men around campfires. The ancient Egyptians revered their cats as evidenced by their entombments together. During the Middle Ages, horses and dogs were important to their masters for companionship, travel, and hunting. Today, animals are an integral part of American society and the natural environment. Statistics show that most Americans will own a pet during their lifetime.1 Animals serve not only as pets, but also as working companions for the physically and mentally handicapped.
Animals are also a part of our natural environment. According to Katcher, the role of pets and domestic animals is closely related to the physiological and psychological well-being of humans, especially as related to touch, intimacy, and nurturance.2
What happens when an elderly person (with a history of animal interactions) enters a nursing home? Residents must relinquish most of their personal possessions, the security of home, and often a relationship with a pet or other animal within their previous environment. Reactions after admission frequently result in depression, helplessness, disorganization, or a rapid deterioration.3
Researchers have identified the importance of animal companionship as having positive psychological benefits to elderly people living in the community and in nursing homes.4,5 Yates found that nursing home residents with decreased physical activity levels often made increased efforts to reach and stroke visiting dogs.6
Animals contribute to our overall well-being. How, then, can we best use animal assisted therapy (AAT) to promote the optimal mental and physical functioning of nursing home residents? This article will focus on the implications of AAT for both the residents and caregivers of long-term care facilities.
ANIMALS AS THERAPY OR ENTERTAINMENT?
Many nursing homes have occasional visiting dogs or other animals that provide a diversion for residents. These diversions are frequently in the form of pet tricks or walking the pets through the lounge and hallways for residents to see and perhaps touch.
Animal assisted therapy differs from animals used as entertainment in that AAT is considered to be an applied science using animals to solve a human problem. It is an interdisciplinary approach using animals as an adjunct to other therapies. It is goal-oriented, using assessment and evaluation procedures.
One of the early pioneers of AAT was Levinson, a psychologist who in 1969 first used a dog in psychotherapy sessions with children. He found that children were often better able to communicate and express their feelings when relating to a therapy dog during these sessions. Critics of AAT have asked who performs the therapy - the animal or the human therapist? Zaki, after conducting AAT for Alzheimer's disease patients, felt that it is a combination of both the animal and the therapist that creates positive patient response (cited in Burton).7
This belief was also expressed by Dom in his work with cognitively impaired nursing home residents.8 One major difference between animals as entertainment and animals as therapy seems to be in the animal-human bond. This bonding can be defined as a special relationship that develops when the person has strong feelings of psychological attachment to the animal. The animal is also responsive to the person and his needs. It is this bonding relationship, used therapeutically, that differentiates AAT from animal entertainment. Finally, the development of individualized resident goals, assessment, planned animal interactions, and evaluation procedures also accentuate the differences between AAT and animal entertainment.
DESIRED HEALTH AND BEHAVIORAL RESPONSES
Residents of nursing homes often display a variety of maladaptive psychological responses after their admission. Physiological problems may also develop in response to their changes in mobility, pain, or sensory awareness. Erickson summarized the adaptive effects that pets could provide for elderly persons: combating loneliness; caring and responsibility; keeping active; touching and fondling; watching and playing; feeling safe; health promotion and longevity; and stimulation and exercise.9
Nebbe further defined desirable human responses by describing five categories of animal assisted therapy that could be prescribed, depending on client needs (Nebbe L. 1988. Unpublished raw data). Each category is described with an example of application for nursing home residents.
* Functional. The animal is identified with the person who cares for it. The person has control of the animal's well-being, resulting in increased selfesteem, confidence, or mobility. A nursing home resident can feed fish in an aquarium or assume care for caged birds within the facility. The resident can also be allowed to walk a dog from room to room, sharing the animal with others who may interact with the person and pet.
* Relationship. The animal interacts closely with the person. The person has love and security needs met, resulting in a feeling of being needed or a higher self-esteem. The regularly scheduled therapeutic visitation of a dog with a specific nursing home resident allows the resident to hold, stroke, and talk to the dog. The dog responds, in tum, by wagging its tail and licking the person's hands or face.
* Passive. As an animal entertains, the person has fun and relaxes. This results in increased stimulation and social interactions. Residents can watch kittens as they chase a ball of yarn around the floor. As the kittens play, residents smile and laugh, as well as talk to each other.
* Cognitive. Animals provide a source for increasing one's own knowledge, resulting in increased self-respect and control of the environment. The person learns about himself through the animal. Programs and outings for residents involving nature and wildlife can be offered. In group sessions, the presence of an animal can trigger discussions about residents1 personal feelings, their awareness of nature, and can increase cognitive stimulation.
* Spiritual. The animal provides a source for feeling a oneness with life and creation. Residents renew their spiritual energy through reminiscence, which is one method of preparation for death in the elderly. A cat interacting with nursing home residents on a daily basis can remind the residents of a pet they owned earlier in life and of incidents that may be associated with that pet.
RESPONSES TO PETVISITATION PROGRAMS
Mrs A was depressed, sensory impaired by deafness, and had difficulty in articulation. During dog and volunteer visits, she attempted to use alternate modes of communication, such as writing, lip reading, and touch. These efforts often continued after the visits ended, thereby increasing her overall functional ability.
Miss B, often very confused, responded positively to a visiting dog by accurately remembering her own dog that had died. She also showed an increase in short-term memory by remembering the visiting dog's name and its previous visits. The dog seemed to offer security in a new environment through this new relationship.
Mr C was terminally ill and usually bedridden with decreased social and activity levels. During the dog's and volunteer's visit, he responded by smiling, stroking the pet, and expressing verbal pleasure at the visit. He also spoke of a previously owned dog. These visits seemed to reflect a renewed spiritual energy for the resident and his spouse, giving them something pleasant to share in the last days of Mr Cs life.
Many residents, staff, and families express pleasure and joy at the pet visits, which indicates a passive response to a much-needed diversion from the routine tasks of the day. Some caregivers and residents want to know more about the visiting animal, indicating a cognitive response and interest.
RESPONSES TO RESIDENT PET PROGRAMS
Mr D was lonely, depressed, and frail. He took responsibility for maintaining a wild bird feeder on the patio. This enhanced his overall functional ability by increasing his ambulation. He was recognized by other residents for performing a needed task.
Miss E is moderately mentally retarded. She is responsible for caring for a resident rabbit for 1 week each month. Her cognitive abilities are increasing by learning new skills. Positive therapeutic relationships have developed with two caregivers as a result of their common interest in the animal.
Animal assisted therapy can help in promoting a variety of desirable health and behavioral responses for residents of long-term care facilities. It is essential, however, that all components of the program be carefully planned and executed.
IMPLICATIONS FOR LONG-TERM CARE
It is essential that a complete nursing and activity assessment be made before the implementation of individualized AAT. A functional assessment can identify individual needs to measure the older adult's overall wellbeing and self-care abilities. Next, an inquiry as to the number and type of pets, years of prior pet ownership, interactions with animals, and present animal interests should be included as part of all admission assessments. Those persons having a history of involvement with pets, or an interest in animals, should be considered as potential candidates for AAT.
Once all of the data have been gathered, a problem list can be developed using applicable nursing diagnoses. These defined problems can then be used in the selection of an appropriate AAT program.
Clients or their families should give permission before beginning AAT. During and after the prescribed AAT program, it is important that evaluation procedures be conducted. Focus should be on the desired resident outcomes. Evaluation can be in the form of a check list of resident responses or combined with a narrative log of behavioral and physiological responses.
Sample Nursing Care Plan
A nursing care plan is described that could be used with an elderly resident exhibiting signs of depression.
Subjective data: "I don't care anymore, there's no one to go home to. My dog died 3 years ago. "
Objective data: Resident remains alone in her room and refuses to attend activities. She has a sad facial expression and speaks slowly.
Nursing diagnosis: Social isolation related to institutionalization.
Short-term goals: The resident will express feelings of loneliness to the nurse. The resident will participate in one social activity daily outside of her room. She will be involved in a biweekly animal visitation program.
Nursing interventions: Collect a pet history; encourage life review by discussing her dog; assess current interest in pets; schedule visiting dog and volunteer for room visits; and encourage participation in AAT activities held in the lounge.
Evaluation of resident responses is to include verbal and non-verbal reactions to the dog and volunteer; conversation content; length of visit; physical activity; social interaction; and memory stimulation.
The type of program depends on the needs and resources of the facility and the needs of the residents involved. AAT is an interdisciplinary teameffort that can enhance the well-being of patients. The facility administration must decide if a resident pet is desired or if it wishes to have AAT provided by an outside consultant or a staff member. If so, will this service be provided on a volunteer, programmatic, or a fee for service basis? Decisions as to staff involvement and their specified duties are important issues to be resolved prior to the start of AAT. Infection control policies and procedures need to be developed and followed according to facility and local public health regulations.
Other important issues are the selection and suitability of specific animals chosen for AAT. Animals must be disease-free and have temperaments mat allow them to interact appropriately with residents and staff. Animals must be properly supervised and protected within the facility environment.
The facility caregivers and family members need to be educated as to the benefits of AAT for selected residents. Those persons not wishing to participate should have the option to decline. Residents demonstrating an interest in animals should be encouraged to have animal pictures, statues, or stuffed toys in their rooms. These personal items modify the environment to be more "home-like" and less institutional. These objects also contribute to increased feelings of comfort and security for residents.
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