Guidelines for animal-assisted activities & therapy tips

Starting a visitation program or a therapy program including a model protocol and discussion of liability issues.

Guidelines:

Supporting & Sample Documents:

Introduction

Animal-assisted activities (AAA, i.e. visitation with animals) and therapy (AAT) can be applied in a variety of settings. Programs in nursing homes and retirement centers are perhaps the best known, However, AAA/AAT can also be very successful in mental health facilities, adolescent rehabilitation centers and other populations with special needs such as hospice programs. Programs have also been successful in main-stream and special schools.

Although dogs and cats are the most commonly used animals, rabbits, horses, dolphins and a wide variety of other animals have also been used. Programs have used adult animals, puppies and kittens, owned animals and ones from shelters.

The purpose of the information that follows is to illustrate how one program, HABIT (Human- Animal Bond in Tennessee), has organized AAA and AAT in over 40 sites in East Tennessee. There are many other successful programs in the United States and around the world and other contacts and resources are cited in our information. We learned much from others and now want to share our experiences, positive and negative, with the hope of helping others. We hope that this information will be useful for others who wish to provide these valuable services to their community.

As you consider the following information, keep in mind that our program is relatively large. We have over 200 volunteers who make approximately 800 visits each week. However, the following information can provide guidance and ideas for individuals as well as organizations interested in being involved in AAA/AAT. Specifically, the information is aimed at the person who would like to share their pet through AAA/AAT and who does not have a formal organization in their area. In addition, the information contains comments that we hope will be helpful for administrators who are considering having such a program.

Our information will be divided into four sections:

  1. Facility Assessment and Program Development
  2. Volunteer Expectations and Preparation
  3. Medical and Behavioral Screening of Animals
  4. Regulations and Liability

The First Step

Before we get to the specifics of developing a program, a word about finding or establishing a support group. Some communities already have active groups that offer AAA/AAT programs. Finding them can be as simple as calling a local humane society, veterinarian's office or the type of facility in which you would like to volunteer. Check out the established group before starting on your own. Even if there is not an established group, the contacts above may know of others who have expressed the same interests and may already be volunteering as individuals. At the very least, try to find one other person to work with. There are many advantages to this approach. First of all, you can encourage each other by sharing successes and experiences that are disappointing. Not all days will be great and a sympathetic ear can be wonderful. Secondly, once a program is in place, the people you are visiting will expect routine visits and can be greatly disappointed if you miss a day. At least two volunteers will reduce the risk of missed visits due to illness (human or animal), vacations, etc.

Facility Assessment & Program Development

It is important to give thought to the facility and it's staff. Both volunteers and staff should have a reasonably well developed vision of what they want to accomplish by AAA/AAT. As importantly, the vision of staff and volunteers should match. This can best be accomplished by meeting together early in the process to discuss expectations. Using a nursing home as an example, such a meeting should include representatives from the administration, recreation therapy, nursing (including infection control), and housekeeping. All of these units will be impacted by AAA/AAT and should be included early in the deliberations on how to implement the program.

Before or during the meeting, a simple survey form can be used to assess level of staff support. Click here for SAMPLE STAFF SURVEY FORM. As Betty White states in her book Pet Love: How Pets Take Care of Us "In any pet-therapy effort, a major contributing factor to its success or failure is the attitude of the staff." (Betty White with Thomas J. Watson, William Morrow and Company, 1983). The survey can be given anonymously or the questions discussed openly at the meeting. Concerns about the proposed program can then be address.

It can also be helpful during the Facility Assessment phase to survey residents (again using the nursing home as an example). Click here for SAMPLE RESIDENT SURVEY FORM. Their opinions should be sought on whether they want animals in the facility and, if so, what species. Even if some residents do not want the animals, a program can still be developed. However, the right of those who do not want to interact with animals must be respected and the program designed to respect that right.

One critical element of a staff or resident survey must be questions about allergies and/or aversions to animals. Again, programs can be implemented in facilities where staff and/or residents are allergic to or afraid of certain species of animals. Once such individuals are identified, the program must be designed to prevent contact between the animals and these people. For example, visits can be scheduled during off- shifts of the allergic staff member or in a part of the building away from the allergic resident.

Aspects of the physical setting should also be considered. For example, will visits take place on the ground floor or several stories high. If not on the ground floor, is there an elevator? If there is an elevator, how does the animal respond to such a ride? Let's assume that the plan is to have a dog visit on the second floor of a facility that has no elevator (i.e., the dog must go up stairs). Does the dog have any medical problems that might be complicated by such obstacles (e.g., hip dysplasia)? This brings up what should be one of the major guiding principles of a credible program - the program should be designed to be enjoyable for all, including the animals. No program can be considered successful if the animals suffer.

Once a thorough discussion has been held regarding expectations, the feelings of staff and residents have been assessed, and the physical setting assessed, volunteer preparation can begin.

Procedures for Becoming a HABIT Volunteer

  1. Submit a completed application form with membership dues.
  2. Attend a general information meeting.
  3. Have animal(s) medically and behaviorally screened. The Medical Evaluation Form must be filled out by the pet's veterinarian and the Behavioral Profile and History Form must be filled out by the owner. Both are then sent to the HABIT office and the owner is contacted to set up an appointment for the behavioral evaluation.
  4. After the Behavioral Evaluation is completed, you will be contacted by the volunteer coordinator.
  5. Observe an experienced volunteer during a scheduled visit. Arrangements will be made by HABIT.
  6. Visit a designated facility for an orientation tour and discussion with facility contact person. (Five and six may be done at the same time.)
  7. Be observed with your animal by an experienced volunteer.

Please realize that you and your animal will be accepted as HABIT volunteers only after all steps are taken and positively evaluated. We also appreciate your patience in realizing that HABIT is administered by volunteers and we will evaluate your animals and work with you on placement as soon as possible.

Liability coverage will be provided by the University of Tennessee.

What is Expected of HABIT Volunteers

  1. Maintain a positive attitude. We are there to promote therapeutic change, not just to entertain.
  2. Dress appropriately as defined by the facility and be on time.
  3. Be willing to listen, cooperate, and communicate with residents, facility contact person, head volunteer and program maintenance committee representative.
  4. Sign in and record number of residents visited each week.
  5. Be responsible for your animal:
    1. Keep animal clean, well-groomed, free of external parasites.
    2. Make sure animal is wearing a clean HABIT scarf.
    3. Have control of animal at all times. Dogs should be on a short lead.
    4. Keep an eye on animal while conversing.
    5. Recognize stress in animal and remove immediately. Be the animals' advocate.
    6. Be aware of items on floor.
    7. Let animals interact outside.
    8. Do not visit if your animal is ill or behaving inappropriately.
  6. Take your commitment seriously. Notify the facility contact person and either the HABIT head volunteer or Program Maintenance Committee member as soon as possible if you cannot make a scheduled visit.
  7. Respect the rights of residents and staff.
  8. Attend annual HABIT meeting.
  9. If approached about publicity, please contact the HABIT office first (974-5633).

Medical and Behavioral Screen of Animals

Although many species of animals are used in AAA/AAT, HABIT only uses adult dogs, cats and rabbits. Consequently, medical and behavioral screening comments will be limited to those species. In addition, HABIT only utilizes owned animals. However, many of the following comments will also apply to animals from shelters. The primary obstacle to adequate medical and behavioral evaluation of shelter animals is the usual lack of any medical history and an opportunity to observe the animal's behavior outside of a shelter setting.

Veterinary medical involvement is critical to the success of any program. For individual volunteers, you need to discuss the "job" you have in mind for your pet with your veterinarian. He or she will need to assess the health and suitability of your animal for the tasks it will be asked to perform.

HABIT has developed forms to record and document the four phases of our evaluation process. Others are free to utilize these forms if they remove the HABIT name. The four phases of evaluation are:

  1. Medical evaluation by the pet's veterinarian
  2. Behavioral profile and history provided by the owner
  3. Behavioral evaluation by an independent, qualified person
  4. On-site monitoring

The medical evaluation is completed by the pet's veterinarian. It includes places to record dates of vaccinations, diagnoses of diseases and conditions, and internal and external parasites. If also includes a place to record medical conditions that could influence placement (i.e., problems that might be complicated by certain types of visits). There is a limited list of zoonotic diseases on the HABIT Medical Evaluation Form. This list may need to be modified if the form is used in another region of the country.

The only vaccination required by HABIT is rabies, which is required by state law. Animals must be currently vaccinated for rabies. Although the other vaccinations are not required, most are an indication of a responsible owner. It is a tragedy for AAA/AAT programs as well as for the owner to lose an animal to a disease that could have been prevented through vaccination. External parasites (e.g., fleas and ticks) cannot be allowed in facilities and the veterinarian has new products for owners to use against these pests.

Medical evaluation should be done annually. HABIT provides its volunteers with a blank Medical Evaluation Form during the month prior to the month when rabies vaccination was given. In many areas, annual rabies vaccination is required and the volunteer can take the form in at the time of their annual visit for vaccination of their dogs and cats. In addition, many health regulatory authorities require that documentation of annual veterinary medical evaluation be on file in the facilities where AAA/AAT occurs.

The owner is asked to provide information on the animal by completing the Behavioral Profile and History form. This is where the owner can tell us about their pet. A critical question on this form is whether the animal has ever bitten anyone. If the answer is yes, the circumstances must be explored thoroughly. In some instances, the animal will be considered inappropriate for AAA/AAT because of liability concerns.

Once the Medical Evaluation and Behavioral Profile and History forms are received, the owner is contacted by a HABIT volunteer who is qualified to conduct a behavioral evaluation. This is usually a staff member of the University of Tennessee College of Veterinary Medicine. There is no charge for this evaluation.

The Behavioral Evaluation is done by an independent, qualified person - a person very familiar with the normal behavior of the species (i.e., dogs, cats, rabbits) and the types of tasks the animal will be performing. Our evaluation is based on one developed by Terry Ryan and Dr. Leo Bustad as published in Animals, Aging, and the Aged, University of Minnesota Press, 1980. The procedure was adopted for our use with permission of the authors.

The American Kennel Club has developed a similar evaluation procedure called The Canine Good Citizen Test. This evaluation is often conducted periodically by local kennel clubs and differs primarily from our test in that it is conducted with groups of people and their pets. Obviously, it is also restricted to dogs only. The Delta Society also has an evaluation process called Pet Partners. Pet Partners training is offered sporadically in various regions of the country.

As an example of how we evaluate animals, lets look at a typical evaluation of a dog. Comments on how cat evaluations differ follow.

Initial Observations

The evaluation actually begins when the evaluator approaches the owner and their dog. The evaluator is observing how the dog reacts to strangers. Does it step forward to greet the stranger? Does it move behind the owner and peak out at the stranger? We are not trying to identify dogs with specific personalities, but describe the personality of the dog. The dog's personality is important in finding the best placement; making the best match between the dog and the facility.

Approach to the Dog

After the initial introductions, the evaluator will approach the dog, if it has not approached the evaluator. Often this is done with an outstretched hand (which could be perceived as a threat or greeting, depending on the dog), with the palm of the hand toward the evaluator (a less threatening position than if the dog was approached with the palm of the hand toward the dog which could be perceived as an attempt to grab the dog). The evaluator will look directly at the dog (which may be perceived as a sign of dominance by some dogs) and not speak (a somewhat unusual response since most dogs will expect strangers to greet them verbally).

Manners and Manageability

These evaluations are first done with the owner. Afterwards, the evaluator takes the dog out of the presence of the owner and repeats this set of tests and the ones following. Dogs must walk calmly on a leash. They do not have to be formally trained even though such dogs often do better in the program. Several dominance gestures (e.g., pressure on the top of the head, holding the muzzle or head, staring) are used to test the dog's response to dominance signals. A strongly dominant dog may not be appropriate for AAA/AAT since the gestures that residents and clients use (e.g., petting) may be perceived by the dog as a challenge. Similarly, the strongly submissive dog may perceived the same gestures as threats and become fearful and even aggressive because of their fear.

Interacting with the Dog

This is play time and should be enjoyed by the dog and the evaluator. During this time, the evaluator may throw a ball. If the dog retrieves it, fine. If the dog does not retrieve it, fine. Again, we are simply trying to describe the dog's personality. Other games may be played during this time during which the dog will be touched all over its body. Any sensitive areas are noted. Also during this session, the evaluator will see if the dog will allow itself to be placed on its back. This is an indirect measure of submissiveness. The dog is not forced on its back if it resists.

Stability

Toward the end of the play session, and when the dog does not expect it, a loud noise will be created. It is important to see how the dog responds because loud, unexpected noises may occur in the facilities where the dog is visiting. Similarly, at some point a toe or ear is pinched (the toe is not used it the dog has already exhibited sensitivity in this area). This is not a severe pinch but is designed to see how the dog will respond if accidently stepped on. Although it is the owner's responsibility to protect their pet during visits, accidents can happen.

Temperament Profile

The evaluator completes the temperament profile. Again, we are not looking for a specific profile but are describing the dog's temperament as an aid to placement.

After the evaluation, the evaluator summarizes their findings including any problem areas that need to be discussed with the owner. One frequently encountered problem is pulling on the leash. Depending on the severity of the problem, obedience training may be recommended followed by reevaluation. Another frequent problem is the dog and that is unsure of itself and nervous because of all of the new stimuli it encountered during the evaluation. Such dogs may become fearful and aggressive, and at the very least will not enjoy the visits. Suggestions on socialization may be given with reevaluation several months later. It has been our experience that these tests can identify the dominantly aggressive or potentially submissively aggressive dog, neither of which are appropriate for AAA/AAT.

Although most behavioral evaluations are done at the UTCVM, they are not done in the clinic area. Dogs and cats sense the clinical setting and may become nervous. Dogs are walked in the hallways away from the clinic where they encounter the same physical setting they are likely to encounter in a facility (e.g., tile and carpeted floors, elevators, stairs, etc.). They are also likely to encounter other strangers which gives the evaluator a chance to observe their response. Finally, the dog and evaluator enter a room, usually a lounge or conference room, with little semblance to the clinic. This is where the Manners and Manageability, Interacting and Stability tests are done.

The Behavioral Evaluation of cats is similar to dogs but may take longer to administer. Typically, the dog evaluation can be done in about 30 minutes. Cat evaluations may take closer to 45 minutes because after the cat is taken from the owner and released in the evaluation room, most cats will insist on exploring the room before they are ready to pay attention to the evaluator.

During visits, cats enter the facilities in carriers or in the arms of the owner. They are not released unless they are in a closed room (e.g., a individual visit in a client's room) and such a procedure is approved by the facility and the HABIT head volunteer. The same criteria are applied to rabbits.

The HABIT program utilizes only adult animals. "Adult" is defined as a dog or cat that is at least nine months of age and we prefer them to be one year of age. Although puppies and kittens are very endearing and most people enjoy seeing them, there are three reasons why we restrict our animal volunteers to adults only. First, puppies and kittens usually have very brief medical histories, it any at all. They may be incubating diseases that could be transmissible to people or diseases that could become a risk to their lives because of the stress of visits. Further, rabies vaccination is not required by some states until the animal is at least three months of age. For legal reasons alone, dogs and cats that have not been vaccinated for rabies should not be used in AAA/AAT. Second, it is difficult to adequately evaluate the personality of a puppy or kitten. Their personalities are still forming and their response to perceived challenges and threats cannot be adequately evaluated. Third, young puppies and kittens do not have the body resources for the stress of some visits. Even a car ride to the site may exhaust some. Disease and behavioral problems can result from such stress that can jeopardize the health, and even life, of these little ones, which is against one of the basic tenets of the HABIT program - the animal must not be harmed and hopefully enjoys the visits as much as the owner.

Some of these same concerns should be considered when using animals from shelters. Rarely is there any medical history on these animals and vaccination, even if done at the shelter, will not necessarily be effective by the time visits occur, especially if the animal has had no previous vaccinations. Also, animals in shelters are already under stress, no matter how good the shelter is, because of the strange surroundings, new food, etc. This can increase the possibility of the animal shedding organisms that could be transmissible to humans. Further, because of the stress of the shelter environment, it can be difficult to adequately assess the personality of the animal. Some may be more aggressive or more submissive, frightened or nervous in the shelter setting.

After the animal has passed the behavioral evaluation and the Medical Evaluation Form and Behavioral Profile and History Form has been reviewed for any potential problems, the animal is approved for an initial visit. Prior to the initial visit by the animal, the owner has already visited the facility for their orientation. On the initial visit of the animal, the owner is accompanied by an experienced HABIT volunteer who gives tips on how to maximize the positive interactions. This initial visit is intentionally short, perhaps only 10-15 minutes. We want the animal to leave while it is still having fun. If the first visit goes well, subsequent visits will be lengthened slowly to a maximum of 45-60 minutes. Most animals will not maintain their attention, even if they are enjoying the visits, beyond this length of time.

Assessment of the new volunteer and their pet in the facility (on-site monitoring) is the final step. Many volunteers feel comfortable being on their own after this first supervised visit with their pet. However, others may be coached longer. Experienced volunteers are available to assist new volunteers even after this final step and the volunteer has a specific facility staff contact to go to if they have questions or problems.

Signs of Stress

Stress is the response of an animal to its environment. It is not necessarily bad since it is what makes an animal alert to what is happening around. However, it is certainly possible for stress to be excessive and result in physical problems. Signs of excessive stress can show up during, before and after visits. It is the owner's responsibility to recognize these signs and take action. Sometimes that means consulting with their veterinarian. Sometimes these signs mean the pet needs a break. With some animals, it means that they are not cut out to do this work and must be retired. What are the most common signs of stress?

During a visit, the excessively stressed animal may be reluctant to enter the facility, the room where visits occur, or even the car. If the only time the pet enters the car is to participate in AAA/AAT, then reluctance to enter the car should be taken very seriously. Other signs include reduced attention span (the animal may initially approach people but quickly looses interest), laying down and/or reluctance to move. Some dogs will actually pull the owner away from interaction, become uncooperative and ignore commands. Dilated pupils and/or excessive panting are other possible signs of stress. Excessive panting must be interpreted within the physical context. For example, many nursing homes are kept at warmer temperatures than some dogs, especially long or thick coated animals, are comfortable in. Water breaks can alleviate this particular sign if it is due solely to the heat.

Other signs of stress can show up before or after visits. Diarrhea or loose stools, urination in inappropriate places, vomiting, lack of appetite, and changes in sleep or activity patterns (e.g., after the visit, the dog sleeps the rest of the day when it is normally more active). Behavior and/or temperament changes may also be signs of stress. If the normally gregarious dog becomes reluctant to interact or the usually friendly dog become grumpy, stress associated with the visits may be playing a role. Most of these signs deserve at least a call to your veterinarian and perhaps a visit. Aggravation of a medical problem definitely calls for consultation with your veterinarian about the appropriateness of continuing AAA/AAT. Discomfort because of hip dysplasia or worsening of a skin problem are two possible examples.

Although not necessarily a stress related problem, lets talk about food treats during visits. HABIT volunteers are strongly discouraged from allowing their animals to take any food during visits. Some residents, especially of nursing homes, enjoy saving "treats" from their meals to give to the animals that visit. However, there are at least three risks associated with such practices. First, the treats are unlikely to be nutritious and can contribute to existing weight problems. Second, once the pet associates treats with the visits, that becomes their primary motivation. They enter rooms and begin to search for the treats or go directly to the place where they have learned the treats are stored. With their attention on the treats, they pay less attention to the people they are supposed to be visiting. Hurt feelings can sometimes occur. Third, and most seriously, the animal that enters a facility looking for something to eat is more likely to pick up things on the floor and swallow them. Several powerful medications are routinely used in most facilities and occasionally, pills and capsules are dropped on the floor. The human doses of these drugs represent substantial overdoses for pets and some can be very serious if ingested by a pet. Very few have antidotes. Consequently, dogs in particular should be trained not to take any food item except on the owner's command and food treats should not be utilized during visits.

If an animal becomes ill before a visit, the visit should be cancelled. The sick animal should certainly not be expected to "work" and, depending on the illness, the animal could be passing an organism that is transmissible to humans. If an animal becomes ill, the owner should ask their veterinarian's advice before letting it return to work.

In summary, the owner must remember that he/she is the animal's advocate. They have the right and responsibility to remove their pet from any situation where they feel the animal is in danger or even uncomfortable. The needs of the animal must always be kept in mind and no program can be considered successful if the animal's needs are not met.

Regulations and Liability

All long-term care facilities will be cover by various regulations, most of which will be enforced by the state health department. When HABIT was first formed in 1986, the following health department regulation existed.

"Cats, dogs, or other pets shall not be allowed in any nursing home."

Because of this restriction, early HABIT organizers worked with the Board for Licensing Health Care Facilities in order to get a waiver of this regulation. The first waiver was granted after HABIT organizers appeared before this board to explain what they wanted to do and how the safety and health of the residents and staff would be protected. The first waiver was granted for a limited period of time and for only one facility. At the end of the waiver period, HABIT provided a report to the board which resulted extension of an indefinite waiver. More requests for waivers followed from HABIT and others. Because HABIT proved itself as a credible program, we were no longer required to appear before the board and the granting of waivers became routine. Ultimately, the state health department regulations were changed to read:

"Pets shall not be allowed in a nursing home, unless the facility has a written protocol approved by the department"
Rules of the TN Department of Health and Environment,1200-9-6-.02 (19)

HABIT provides a Model Protocol for those facilities in Tennessee that fall under this regulation. This model is not applicable outside of Tennessee. Outside of Tennessee, facility staff should contact their local health department for guidance on the procedure in their state.

Liability is often an issue that concerns both volunteers and facility staff. Before we discussion the options available, it must be understood that liability coverage, no matter what the source, does not cover incompetence or recklessness. Proper preparation of volunteers and animals and monitoring of their actions must be foremost in the minds of those who want to participate in AAA/AAT. Assume that an incident occurs that results in the testing of liability coverage. Also assume that the liability coverage is adequate. Although apparently successful, the consequences very likely will be a loss of confidence in the benefits of AAA/AAT. Consequently, all those who participate in AAA/AAT have an obligation to and partnership with all other participants.

The HABIT program, as a part of the University of Tennessee College of Veterinary Medicine, has the luxury of extending liability coverage from the University to volunteers who have completed all of the preparatory and screening steps. Consequently, individuals interested in volunteering might try to align themselves with a public or private institution. Such institutions will likely have some mechanism for coverage of volunteers. However, the potential volunteer will have to convince authorities that they are responsible and trustworthy.

Alternatively, most facilities where AAA/AAT visits occur also have a mechanism to provide liability coverage to volunteers. Such facilities will usually have other volunteers already and AAA/AAT volunteers might be added easily if a credible program is designed.

The Delta Society, through their Pet Partners program, offers liability coverage at a reasonable cost.

Finally, groups of volunteers might seek their own group liability/insurance coverage. Individuals could explore a personal insurance rider on their home owners policy. However, these options are likely to be expensive.

Requisites of a Credible Program

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