Stony Brook University (SBU) is a public research university located on New York's Long Island. The Commission on Collegiate Nursing Education–accredited School of Nursing (SON) offers baccalaureate, masters, and doctoral degrees. The SON offers three pathways to the baccalaureate degree: a 1-year onsite accelerated program, a 2-year onsite basic baccalaureate program, and a RN-to-BS post-licensure program offered in a distance education format.
In 2014, the SBU SON was awarded a 4-year cooperative agreement from the U.S. Department of Health and Human Services, Health Resources and Services Administration to create a nursing education pathway specifically responsive to the unique circumstances of Veterans. The SON designed and implemented strategies to operationalize the Veteran to Bachelor of Science Program in Nursing (VBSN). These measures were designed to assist Veterans returning to civilian life and engaging in a new nursing career development activity.
It was understood from the literature that unique stressors might emerge as a consequence of transitioning out of the military and reconnecting to civilian and academic cultures (Ahern et al., 2015). Koenig, Maguen, Monroy, Mayott, and Seal (2014) use the term reverse culture shock to describe the experience of readjustment from military command to the responsibilities of making day-to-day, self-directed (civilian) choices. It was anticipated that these sources of stress might arise from personal and financial (socioeconomic) lifestyle changes (Snyder, Wick, Skillman, & Frogner, 2016), and challenges arising from medical or psychosocial conditions that are a consequence of military service (Koenig et al., 2014). It was also anticipated that sources of stress could include the challenge of re-immersion into the academic setting, requiring re-learning study and test-taking skills and, perhaps, adaptation to unfamiliar computer-mediated learning technologies.
The current article describes an optional program offered to SBU SON Veteran nursing students to participate in an experience interacting with horses, which was intended to serve as a stress-reduction intervention. This experience is sometimes called therapeutic riding but was termed equine therapy (ET) in this circumstance. The community in which the SON is located provided the opportunity to select ET from a variety of therapeutic interventions for reduction of stress. The current authors share lessons learned from implementation of ET for Veteran nursing students so that other SONs can incorporate this information into their own understanding of the benefits of the approach and, if possible, include consideration of ET as a strategy promoting students' enrollment retention and personal well-being.
The concepts underpinning the theoretical benefits of human/equine interaction include the beliefs that horses are social creatures capable of creating and responding to relationships. Horses naturally scan their environment, and are thus capable of modeling awareness, inner knowledge, and self-regulation. Developing a human/animal bond provides an opportunity to realize the power of co-creating a trusting relationship (Vivo, 2015), which is often difficult for returning Veterans. Interaction with horses is a way of exploring and understanding personal styles of connecting to others to build trusting relationships. This interaction is predicated to be a transformative experience and restorative to mind, body, and spirit. Horses read energy, not minds, giving the human immediate, honest, and nonjudgmental feedback (Tartakovsky, 2015). The most common emotional benefits attributed to this interaction are increases in confidence and self-esteem and a sense of control. It has been noted that these benefits can be derived within a relatively short period of time (Kendall, Maujean, Pepping, & Wright, 2014).
The literature on use of ET as a health intervention crosses disciplines of health care and age groups. ET has been widely used as a therapy for those experiencing physical limitations and challenges, helping to increase muscle strength, coordination, mobility, balance, and sensory motor function (Bender & McKenzie, 2008). Equine-related treatment for cognitive concerns has also been widely reported in the literature, having been used with children, adolescents, and adults with autism, attention-deficit/hyperactivity disorder, eating disorders, and a range of mental illnesses (Masini, 2010). Earles, Vernon, and Yetz (2015) studied the application of ET as an intervention to symptoms of anxiety and post-traumatic stress disorder (PTSD). They reported that after completion of six weekly 2-hour sessions, participants reported marked reductions in symptoms of emotional distress, anxiety, depression symptoms, and alcohol use (Earles et al., 2015).
O'Brien (2014) noted that research on the effects of therapeutic horseback riding for the Veteran population was limited. She offered a summary of the main outcomes that can be accrued by Veterans participating in equine activities, including fostering independence, reducing isolation, increasing self-esteem, improving physical and mental well-being, and fostering trusting friendships (O'Brien, 2014).
An early report of ET as a “Veteran-friendly” intervention for the reduction of stress indicated that ET could improve quality of life by making a positive contribution to the cognitive, physical, emotional, and social well-being of Veterans with disabilities (Professional Association of Therapeutic Horsemanship International, 2013). MacLean (2011) described a program of equine-assisted therapy for Veterans self-reporting PTSD, noting that interacting with horses seemed to help participants become more aware of their body language and expressions of emotion. Lanning and Krenek (2013) noted that members of the military value loyalty, duty, respect, selfless service, honor, integrity, and personal courage, and, therefore, mental health issues are likely to be underreported. Their mixed-method study documented improvement in physical and emotional health of Veterans who participated in a program of equine-assisted activities and therapies. Depression scores decreased approximately 6 points after a 12-week program (Lanning & Krenek, 2013. Ferruolo (2016) described a program specifically designed for treatment of Veterans with depressive and anxiety disorders and reintegration issues, called equine-facilitated mental health. Outcomes evaluation indicated that the therapy helped 100% of participants learn about themselves, and that participation helped lessen their depression and lower their anxiety.
On the other hand, a systematic review of studies related to equine-related treatments for mental disorders indicated that there is little justification at present to support ET as a “stand alone or adjunctive treatment for any mental disorder” and particularly for diagnoses (e.g., PTSD) and populations (e.g., military personnel) (Anestis, Anestis, Zawilinski, Hopkins, & Lilienfeld, 2014, p. 1127). Anestis et al. (2014) dispute the findings from an earlier review (Selby & Smith-Osborne, 2013), concluding that insufficient research evidence exists to make a definitive determination of effectiveness, but call for intensive study of the issues given the clear potential demonstrated in a number of the studies included in both systematic reviews.
Description of the Equine Intervention
The ET program was offered to all (N = 40) Veteran nursing students enrolled from 2014 through 2017. Veteran nursing students were invited to attend ET sessions via their online learning management system. Students were informed that these sessions were voluntary and for the purpose of stress reduction. The ET sessions were held on Saturdays and Sundays, with four sessions offered each semester. Each session was approximately 3 to 4 hours, with Veteran nursing students having the option to remain after the group session to work individually with the trauma specialist if necessary. Invitations were extended to family members of Veteran nursing students. Thirty-six of 40 Veteran nursing students attended at least one ET session; of these 36 students, 100% attended two or more sessions.
A variety of therapeutic interventions were implemented as part of the equine program. Initial interactions with horses involved learning the language of the horse and trusting the power of the relationship. Veteran nursing students and horses engaged in a “trust walk” that developed Veteran nursing students' ability to stay present, self-aware, and attuned to the horse. Veteran nursing students were then invited to participate in activities that included exercises designed to decrease tension, anxiety, and stress. These exercises included guided visualization and meditation.
Narrative writing about emotional experiences was another activity. Veteran nursing students were asked to describe a situation, in writing, that was emotionally difficult. Horses remained in close contact with Veteran nursing students as they read their story, allowing inner feelings to be expressed and vocalized. Horses' behaviors were observed as they responded to the verbalizations of Veteran nursing students.
An activity of meditation was used by sitting the Veteran nursing students atop a horse and allowing them to experience movement and transitions of gait. At times, when appropriate, Veteran nursing students were instructed to close their eyes as they were led around by experienced horse handlers. This slow rhythm was used to promote relaxation and healing. Upon completion of the riding intervention, Veteran nursing students were directed to create a symbol that represented the day's experience (i.e., a personal totem). Groups of Veteran nursing students worked with several horses, which became their canvases, as they painted with water color paint, using their hands or brushes. Veteran nursing students, along with their partners, children, and friends, worked together to create an artistic expression of the experience.
In subsequent sessions, a demonstration of the horses' innate natural boundary ability and their keen awareness of personal space was presented. Leadership exercises were practiced with the horses (e.g., “Who's leading whom?”). Veteran nursing students were asked to reflect on the experience that was designed to address the feeling of safety between self and others. Students were then asked to apply this experience to their interpersonal relationships and nursing practice.
Veteran nursing students were taught the art of creating a rhythm and pace with the horses through groundwork, rein-leading, and transition work between walk, trot, and canter. This exercise was designed to assist in the self-regulation of feelings and identification of which movements triggered emotions.
Assessment of the Equine Intervention
Information about the Veteran nursing student experience with ET was gathered through three independent but parallel pathways. It was understood that the feedback requested from the Veteran nursing students who voluntarily participated in this ET intervention could not be considered a definitive assessment of therapeutic value to individuals or the group of participants. Each participant brought a personal worldview to the equine intervention, including the unique context of his/her individual military and academic experiences and personal state of physical and psychosocial well-being. Nevertheless, it was believed this feedback would reflect the perceptions of value of the equine intervention and provide information to the program to justify its inclusion in the SON's VBSN program in future years.
ET participants provided feedback to three inquiries (i.e., pathways), voluntarily and anonymously. The first feedback pathway involved a standardized student survey. Enrolled Veteran nursing students are surveyed twice annually about their perceptions of the value of the SON's various support strategies that are intended to promote their academic success. Students were asked to rate the degree to which participation in ET may have contributed to sustaining their enrollment in the program of nursing studies. A total of 20 students had participated in the intervention as of the date of the survey. All 14 students who responded to this inquiry indicated that the intervention was very or somewhat helpful for the purpose.
The second feedback pathway involved a special Institutional Review Board-exempt, nine-item, open-ended (qualitative) questionnaire that was distributed to Veteran nursing students. Eleven students offered comments in response to this survey. All students indicated that equine-assisted therapy served as a stress reducer and improved their ability to communicate and establish healthier relationships. Some example responses were:
- “…Just being by those animals made me feel calmer and more relaxed.”
- “I feel that I'm [a] calmer and happier person on the inside and it has show[ed] outwardly through my behavior. I'm noticeably more relaxed.”
- “I am much more respectful and cautious of others' personal space…. This experience has helped me to become more sensitive and listen in other ways than just…verbal communication.”
This questionnaire was augmented by a four-question quantitative survey, to which 21 of 22 students responded to all questions. Participants were asked to rate their level of student stress before participation in the ET program on a scale of 1 (not at all) to 5 (very much). One half of respondents self-reported the highest level of stress, and an additional 36.8% noted the next lower level. Respondents were also asked whether the invitation to participate in the ET program caused their stress level to increase or decrease. Four (19%) of 21 respondents reported that their level of stress had increased upon receipt of the invitation. Participants were further asked whether their stress level had increased or decreased after participation in ET, of which 18 (85.7%) of 21 respondents reported that it had decreased.
A final survey question asked respondents to indicate whether participation in ET should be required of all Veteran nursing students. Four (18.2%) of 22 respondents expressed the opinion that it should not be required; nine (40.9%) indicated that it should be required for those who self-report a degree of stress, and an equal number (n = 9, 40.9%) responded that it should be required for all students regardless of report of stress.
A third avenue of feedback was an open invitation to all Veteran nursing students to participate in a national webinar about the ET program, and to offer “one thought that you had about the ET.” Illustrative responses that informed the potential for retention of this intervention within the VBSN program included:
- “Equine therapy was an amazing opportunity that gave us a chance to relax and step back from the stress of nursing school. It provided an excellent therapeutic environment and was perfect for our Veterans program.”
- “The equine therapy has opened up a new level of awareness with myself and people I come in contact with…. I learn something new about how my thoughts and expectations are linked to the outcome of a situation.”
- “Being…with the horses brought a wonderful calming effect that was needed from this intense year of academics and adjustment.”
- “I'm able to stand taller with confidence despite the overwhelming stress generated from the fast-paced academic rigors of nursing school.”
Kendall et al. (2014) offered three hypotheses to explain the psychological benefits of therapeutic riding. The first is that these benefits are unrelated to the horse and would occur in any similar program that was conducted outside of the usual setting (in this case, the Veteran nursing students' academic and clinical learning sites). This hypothesis proposes that the social and recreational value of the experience explains the calming and restorative benefits reported by the Veteran nursing students.
The second hypothesis is that the horse itself serves as a medium for the therapeutic process, offering a positive context through which psychological gains can be channeled. Many of the affirming comments offered as feedback to the program by those who participated in the ET intervention related to their perceptions that human/equine communication transpired and that it generated insight into personal patterns of human/human interaction.
The third hypothesis is that the horse itself has specific therapeutic qualities that bring about unique psychological changes not otherwise likely to occur. In this sense, the horse serves as a catalyst for therapeutic change, including trust, control, mastery, emotional expression, and sensory integration. Feedback received about the SON's ET program supported this theory, indicating that participants identified the relationship between the ET experience and how the new learning could be transferred to their personal and academic lives.
Summary and Conclusion
The SON made a substantial voluntary investment of faculty, staff, and program resources into implementation of the ET program for its Veteran nursing students. Interactions with individual students' academic or health-related experiences are unable to be assessed, and the longer-term impact on students' psychological well-being is unable to be studied, as graduate follow up is conducted for only 3 years following completion of the program. However, based on the understandings that could be gleaned from all sources of feedback, the ET program was affirmed to be a value-added intervention, contributing to the well-being of these students, even if only short-lived in its effect. Other SONs whose circumstances enable them to include consideration of ET as one modality that could be offered as a student-support strategy for management of personal and academic-related stress are encouraged to do so.
Patricia Voelpel, EdD, RN, ANP, CCRN
Clinical Associate Professor and Director of
Undergraduate Special Programs
Stony Brook University School of Nursing
Stony Brook, New York
Lori Escallier, PhD, RN, CPNP-PC, FAAN
Dean and Professor
State University of New York, Downstate
Medical Center, College of Nursing
Brooklyn, New York
Judith Fullerton, PhD, CNM
University of California San Diego, School of
San Diego, California
Louise Abitbol, MSW
Riverhead, New York
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