Journal of Gerontological Nursing

Feature Article 

Health Benefits and Risks of Pets in Nursing Homes: A Survey of Facilities in Ohio

Jason W. Stull, PhD, VMD, MPVM, DACVPM; Cydney C. Hoffman, MPH-VPH, BA; Timothy Landers, PhD, RN, CNP, CIC

Abstract

Pets are encountered in nursing homes and although they provide health benefits to individuals, they are also a source of health risks. The current study aimed to determine the frequency and types of animals in nursing homes, perceived benefits, and content of policies addressing health risks. Ninety-five administrators from unique nursing homes in Ohio completed an online survey addressing perceived benefits and risks of animals and policies in place. Animals were permitted in 99% of nursing homes, with dogs (95%), cats (85%), birds (71%), fish (55%), and farm animals (40%) most frequently reported. Respondents perceived animal interactions resulted in high health benefits for residents. Most facilities (70/75; 93%) reported having an animal policy, yet important gaps were frequently identified in the content of policies. Most respondents (75%) did not report health and safety concerns with animals in facilities. Best practice guidelines and policies should be developed and implemented in nursing homes to address requirements for different animal ownership models, range of animal species, and staff knowledge. [Journal of Gerontological Nursing, 44(5), 39–45.]

Abstract

Pets are encountered in nursing homes and although they provide health benefits to individuals, they are also a source of health risks. The current study aimed to determine the frequency and types of animals in nursing homes, perceived benefits, and content of policies addressing health risks. Ninety-five administrators from unique nursing homes in Ohio completed an online survey addressing perceived benefits and risks of animals and policies in place. Animals were permitted in 99% of nursing homes, with dogs (95%), cats (85%), birds (71%), fish (55%), and farm animals (40%) most frequently reported. Respondents perceived animal interactions resulted in high health benefits for residents. Most facilities (70/75; 93%) reported having an animal policy, yet important gaps were frequently identified in the content of policies. Most respondents (75%) did not report health and safety concerns with animals in facilities. Best practice guidelines and policies should be developed and implemented in nursing homes to address requirements for different animal ownership models, range of animal species, and staff knowledge. [Journal of Gerontological Nursing, 44(5), 39–45.]

Pets provide many documented physical, social, and emotional health benefits to individuals. These benefits are particularly important for older adults (Banks & Banks, 2002; Cherniack & Cherniack, 2014). Reductions in blood pressure (Wright, Kritz-Silverstein, Morton, Wingard, & Barrett-Connor, 2007), decreased depressive symptoms (Orlandi et al., 2007), enhanced social interactions (Bernstein, Friedmann, & Malaspina, 2000), and improved mental health (Colombo, Buono, Smania, Raviola, & De Leo, 2006) have been attributed to pet contact. Further, animals may be incorporated in physical therapy programs, such as dog walking or animal brushing, to increase participation in targeted activities aimed at restoring or promoting physical function and mobility (Abate, Zucconi, & Boxer, 2011).

In the United States, similar to other countries, more than 50% of the population has a pet, and most pet owners consider these animals to be family members or companions (American Veterinary Medical Association, 2012). Temporary or permanent separation from pet companions can be a source of stress, anxiety, and grieving, and result in reduced quality of life (Banks & Banks, 2002). Thus, the presence of animals may contribute to a home-like environment, an area that is becoming more important in nursing home models (Guay, 2001; Morley & Flaherty, 2002). In contrast to increasing evidence suggesting the benefits of human–animal interactions, little attention has been paid to identifying current animal practices, potential risks, or evidence-based best practices for animals in nursing homes. The presence of animals may be associated with increased risk of falls, injuries, allergies, adverse psychological events, and animal-to-person (zoonotic) diseases (Guay, 2001; Huss et al., 2001; Murthy et al., 2015; Stevens, Teh, & Haileyesus, 2010).

Broadly, animals in nursing homes can be classified as being owned by individual residents, facility-owned, or visiting. Animals are used in animal-assisted activities, animal-assisted therapy, as service animals, as companion animals, or to make the nursing facility more “home-like” (Parenti, Foreman, Meade, & Wirth, 2013). There is variation in human–animal interaction depending on the intended purpose of the animal, personal characteristics, patient preferences, and animal-specific attributes; therefore, it is important to understand the frequency and use of different types of animals to effectively study their impact on human health and guide best practices to safeguard human and animal health (Zasloff, 1996). In Ohio, nursing homes that allow animals (resident- or facility-owned) to reside in the facility are required to have a written protocol regarding animals that protects the health and safety and rights of residents (Ohio Department of Health, 2012); however, the frequency of compliance and specific content of facility protocols are unknown.

To identify current practices and policies related to pets in nursing homes, the aim of the current study was to determine the frequency of animals in Ohio nursing homes, their perceived benefits, and the content of policies and procedures used by nursing homes for animal presence.

Method

From a publicly available list of 952 licensed nursing home facilities in Ohio (United States), a random sample of 250 nursing homes was selected to receive an online survey. In addition, the survey was distributed to a convenience sample of 75 facilities through a professional association for nursing home administrators. An e-mail with an anonymous link was sent to the facility administrator inviting participation in the study. Reminders were sent at 2-week intervals for 2 months.

A 25-minute survey (106 questions) was developed through consultation with experts in nursing home administration; human health care, infectious disease, and veterinary infectious disease specialists; and epidemiologists. Fixed-response and free-text questions were used to gather information on facility demographics, extent of animal visitation, facility- or staff-owned pets, and resident-owned pets. The survey collected data on the presence of policies addressing animals and the content of these policies using scenario-based exclusion criteria. A 5-point Likert scale was used to capture level of agreement with statements pertaining to perceived benefits and risks of animals in the respondent's facility, with 1 = strongly disagree to 5 = strongly agree. The survey was pilot tested by administrators and experts in nursing home care and revised for content validity. Skip logic was used to reduce user fatigue. Participants had the option of beginning the survey and continuing it at a later time. An incentive (random drawing for books on the topic) was offered to encourage participation. The online survey was administered through Qualtrics® and open from November 1, 2014 through March 31, 2015. The Ohio State University Biomedical Institutional Review Board (IRB) approved the study. Participants provided web-based consent to participate in the study and a waiver of consent documentation was granted by the IRB.

Data collected were exported into Microsoft® Excel® and SPSS version 22 for analysis. Blank responses were excluded from analysis. Responses of strongly agree and agree were combined and coded as agree, and disagree and strongly disagree were coded as disagree; neither agree nor disagree remained a third category. All valid partially recorded responses were included in the data analysis up to the point the respondent stopped answering. Descriptive statistics were calculated for all variables. Associations between animal policies and type of animal (i.e., facility-owned, resident-owned, visiting) were assessed using Pearson chi-square test or, if ≥20% expected cell values were ≤5, Fisher's exact test. Associations with p values <0.05 were considered significant.

Results

A total of 131 individuals accepted the invitation to the survey by visiting the online link, with 95 eligible participants from unique (i.e., all different) facilities completing through Part 1 of the survey (i.e., facility description and permission of animals in the facility) and 64 completing the entire survey (Figure 1). Respondents represented a range of facility affiliations, locations, and sizes, with facilities from 37 of 88 counties in Ohio (Table 1). Facilities had a median of 114 certified beds (range = 20 to 634 beds).

Flow diagram of Ohio nursing home study enrollment.

Figure 1.

Flow diagram of Ohio nursing home study enrollment.

Facility Description of Ohio Nursing Home Survey Respondents (N = 95)

Table 1:

Facility Description of Ohio Nursing Home Survey Respondents (N = 95)

Animal Inclusion in Nursing Home Facilities

Animals were reportedly permitted in 94 (99%) facilities. Numerous species were reportedly allowed to live in or visit many of the facilities, including dogs, cats, birds, fish, farm animals (e.g., pigs, goats), rodents, reptiles/amphibians, and miniature horses. Many of these species had been present in the facility within the preceding 12 months (Figure 2).

Proportion of responding facilities (N = 75) that allowed pets to live in or visit the facility and reported presence of species within the facility in the past 12 months.

Figure 2.

Proportion of responding facilities (N = 75) that allowed pets to live in or visit the facility and reported presence of species within the facility in the past 12 months.

Most respondents (92/95; 97%) reported allowing animals to visit their facility. Reasons for visitation were provided by 65 respondents and included accompanying a friend or family member to visit a specific resident (95%), part of a socialization-directed therapy program for residents (71%), accompanying a staff member to work (59%), and as part of a physical therapy program for residents (59%).

Facility Policies Related to Animals

Most nursing homes (70/75; 93%) had a policy concerning animals, although fewer had policies that addressed multiple categories of pet ownership (i.e., facility-owned, resident-owned, visiting) (Table 2). Of facilities with policies, there was significant variation in the proportion of facilities allowing animals across ownership categories, with 97% allowing visiting, 88% allowing facility-owned, and 75% allowing resident-owned animals (p = 0.003). Content and scope of policies varied by animal ownership categories (Table 2). Reported facility policies frequently designated a primary caregiver for different categories of animals (47% to 73%) and included vaccination requirements for animals (46% to 88%). Gaps were noted in numerous areas, including hand hygiene (21% to 47%), procedure to follow if an animal bites a staff member or resident (40% or 54%), requirements for animal temperament testing (39% to 45%), training of staff (18% to 33%), within-facility location and species restrictions (23% to 55%), and animal age restrictions (2%). A lower proportion of respondents reported inclusion of content for resident-owned than facility-owned or visiting animals in eight of 10 questioned policy content areas. Across ownership categories, significant variation was noted in the proportion of facilities reporting policies that designated a primary caregiver for the animal (p = 0.02) and vaccination requirements (p < 0.001).

Content and Scope of Animal Policies for Facility-Owned, Resident-Owned, and Visiting Animals at Nursing Homes in Ohio (N = 75)

Table 2:

Content and Scope of Animal Policies for Facility-Owned, Resident-Owned, and Visiting Animals at Nursing Homes in Ohio (N = 75)

Scenario-Based Restrictions

Respondents were asked if an animal would be excluded from visiting the facility given a particular health-related scenario for the animal. The majority of respondents would exclude an animal known to currently have diarrhea (96%), have vomited in the proceeding 24 hours (81%), or that appeared sick (88%) (Table 3). When asked about exclusion policies, there was a lack of knowledge about animal exclusions for animals that had vomited or had diarrhea in the past 2 weeks or were currently taking an antibiotic (41%, 31%, and 33% unsure, respectively). Animals that had not received a bath in the prior 24 hours or did not have a veterinary health check in the past 7 days were often allowed to visit the facility (57% and 62%, respectively).

Reported Scenario-Based Restrictions to Animals Visiting Nursing Homes in Ohio

Table 3:

Reported Scenario-Based Restrictions to Animals Visiting Nursing Homes in Ohio

Perceived Benefits of Animal Interactions

Respondents were asked about perceived animal-associated health benefits for residents with interactions with the most frequently encountered pet species: dogs, cats, birds, and fish. Overall, perceived benefits were high, with respondents agreeing with the statements, “residents frequently request to spend time with animals” (42% [birds] to 56% [dogs]), “seem happier after spending time with animals” (58% [birds], 79% [fish], 91% to 94% [cats and dogs]), and “are useful in calming agitated or upset residents” (61% to 64% [birds and fish], 86% [cats], 94% [dogs]).

Animal-Associated Risks

Injuries to animals or individuals were infrequently reported. One respondent reported an animal (cat) had been mistreated by either residents or staff in the preceding 12 months. None of the respondents reported an instance in which an infection in a resident was known or suspected to be linked to an animal at the facility. Most respondents who allowed animals to live in their facility stated they prevented the animals from interacting with residents who have allergies (32/37; 86%). Approximately 25% of respondents agreed with the statement “there are health and safety concerns about having animals in the facility,” although agreement varied by species of animal (dogs: 9/32 [28%]; cats: 5/21 [24%]; fish: 7/29 [24%]; birds: 1/25 [4%]).

Perceived Education Needs

Respondents (n = 61) identified a number of topics on which they believed their organization could better promote human and animal health. Topics included specific information about when an animal should not have contact with humans (e.g., instances of diarrhea, vomiting) (54%), general animal care guidance documents (39%), species-specific health guidance (34%), resources describing recommended veterinary care (33%), and recommendations for particular organism screening (33%); some respondents believed no additional educational needs were required (21%).

Discussion and Implications

The current study provides background about the presence of animals in Ohio nursing homes and the policies and practices regarding these animals. The results demonstrate that although animals are frequently permitted in nursing homes, many facilities lack policies that address generally recognized key components of protocols to enhance the safety of these interactions (Hardin, Brown, & Wright, 2016; Murthy et al., 2015). Furthermore, the results serve as a foundation to develop future recommendations to maximize resident safety during human–animal interactions.

Despite its apparent popularity, few studies have examined the presence of animals in nursing homes (Linder, Siebens, Mueller, Gibbs, & Freeman, 2017; Schuurmans, Enders-Slegers, Verheggen, & Schols, 2016). The current study findings are similar to these prior studies in that nursing homes frequently used animals (e.g., 76% to 98% of Dutch and U.S. facilities), with dogs being the most popular species, but with many species used (Linder et al., 2017; Schuurmans et al., 2016). Most facilities in the current study reported the presence of a policy for animals, a notable difference from other studies (Linder et al., 2017; Schuurmans et al., 2016). In Ohio, state law and regulation require that facilities have a policy that protects the health, safety, and rights of residents if facilities permit live-in animals (Ohio Department of Health, 2012), perhaps in part responsible for the observed high proportion of facilities with protocols. Yet, respondents displayed limited knowledge and policy-directed guidance regarding safety concerns for residents.

Compared to established recommendations for health care facilities (Murthy et al., 2015), many gaps were identified in reported policies, and respondents appeared to be unconcerned about health risks. Although there are limited data to define the level of risk to nursing home residents by animals, prior work has reported zoonotic agents are frequently present in visiting animals (i.e., 80% of therapy dogs in one study) (Lefebvre et al., 2006), older adults and immunocompromised individuals are at increased risk for pet-associated infections (Stull, Brophy, & Weese, 2015), and animals have been identified as a source of disease outbreaks in nursing homes (Moffatt et al., 2014). Further, allergies and injuries (e.g., falls) associated with animals in nursing homes can be important health concerns (Huss et al., 2001; Stevens et al., 2010). Policies aimed at reducing these risks, such as prohibiting animals based on age (i.e., young) or species (i.e., high-risk for pathogen shedding, bites/scratches), are integral in best practices for health care settings (Murthy et al., 2015) and similarly encouraged in nursing homes (Guay, 2001). However, in the current study, age and species restrictions were infrequently included in facilities' policies (2% and 25%, respectively), and many respondents reported the recent presence in their facility of species posing a high zoonotic disease risk (e.g., reptiles, amphibians, farm animals) (Stull et al., 2015). Reported policies lacked additional components considered integral to health care facilities, such as specific locations in the facility where animals were prohibited (e.g., food preparation areas), instructions for hand hygiene practices before and after animal interactions, procedures for animal-associated illness or injury, and temperament testing requirements for animals (Murthy et al., 2015).

The current study also noted variation in content and scope of policies by animal ownership categories. It is important that nursing homes develop comprehensive policies for all animal ownership categories allowed. Relying on staff, residents, or outside groups to independently ensure health and safety of pets and residents is unlikely to be successful. For instance, regional and local therapy animal organizations have been shown to frequently have suboptimal health and safety policies (Linder et al., 2017). In the current study, 59% of facilities allowed staff to bring their own animals to work, highlighting the variety of animal sources and importance of ensuring comprehensive policies are in place at facilities. Study participants reported a need for specific strategies to mitigate health risks and allow the safe interaction of pets and residents.

Based on the current literature and adapting best practice recommendations for health care facilities (Murthy et al., 2015), an educational tool and a downloadable model policy were developed for nursing homes, advertised to facilities through local mailings and conferences, and made publicly available (access http://www.go.osu.edu/nhpets). The model policy includes key areas that should be addressed in a facility's policy: (a) requirements and exclusions for the various animal ownership categories; (b) resident requirements and exclusions for participation; (c) environmental infection control (e.g., cleaning and disinfection following animal visits and animal feces, urine, or other contamination of areas); (d) education for staff and animal handlers and participating residents; and (e) responsibilities of an internal committee to oversee development and maintenance of relevant polices. In addition, several organizations have registration programs for animals and handlers that provide relevant training that can be leveraged to help meet animal and handler training and evaluation requirements (e.g., Pet Partners, Therapy Dogs Incorporated, Therapy Dogs International).

It is important to note that there were high perceived health benefits of animals for residents and reported health risks were low. Further, perceived health risks were low, with only 25% of respondents acknowledging health and safety concerns with animals in a facility. Accurately measuring health benefits and risks from animal contact is currently a challenge, and more work in this area is encouraged to assist in allowing nursing home administrators to best weigh advantages and disadvantages of using animals in the facility and identify a facility's needs and resources (Barnett & Quigley, 1984; Stull et al., 2015). The development and use of tools to objectively measure and track health benefits and risks will be helpful in guiding the use of animals and specific policies.

Limitations

The current study has limitations. Because participants were from one state, the results may not be generalizable to all nursing homes. Furthermore, there is also the potential for response bias if nursing homes that had well-developed pet programs in place were more willing to participate in the study as they would be expected to have formal policies. It is unknown if policies reported by participants were being adhered to at all times.

Conclusion

The current study provides an overview of existing practices regarding animals in nursing homes that can be used to develop practical, evidence-based recommendations for pet therapy and other animal-related interactions. Nursing home administrators, clinicians, and patient representatives should be encouraged to work with veterinarians to develop program guidance that allows individuals to enjoy the benefits of animal interaction while mitigating potential risks.

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Facility Description of Ohio Nursing Home Survey Respondents (N = 95)

Variablen (%)
Affiliation
  Non-profit organization42 (44.2)
  Private—for profit chain46 (48.4)
  Public—county organization1 (1.1)
  Other/Prefer not to answer6 (6.3)
Location (population)
  Large metropolitan (≥1 million)25 (26.3)
  Medium metropolitan (250,000 to 999,999)18 (18.9)
  Small metropolitan (50,000 to 249,999)7 (7.4)
  Micropolitan (10,000 to 49,999)23 (24.2)
  Noncore (non-metropolitan, non-micropolitan)6 (6.3)
  Prefer not to answer16 (16.8)
Number of certified beds
  <504 (4.2)
  50 to 9930 (31.6)
  100 to 20036 (37.9)
  >20018 (18.9)
  Prefer not to answer7 (7.4)

Content and Scope of Animal Policies for Facility-Owned, Resident-Owned, and Visiting Animals at Nursing Homes in Ohio (N = 75)

Variablen (%)p Valuea
Facility-OwnedResident-OwnedVisiting
Policy present59 (78.7)51 (68)58 (77.3)0.26
Type of animal ownership/visiting permitted52 (88.1)38 (74.5)56 (96.6)0.003
Policy content
  Instructions for hand hygiene practices for staff and residents who interact with animal18 (34.6)8 (21.1)25 (44.6)0.062
  Information on training or other educational activities for staff involved in animal's care17 (32.7)7 (18.4)14 (25)0.31
  Description of specific areas in the facility animal is not permitted23 (44.2)15 (39.5)31 (55.4)0.27
  Procedure to follow if animal bites staff or resident24 (46.2)15 (39.5)30 (53.6)0.40
  Procedure for other animal-associated illness or injury in staff or residents22 (42.3)13 (34.2)22 (39.3)0.74
  Species restriction12 (23.1)9 (23.7)14 (25)0.97
  Designation of who is responsible for animal's care and veterinary records27 (51.9)18 (47.4)41 (73.2)0.020
  Age restrictionb1 (1.9)1 (1.8)1.0c
  Vaccination requirementsb24 (46.1)49 (87.5)<0.001
  Temperament testing requirementsb20 (38.5)25 (44.6)0.52

Reported Scenario-Based Restrictions to Animals Visiting Nursing Homes in Ohio

ScenarioAllowed to Visit the Facility (n, %)
YesNoUnsure
If animal is known to currently have diarrhea042 (95.5)2 (4.5)
If animal is known to have had diarrhea in the past 2 weeks7 (16.7)22 (52.4)13 (31)
If animal has not received a bath in the prior 24 hours24 (57.1)9 (21.4)9 (21.4)
If animal is known to have vomited in the past 2 weeks7 (16.7)18 (42.9)17 (40.5)
If animal is known to have vomited in the past 24 hours1 (2.4)34 (81)7 (16.7)
If animal appears “sick”038 (88.4)5 (11.6)
If animal has not had a veterinary health check within previous 7 days26 (61.9)8 (19)8 (19)
If animal is currently taking an antibiotic prescribed by a veterinarian14 (33.3)14 (33.3)14 (33.3)
Authors

Dr. Stull is Assistant Professor, College of Veterinary Medicine, Ms. Hoffman is Graduate Student, College of Public Health, and Dr. Landers is Associate Professor, College of Nursing, The Ohio State University, Columbus, Ohio. Dr. Stull is also Adjunct Professor, The University of Prince Edward Island, Atlantic Veterinary College, Charlottetown, Prince Edward Island, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was supported by The Kenneth A. Scott Charitable Trust, a KeyBank Trust.

Address correspondence to Jason W. Stull, PhD, VMD, MPVM, DACVPM, Assistant Professor, The Ohio State University, College of Veterinary Medicine, 1920 Coffey Road, Columbus, OH 43210; e-mail: Stull.82@osu.edu.

Received: October 08, 2017
Accepted: February 09, 2018
Posted Online: April 02, 2018

10.3928/00989134-20180322-02

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