The number of companion animals in Canadian households has increased over the past decade with approximately 41% of households containing a dog and 37% a cat [1
]. While the cat population has stabilized over the past several years in Canada, the dog population has increased [1
]. Emerging research has indicated that interacting with companion animals can have a positive effect on humans, including improved psychological, emotional, and physical health [2
]. A recent review of the literature by Hodgson et al. identified four key benefits of pet ownership to human health: “as builders of social capital, as agents of harm reduction, as motivators for healthy behavior change, and as potential participants in treatment plans” [2
] (p. 526). They refer to the benefits to human health from interacting with animals, focusing on companion animals, as zooeyia [6
Therapy dogs have been gaining acceptance as a complementary health intervention over the past decade in a variety of health care settings. Therapy dogs are companion animals who volunteer alongside their human handlers to offer other people a brief (approximately 10 min) visit in a setting where individuals do not typically have access to a pet [7
]. This is referred to as “being visited” by a therapy dog in this paper and is commonly referenced in the literature as an animal assisted activity [7
]. There are no professional therapeutic goals identified for these visits, but the interaction may be considered therapeutic [5
]. Handlers and their therapy dogs who volunteer in infirmary-related animal assisted activities commonly visit nursing facilities, palliative care wards, psychiatric units, surgical wards, and rehabilitation centres [8
]. Research evidence is indicating that being visited by a therapy dog can have a positive effect on reducing patient stress, pain, anxiety, and anger [5
]. Research is likewise demonstrating that therapy dog visits can provide participants with a sense of comfort and support [16
]. Emergency department (ED) patients commonly experience distress in a hospital ED, experienced as “a mix of anxiety and depressive symptoms” [21
]. A recent US study found that being visited by a therapy dog was accepted by staff and patients in an ED environment [22
Despite the documented benefits of animal assisted activities in hospital and other settings, researchers have criticized the emerging field for its lack of methodological rigor. Studies have also disproportionately focused on aging populations and have paid limited attention to the impact of gender. Researchers have suggested the need for increased research on therapy dog visiting programs generally, including in the novel area of hospital ED visits [14
Building from Dell et al.’s Canadian study of the experiences of patients visited by a therapy dog in the Royal University Hospital (RUH) ED, the current study aims to provide empirical evidence of patient opinion on desire to be visited by a therapy dog in the ED and why or why not [14
]. Further, this study aims to better understand the characteristics of patients who are supportive and nonsupportive of therapy dog visits, including age, gender, and dog ownership experience. A patient-oriented research approach that prioritizes patient, as well as health care worker, views throughout the research process was applied in this public health study. There is a growing call to recognize the patient experience as an important contributor to quality healthcare in both practice and research [29
3.1. Opinion of Therapy Dogs Visiting in the ED
A large majority (80%) of the study participants indicated they would want a therapy dog visit in the ED if it was available. Many study participants agreed or strongly agreed that patients may want to visit a therapy dog in the ED to reduce anxiety (92%), reduce frustration (87%), increase comfort (90%), and increase satisfaction (90%). Mean values for the reasons one may want to visit a therapy dog ranged from 4.1 to 4.3 (where a 4 rating was “agree” and a 5 rating was “strongly agree”). Over half of participants (59%) agreed or strongly agreed that other patients may want a visit by an ED therapy dog to reduce their pain (M = 3.7). Additional responses participants offered for possibly wanting a visit by a therapy dog in the ED included: as a distraction (e.g., cute, relieve boredom) (6%); to offer companionship and affection (4%), and to bring happiness (3%).
Participants were asked in the questionnaire the degree to which they agreed a patient may not want to have a visit by a therapy dog in the ED because of fear or allergies, and a strong majority agreed—85% allergies, 82% fear. Mean values were 4.0 and 3.9, respectively. Forty percent of the participants agreed or strongly agreed that patients may not want to visit a therapy dog because of cultural background or tradition (M = 3.2). Relatively fewer participants (15%) agreed or strongly agreed that patients may not want to visit due to the potential for zoonotic (animal to human) disease transmission (M = 2.2). Additional responses given for patients potentially not wanting a therapy dog visit included: the sanitary environment of a hospital and dogs being unsanitary (e.g., shedding) (4%); potential harm to the dog (2%); and dislike or no experience with dogs/like cats (3%).
3.1.1. Opinion Variation by Gender
On average, women were statistically significantly higher in agreement than their male counterparts that patients may not want a visit by a therapy dog in the ED due to cultural background or tradition (Mean difference 0.53, t
(1.98) = 2.87, p = 0.005, and Effect size Cohen’s d = 0.57) (Table 1
3.1.2. Opinion Variation by Age
A higher proportion of the “50 and over” age group (63%) was in agreement that patients may not want to visit a therapy dog in the ED due to cultural background or tradition compared to their counterparts (28% of “35 or lower” and 30% of “36 to 49” age groups) (Table 2
). This finding was statistically significant (Proportion difference of 35%, z = 2.81, p = 0.005, Effect size Cohen’s h = 0.72 and Proportion difference of 33%, z = 2.67, p = 0.008, Effect size Cohen’s h = 0.67).
3.2. Opinion Variation by Dog Ownership
The data shows that 38% of participants currently have a dog as a pet and 66% also stated that they have a lot of experience with dogs. A significantly higher proportion of the study participants that currently have a dog as a pet (95%), compared to those that do not (71%), indicated they would have a therapy dog visit them in the ED if it was offered (z = 2.92, p = 0.0035, Effect size Cohen’s h = 0.69). In addition, a significantly higher proportion (90%) of those who self identified as having lots of experience with dogs indicated they would want to have a therapy dog visit in the ED compared to those with some or no dog experience (62%) (z = 2.92, p = 0.0035, Effect size Cohen’s h = 0.69).
The majority of participants were of the opinion that patients may want a visit by a therapy dog in the ED to reduce anxiety and frustration and to lessen pain, as well as increase comfort and satisfaction with their ED experience. A 2019 study in the RUH ED concluded that participation in a therapy dog intervention improved patients’ comfort, decreased unpleasant and distressing emotions, and provided a helpful distraction from the ED setting [14
]. This is synchronous with the general ED patient experience literature which indicates that patients commonly experience the ED as a stressful environment. This is due to such ED experiences as overcrowding, delayed pain management, long wait times, and troublesome emotions (e.g., anxiety) with an unknown diagnosis [31
]. Researchers have found that a supportive and caring hospital environment can reduce patient stress and anxiety [40
]. Therapy dog research has indicated that being visited by a therapy dog in a stressful environment, such as a hospital, can support positive emotions (e.g., joy, love, calmness) among participants [43
]. Our current study’s finding is an important addition to the ED literature which seldom forefronts patient opinion in the offering of care [30
Participant opinions in this study supported concerns found elsewhere in the literature for why a patient may not want a visit by a therapy dog in the ED, including allergies, fear, cultural background or traditional reasons, and potential for disease transmission [5
]. Most reasons for why patients may not want a visit by a therapy dog were not remarkably different by gender or age group. The notable differences with medium size effects were that women and older individuals tended to identify cultural background or tradition as a possible reason patients may not want a visit by a therapy dog compared to their counterparts. This supports consideration of the influence of gender and age in future studies and ED therapy dog program considerations. The only other two studies known to the authors that examined the acceptance of therapy dogs in an ED environment concluded that they were accepted but did not examine this by reason or account for the influence of gender and age as the current study did [28
Reasons for the difference in opinion by gender and age on cultural background and tradition as a reason not to be visited by a therapy dog are unknown and require further study. This may include, for example, exploring potential differences in cultural tolerance and awareness by gender and age [48
]. While a study does not exist, we do know from the case study of the patient wait experience in the RUH ED with therapy dogs that females reported a greater benefit than males after a therapy dog visit [14
]. Further, we know that the majority of therapy dog studies have focused on the experiences of visits with seniors and school-aged children [50
] but have not considered the influence of gender and age.
Related to this, the importance of accounting for age and gender is identified in the pet ownership literature. This is highlighted, for example, in the work of Saunders et al. (2017); they suggest that “pet owners and nonpet owners differ across many traits, including gender, age, race/ethnicity, living arrangements, and income… (and these factors) are related to a range of mental and physical health outcomes” [52
] (p. 1). The influence of gender and age should be considered in the unfolding therapy dog research field, including as considerations in the implementation of therapy dog programs in an ED setting. Exploration of the pet ownership literature may provide guidance.
Data collected about the participants’ ownership of a pet indicated that a greater number of individuals currently did not own a pet dog compared to those that did, and a greater number of individuals indicated they had a lot of dog experience compared to those that indicated they did not. Reflecting on their own opinion about being visited by a therapy dog in the ED as a patient, the majority of participants indicated they would want a visit. Individuals who currently had a pet dog or have experience with dogs were more likely to want to be visited by a therapy dog in the ED than those who did not. While research into this area is lacking, reasons for this difference may include that those with a pet dog and/or with extensive dog experience simply like dogs more, are more acutely aware of the comfort dogs can offer because they live or have lived with one, and for some, have personally experienced pain and anxiety reduction related to an illness because of their pet. As another consideration, Crossman et al. found that people who hold positive perceptions of companion animals are more likely to positively perceive animal related interventions than those with negative attitudes toward pets [53
]. A clinical trial in the United States demonstrated that canine visits reduced patient perception of anxiety in an emergency care setting but did not account for pet ownership and experience [15
]. Once again, further research is required.
Having the opinions in this study originate from the patients’ perspective supports a patient-centred approach to public health in an ED setting. There is a need for further patient-oriented research in the therapy dog and ED field. There has historically been a dearth of attention to accounting for the patient experience in health care, though this is changing [29
]. The Canadian Institutes of Health Research is a major health research funding body in Canada and in the past decade it has developed a national strategy for patient-oriented research [54
]. Therapy dogs are a discernable area to apply a patient-oriented approach, and as this study did, starting with the foundational question of whether patients want to be visited by a therapy dog, and why or why not.
There are several main limitations to this study. First, the survey was only completed in the English language and excluded the views of patients under the age of 18 years. Although all participants were English-speaking, some may not identify English as their primary language and not be as fluent. Eighteen years was considered the minimum age of inclusion because the RUH ED does not provide care to those under 18 years of age. We also did not ask a question on race/ethnicity. Next, patients self-selected out of participating in the study and it was not determined if they declined due to pre-existing concerns with dogs/therapy dogs, so it is possible perceptions of reasons not to have a visit by a therapy dog were missed. In addition, patients admitted to the ED as high priority, critical care patients were not accessed so as not to impede on their medical care. Fourth, potential for sampling bias and sampling error is inherent to a convenience sample. Fifth, patients were asked reasons people would want to have a visit by a therapy dog or not in the ED. The question was worded in this way to capture the public nature of the ED setting, asking about their individual opinion as well as others’. A limitation of this approach is that it can capture stereotypical opinions of other patients. Sixth, it is unknown if the demographics of the sample in this study mirror the typical ED client population. For example, it is unknown if the low recognition of cultural background or tradition as a reason for not wanting to have a visit by a therapy dog reflects an opinion representative of the RUH ED population. Further, we did not have any participants identify with a nonbinary gender identity. Next, to have the questionnaire brief enough for an ED environment, only the top five reasons for wanting to have a visit by a therapy dog in the ED and the top four for not were chosen from the literature. Finally, despite attempts to control for participants’ interaction with a therapy dog, it is possible patients may have had contact with a therapy dog at a prior ED visit and it was unknown to the data collection team. This may influence the participants’ responses.