Thesis Nurs. 1995 A545c c. 2 Anderson, Barbara S. A comparison study of resident pet and pet 1995. A COMPARISON STUDY OF RESIDENT PET AND PET VISITATION PROGRAMS AND THEIR EFFECT ON THE LONELINESS OF NURSING HOME RESIDENTS by BARBARA S. ANDERSON, B.S.N., R. N. Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by: A) - j "Bate Chairperson of Thesis Committee Edinborb) University of Pennsylvania ________ Committee Member /■tyf Committee Member / Date L. 2/ ABSTRACT This study compared a resident pet program and or visitation pet program and their effect on the loneliness experienced by nursing home residents. The sample was comprised of 52 subjects from two nursing homes in Northwestern Pennsylvania. The evaluation tool was the UCLA Loneliness Scale (version 3) by Russell. questionnaire. Subjects completed a 20-question The statistical tests were the t-test and the pearson correlation coefficient. Review of the data analysis suggested there was no significant difference in the loneliness scores and the type of pet program. An inversely related correlation was found between the loneliness scores and the number of years in the nursing home. ACKNOWLEDGMENTS I would like to express my sincere thanks to committee members Dr. Charlotte Paul, Dr. Alfred Stone and Jan Newcamp for their support and guidance throughout this study. Grateful acknowledgement is given to the patients who participated in the study. I want to thank my family for their understanding and encouragement throughout my education and this study. A special thank you to my husband, Tom, for his unselfish love, support, and friendship. He has been an inspiration in my life and throughout this study. ii TABLE OF CONTENTS Page ACKNOWLEDGMENTS ii LIST OF TABLES v CHAPTER I. II. INTRODUCTION Background of the Problem 1 Statement of the Purpose 3 Hypothesis 3 Definition of Terms 4 Assumptions 5 Limitations of the Study 5 REVIEW OF THE LITERATURE 6 6 Loneliness Origin of Pet Therapy 11 Psychological & Social Effects of 15 Pet Therapy Physiological Effects of Pet Therapy. 21 28 III. METHODOLOGY 28 Introduction Conceptual Framework Sample and Setting Type of Pet Programs iii IV. V. Instrumentation 33 Data Collection 34 Procedure for Analyzing Data 36 PRESENTATION AND ANALYSIS OF DATA 38 Demographics 38 Analysis of Data 40 CONCLUSION 43 Summary 43 Discussion 46 Conclusions 46 Recommendations 46 47 APPENDICES A. Letter Requesting Permission to Complete Study B. Authorization to Participate as a 48 subject C. Demographic Data Form D. Modified Short Portable Mental Status Questionnaire E. 49 50 UCLA Loneliness Scale 51 (version 3) F. 47 Letter Granting Permission to Use UCLA Loneliness Test (vers. 3) 53 54 REFERENCES iv List of Tables Page Table 1. Gender Ratios in the Sample Population 39 2. Variables Correlated with the Loneliness Scores 40 3. Two-Tailed t-Test of Loneliness Scores and 42 Type of Pet Program v CHAPTER 1 Introduction Background of the Problem Since the turn of the century, the number of aging individuals has been steadily increasing. Presently in the United States, 12% of the population is 65 years or older. By 2030 this population is estimated to increase to 20% or 59 million elderly (Burke & Sherman, 1993). The majority of older adults live in the community; however, the number residing in nursing homes is rising. Declining health is often the primary cause for entering a nursing home. Institutionalization often negatively effects the sense of well-being. The deterioration in physical and mental health in addition to leaving one's home, family, pets, and personal effects contributes to feelings of frustration, anger, loneliness, depression, and disorientation for nursing home residents. Studies on the human/animal relationship have shown positive effects on both mental and physical health as well as the social interactions of individuals. 1 The use of animal/pet 2 programs termed as pet therapy, animal assisted therapy, animal facilitated therapy, or pet facilitated therapy programs have alleviated some of the negative effects of institutionalization . The therapeutic use of animals can be valuable in reaching treatment goals. Pets used as social facilitators have improved residents responsiveness, alertness, and communication patterns. Depression has been notably reduced with pet therapy. Many elderly and lonely people have discovered that pets satisfy their vital emotional needs. only link with reality. Often they act as a person's Pets provide a boundless measure of unconditional love and unqualified approval. A person's sense of belonging and worthiness is nurtured which increases their self-esteem. Pet therapy may use a resident (live-in) pet or visitation pets. Laws banning pets in governmental housing and in health care facilities have been repealed. Therefore, pet therapy programs are becoming more widespread. Resident pets foster a sense of responsibility, being dependent upon their human companions to provide food, shelter, grooming, and safety. They encourage activities such as walking, grooming, petting, or playing. The activities add structure to the daily regimen of institutional living. 3 Lack of sensory stimulation is common among these residents. Pets offer a variety of stimulations for the senses (touching, visualization, stroking), embracing an animal promotes stimulation, relaxation, and reduces anxiety. Pet therapy programs may act as positive catalysts and in doing so may enhance the quality of life for those living in nursing homes. Although studies have been completed on the human/pet relationship, further research is essential to establish the therapeutic nature of this treatment modality. Statement of the Purpose This study was designed to compare a resident pet program and a visitation pet program and their effect on the loneliness experienced by nursing home residents. Hypothesis The resident of a nursing home with a resident pet program will experience less loneliness than the resident of a nursing home with a pet visitation program. 4 Definition of Terms The following terms were defined by the investigator and related to this study: 1. Resident pet program - a program in which a domestic animal resides in the nursing home eight hours a day, five days a week, and is permitted to roam within a given territory. 2. Pet Visitation program - a program in which a domestic animal is taken by the owner to visit residents in the nursing home twice a month. 3. Loneliness - the nursing home residents total scores as measured by the UCLA Loneliness Scale (Version 3) . 4. Nursing home - A facility providing care for the chronically ill or those recovering from acute illness who need extended care, but not hospitalization. These facilities contain three levels of care; skilled nursing care, intermediate nursing care, and custodial care (American Association of Retired Persons, 1986). 5 Assumptions 1. Nursing home residents have the feeling of loneliness. 2. The state of loneliness can be measured. 3. Residents will be able to answer the questionnaire. 4. Pets can aid in the reduction of loneliness. Limitations of the Study 1. Two nursing homes served as settings for the study. 2. Sample was not randomly chosen from the population. CHAPTER 2 REVIEW OF THE LITERATURE Loneliness In the United States the number of aging people has been increasing steadily since 1900. Due to the the post-World War II "baby boom", the reduction of infant and children mortality, and the advances in health care and technology a "gerontology boom" is expected by the year 2010. Ebert, 1980). (Yurick, Robb, Spier, & Butler, Lewis, and Sunderland (1991) find the 75 plus and 85 plus age groups are and will continue to be the fastest growing age groups. This causes great concern because of the excessive healthcare needs of these individuals. The majority of elderly people enjoy a good quality of life and are healthy, but chronic diseases and functional impairments have become a major cause of disability and death among these individuals. Chronic diseases such as heart disease, arthritis, hypertension, diabetes, stroke, and lung diseases may lead to disability and dependency (Butler et al., 1991; Eliopoulos, 1987; Kane, Ouslander, & Abrass, 1989; Yurick et al., 1980). These chronic diseases cause many health problems for the 6 7 elderly which may lead to impairment, hospitalization, and possibly the need for long term care, It has been estimated that more than 4 0% of the people over 65 will spend some part of their remaining years in a nursing home (Butler et al., 1991) . Butler et al., (1991), state that "in 1989, approxi­ mately 1.6 milion older people lived in nursing homes in the United States and by 2030 this number is expected to double" (p.7) . The elderly comprise the largest group of people for whom hospitals, home health and community nursing homes provide care. Carroll and Brue, (1988) suggest as this elderly population grows, health resources need to be directed towards meeting the needs of this population. Loneliness is often viewed as a problem of the elderly. It is believed to effect the elderly because of life events which may lead to its development is frequently precipitated by loss. (Rodgers, 1989) . Loneliness For the elderly, the loss or separation from people or things which have significance to them may provoke feelings of loneliness, A decline in physical and mental health, diminished support systems of family and friends, a decreased income, retirement, and growing old in a youth-oriented society contribute to feelings of loss, isolation, depression, grief, and ultimately loneliness. 8 Rodgers (1989) studied hospitalized older adults and the loneliness they experienced. moderate. The loneliness scores were Many subjects indicated that the separation from significant persons and things contributed to their distress. Rodgers (1989) postulated that promoting a familiar environment and facilitating a degree of control by patients may decrease the incidence of loneliness among the elderly. Austin (1989) wrote "those persons perceived to be immune to loneliness possess characteristics that permit growth and constructive behaviors when faced with loss or change n (p. 25). She indicated that some individuals could take losses and create something positive out of them. Nursing could assist patients by assessing their coping mechanisms and assisting them in developing those creative characteristics (Austin, 1989). She also suggested using pets as means to meet the elderly's nurturance needs. Butler and associates (1991) describe two components when discussing the feeling of loneliness: survival in a threatening Aloneness, a fear of environment, and Loneliness, the fear of emotional isolation, of being unable to attain the satisfaction of positive relationship with others. number of causes for loneliness Burnside (1981) listed a 9 in the elderly: loss of siblings, children, spouse and friends, pain, loss of a pet, and sensory deficits. A variety of developmental stressors and changes predispose the elderly to psychological and physical illness. Significant chronic illnesses contribute to psychological problems. Additionally, the elderly experience reduced opportunities for social interaction, reduced income, losses, relocation, diminished self-esteem, and possibly death (Butler et al., 1991, Carroll & Brue, 1988; Yurick et al., 1980). Aging has been defined by Stotsky (1968) "as a loss or decline in performance of specific functions due to structural or functional changes in the individual" (p. 1). He believed that with American society's emphasis on youth that the elderly suffer from disengagement, loss of status, and loss of a productive role in their life. "The personal cost of this surrender is self“devaluation, anxiety, depression, boredom, isolation, and loneliness" (Stotsky, 1968, p. 8). Corr and Corr (1990) suggested that institutionalization, which is frequently associated with depersonalization and separation from the outside world, would lead to social isolation and loneliness. While Burnside (1981) noted the greatest problem facing the elderly was the feeling of loneliness, helplessness, and isolation. Various factors contribute to social isolation and 10 loneliness for the elderly. Biological changes such as sensory changes, neuromuscular changes, chronic illness, and disease all foster the feeling of loneliness. to loneliness: Other factors may contribute living in rural areas, children grown-up and gone, the death of spouse, children or friends and the fear of leaving one's home for safety reasons. Calvert (1989) found that elderly nursing home residents who had higher levels of pet interaction experienced less loneliness than residents with lower levels of pet interaction. Her study noted that subjects of a resident animal program demonstrated less loneliness than subjects from a pet visitation program. Several subjects commented that they did not see or interact with the resident animal often. This could explain why there was not more of a significant difference in loneliness between the two pet therapies. Other psychosocial stressors commonly experienced by the elderly which could lead to loneliness were presented by Carroll and Brue (1988). The stress of relocation to residential or institutional locations could result in loss of control and independence, social isolation, immobility, disorientation, feelings of hopelessness, loss, and depression. Loss of one's in social interactions reflect support system and a decrease negatively. The reality of death and fears associated with death such as pain, fear of death of others, and impact of their 11 death upon others are needs that should be addressed, Loss of self-esteem may be created by the loss of independence, meaningful relationships, space, touch, and sexuality. When these components of one's self-esteem are missing, the common response is grieving, and the feeling of powerlessness, uselessness and dependency which may be exhibited by withdrawal. Carrol and Brue (1988) state that nursing home residents are at the greatest risk for loss of self-esteem and feeling lonely. Although different therapies have been used to increase self-esteem, touch has been proven to be an important means to convey the feeling of acceptance and caring especially to persons facing social isolation. Pets are an alternate approach to reduce loneliness and withdrawal while encouraging touch. Origin of Pet Therapy The origin of pet therapy can be traced back to the 18th century. One of the first documented use of animals as adjuncts to treatment was in 1792 at the York Retreat in England. Founded by Quakers, the York Retreat was an alternative to asylums and lunatic hospitals of the day. harsh forms of Instead of being punished by treatment, positive measures were used to control 12 behavior. Small animals such as rabbits and poultry were contained in the courtyards and patients were encouraged to care for them. York Retreat was one of the first programs to use a positive reinforcement program (Bustad, 1980). In 1867, Bethel, a home for epileptics in Bielfield, West Germany, used cats, dogs, horses, and birds as an integral part of the living environment. Besides using the traditional pet animals, Bethel included farm animals and a wild game park as part of its program. Patients were treated in a home-like atmosphere and encouraged to care for the animals. The first recorded use of pet therapy in the United States was in 1942 at Pawling Army Air Force Convalescent Hospital in Pawling, New York. While convalescing from battle fatigue and trauma, veterans were encouraged to work with farm animals as well as creatures of the field and forest (Cusack & Smith, 1984). Boris Levinson was one of the first psychologists to use animals in psychotherapy. by accident. Levinson's work in pet therapy began His dog was in his office when a mother and her disturbed son arrived early for their appointment. The dog improved the child's interaction and helped to build a greater rapport and trust between the therapist and subsequently others which ultimately led to the child's recovery (Cusack & Smith, 1984). Levinson emphasized the importance of therapeutically using pets in treating not only children but also adults, 13 particularly the elderly. therapy. Levinson was a pioneer in pet He pleaded for research to set the boundaries and principles of using animals in therapy as well as learning to select and train animals for psychotherapy. In the 1970s Samuel and Elizabeth Corson started a program at Ohio State University to study the feasibility of using pet therapy in the hospital setting. They decided to use pets as a form of therapy for psychiatric patients who failed to respond to the standard forms of therapy. The patients selected were the most withdrawn and uncommunicative. patients accepted dogs. Twenty-eight A mixture of dogs were selected and an attempt was made to match the dogs temperament with the needs of the patient. The Corsons described the dogs as social catalysts. Observation indicated a positive reaction first of the patient to the dog then it widened to the therapist and then to other patients and staff (Bustad, 1980). The dogs were viewed as a non-threatening source of interaction and tactile stimulation. Many of the patients showed improvement and were discharged. The Corsons believed the dogs provided a sense of responsibility and a sense of being for the patients. The dogs seemed effective in this role because of their ability to offer love and tactile reassurance without criticism, and their 14 maintenance of a sort of perpetual infantile dependence which could stimulate one's natural tendency to offer support and protection (Bustad, 1980). Due to financial constraints, the Corsons moved to Castle Nursing Home in Millerburg, Ohio, using the same dogs for therapy. Residents who were withdrawn, lonely, and dependent were selected for therapy. Positive changes in social interaction as well as improved physical activity, emotional well-being, self-reliant behavior, and changes in appearance and personal hygiene were seen. No quantitative data was documented due to the lack of research funding but the Corson's reported similar responses as those that occurred at Ohio State University (Corson & Corson, 1978). Surveys have shown that the number of animals used in clinical or therapeutic environment is growing since the onset of these early studies. Levinson in 1972 surveyed the New York state psychologists and found 50% of those surveyed used pet therapy in some manner (Cusack & Smith, 1984) . A writer, Phil Arkow, associated with the Humane Society in Colorado stated in 1977 that only 15 Humane Societies and in 1982 there were 75 were utilizing pet therapy programs, programs (Cusack, 1988). As studies are completed showing the therapeutic value institutions will of using animals in therapy, hopefully more begin to initiate pet therapy programs. 15 Psychological and Social Effects of Pet Therapy Animals are part of our natural environment. Every person who has ever owned a pet can attest to the benefits of associating with our animal friends. greater than 50% Manor (1987) states that of the households in the United States have at least one or more pets, and 26% of older adults have owned or presently own a pet. Pets offer unconditional love, acceptance, and affection. They provide stimulation and interest, warmth, and comfort to an individual's life (Erickson, 1985). Their antics incite humor, laughter, and entertainment. Pets enable humans to extend beyond themselves increasing their responsiveness, social interactions, acting as distractions from life's problems, and as a means for forgetting the fears of the future (Cusack, 1988) . Caring for pets fosters responsibility, nurturance, and incorporates structure into the daily routine and activities of the older adult (Harris & Gellin, 1990). Picking up, petting, or playing with a pet helps restore and maintain muscle strength and coordination, enhances joint mobility, and promotes exercise. McCulloch (1983) suggests pets be prescribed for therapeutic purposes for individuals suffering from chronic illnesses and disability, depression, loneliness, isolation, diminished self- 16 esteem, helplessness, and hopelessness. Frank (1984) states, Love for a pet creates a relationship of mutual trust and confidence while building a~ bridge to the ---- -------future and to greater self-awareness, self-awareness. A pet offers infinite comfort, The pet, in a sense becomes a mirror in which a person sees himself wanted and loved not for what he should be or might be or might have been but for what he is. An individual learns that it is possible to communicate one's inner most feelings without words, by mere gestures, a glance or even bodily posture, (p. 30) Robb, Boyd, and Pristash (1980) conducted research to determine the effects of a wine bottle, plant, and puppy on the social behaviors of male patients at a Veteran's Medical Center. Five social behaviors (verbalization, smile, look, eyes open, and leans toward stimulus) were observed during the introduction of these objects one at a time. Robb et al. (1980) noted that any object of any animation level would lose its ability to stimulate social interactions as the time of exposure increased. Of these three stimuli, the caged puppy produced the most dramatic increase in the social behaviors. The wine bottle had the smallest display of social behaviors. a social Robb stated the caged puppy acted as catalyst. "Old age is 1981, p. 66). fertile ground for loneliness" (Burnside, Combating loneliness in the elderly is that one can be in the midst It has been reported The elderly being relocated of a crowd and still be lonely. difficult. 17 from home to home or home to institution feel emotionally isolated, lonely, and rejected. The implementation of pet therapy has had positive effects on their social interactions. Winkler, Fairne, Gericevich, and Long (1989) surveyed staff and residents of a nursing home to examine the perceptions and social interactions of each after introducing a resident dog to the unit. Staff and patients were interviewed six weeks before the dog arrived and again at six and twenty-two weeks after the dog arrived. A significant increase in the social interactions of both patients and staff was noted six weeks after the arrival of the resident dog. By twenty-two weeks the staff's behaviors remained high, while the patients behaviors returned to levels observed at the start of the survey before the introduction of the dog. Possibly the same effect occurred with this study as did with Robb et al. (1980). The dog lost the ability to stimulate the social behaviors as the time interval increased to twenty-six weeks. Winkler et al. (1989) suggested that patients should have more control over the animals daily routine; thereby attached and reducing the possibility of the dog becoming more interactive with the staff. It was also suggested that attention should be given to the personality and temperament of the pet selected to meet the needs of the patients. no beneficial effect on the The use of live pets had 18 daily activities of nursing home residents as reported by Hendy (1984) . She examined the effect of four different pet presentations (live pets, no pets, stuffed pets, and videotaped pets) on the social and behavioral activities of the residents. The live pet presentation produced an increase in the desired behaviors. Hendy suggested that the presence of other people (non-residents) may be more effective towards achieving the desired outcome. Hendy (1987) continued her research to compare changes in social behaviors (talking, smiling, ambulation, proximity, and alertness) of nursing home residents with use of different visitation programs (people-alone, pets-alone, people-pluspets, and no visit) . She noted of the social behaviors only smiling and alertness showed a significant increase, These results were similar to her previous study. Hendy (1987) also surveyed age, frequency of other visitors, and years of residence in the institution and found they were not related to the effectiveness of the pet therapy programs. Pet therapy may be utilized by occupational therapists for long-term care patients. McQuillen (1985) presented criteria for establishing a program as well as the procedures the occupational therapist should follow to meet the needs of the patient. She emphasized the importance of soliciting support from the community, hospital administration, physicians, 19 and staff as a vital component in initiating pet therapy programs. Kalfon (1991) evaluated the changes in social behavior among long term residents during pet visitation versus another leisure activity. The subjects exhibited less withdrawn behavior and less disorientation at the conclusion of the six week series of pet visitation sessions. The pet, a rabbit, had more positive psychosocial responses than the leisure activity. Kalfon found no changes in patients in response to self-care functioning, irritable behavior, or depressed/anxious mood. Over the last one hundred years we have added some 25 years to the average life expectancy. This reality means our population is living longer and becoming older and more knowledgeable. The elderly compose the fastest growing age group in society. "Because the elderly often withdraw from social activities and place more importance on the nonhuman environment, they have greater potential for gaining from the companionship that animals have to offer" (Fick, 1993, p. 529). With increasing longevity and the deterioration of physical and mental health, the number residing in long term care facilities • .becoming . is larger. in the areas of These inesc people are candidates for deprivation socialization and sensory stimulation. 20 An exploratory study in Australia attempted to determine what behavioral and interactive changes took place with terminally ill patients and a resident dog. Chinner and Dalziel (1991) found that contrary to research on pet therapy, hospice patients who were isolated and uncommunicative displayed no affection toward the dog. They suspected that the terminally ill may distance themselves from affection and the companionship of the animal, so that they may not face death with many emotional ties and too much grief. Due to their medications and illness these patients were tired most of the time, but the subjects expressed their like for the dog and the calming effect he had on them. The loss of a pet can be a tragedy for the elderly especially if they have turned to a pet for unconditional love and support. The elderly, especially those living alone, may see their own death in the death of their pet. pet should not be taken lightly. should be given to their owner. The death of a Compassion and sensitivity Cusack (1988) indicated The death of a pet is not a merely a 'dress rehearsal' for more3 significant events to come; it is an intense, deeply moving experience • - by ' “3 and emotional itself, and is affected age as degree development as well _j as such sue.. factors _?.• the pet and manner in which of attachment to (p. 182 182)> the pet died, (p* 21 Physiological effects of Pet Therapy The benefits from pet therapy are also physiological in nature. Reduction of stress and an increase in relaxation are some of the physiological benefits. Friedmann, Katcher, Lynch, and Thomas (1980) investigated the association of pet ownership and the survival rate of 92 coronary heart disease patients following their discharge form a coronary care unit. One year later, 3 of the 53 patients who were pet owners died, while 11 of the 39 patients who did not own pets died. The presence of the pet was the strongest social predictor of their survival for one year post hospitalization. “Most importantly the effect of pets was not present only in those people who were socially isolated, it was independent of the marital status and access to social support from human beings1' 1980, p. 49) . (Friedmann et al., These results support the premise that pets have an important effect on lives, independent of the companionship of others and produce positive health benefits. Katcher, Friedmann, Beck, and Lynch (1985) studied the Two effects of interactions with dogs on blood pressure, of children were used in the presence or experimental groups Blood pressure was significantly decreased absence of a dog. children in the room, than when the when the dog was with the children were silent or reading aloud. 22 The physiological effects of blood pressure and heart rate and human/animal bonding was further studied by Baum, Bergstrom, Langston, and Thomas (1984) Blood pressure, heart rate, respiration rate were recorded on three groups of subjects: subjects petting their own dog, subjects petting a strange dog, and subjects reading quietly. Over time, a decrease in both the systolic and diastolic blood pressure readings occurred with subjects petting their own dog as well as a strange dog. The greatest decrease in both systolic and diastolic pressures occurred with the human/animal bond. The heart rate did not change in the subjects with the bonded or strange dog but it was lowered during quiet reading. Respiratory rate did not significantly change with any group. Vrombrock and Grossberg (1985) noted similar results from their research of college students, The students blood pressure was measured at rest without the dog, touching the dog, talking to and touching the dog, and talking with the Results reported experimenter and without the dog present. lowest when petting the dog, that blood pressure levels were dog and highest while talking to the higher while talking to the to be a major factor of the pet experimenter. Touch appeared when talking or touching the dog effect. Heart rate decreased touching and talking to the dog. The and increased while both contact, comfort response element of touch appeared to be a 23 which influenced the blood pressure but not the heart rate. In a study of homebound elderly, the Visiting Nurse Association initiated an animal assisted therapy program, The data that was collected on 16 homebound elderly patients sup­ ported the research that interaction with a pet produced a significant effect on the blood pressure. study were previous pet owners. All subjects in the First, subjects were visited weekly for four weeks by a nurse alone. The next four visits included the nurse, the pet (a dog) , and pet owner Rinehart, & Gertsman, 1993). (Harris, The data again indicated that the visit alone did not change the blood pressure level, but the pet visit did. "The physical, psychological, and social benefits provided by an animal companion are available to anyone who is willing to accept them" (Cusack & Smith, 1984, p. 45). Animals may assume a more significant role for those people who have special needs or physical impairments. Dogs have been used to assist the hearing and sight impaired persons as well as the physically In the recent years, equestrian therapy, challenged. and a multifaceted treatment, has provided physical, social, psychological benefits to handicapped individuals. The decision tor using pet therapy shall include several factors. Animals used in pet therapy program, must he carefully entering a program. screened before Parasitic infections as 24 well as zoonotic infections are a potential problem. Elliott, Tolle, Goldberg, and Miller (1985) found that pet associated illnesses are uncommon despite the frequency of pet/human contact. They stated that health care providers should be more knowledgeable of the transmission of pet associated illnesses as well as preventive measures. They recommended vaccination, flea control, and treatment of intestinal parasites for any pet. Wallace (1992) noted that animals posed no threat of infection to the hospitalized patient when they were tested and infection control guidelines were followed. She recommended high risk patients such as spleenectomy patients be barred from pet visits due to their susceptibility to dysgenic fermentin Type 2, a bacteria that is normal flora in dog saliva. Patients with known methicillin-resistant staphylococcus aureus infections are not candidates for pet therapy because of the concern that animals could act as fomites in transmitting the pathogen from patient to patient (Haggar, 1992; Wallace, 1992). Wallace (1992) also warns that dogs particularity need protected as they may become infected with tuberculosis if exposed to patients with the disease. Particular attention should be given to those persons who have respiratory conditions or are allergic to animals. Determination of the patients allergies should be obtained before introducing an animal (Bustad, 1980; Cusack & Smith, 25 1984; Michaels, 1982). Some people may be allergic to only certain breeds of animals. Hibell (1987) noted that animals with long hair may cause more intense allergic reactions and recommended that short-haired cats be used when working with the elderly. Careful selection of an animal and proper training can reduce the risk of injury. may bite or scratch. Pets such as dogs, cats and rabbits Corson and Corson (1978) identified two approaches to this problem. First, screening, selection, and training of the animal used in pet therapy, and second, education of the person handling the animal. Direct observation and supervision during the initial stages of pet therapy is needed to insure resident/pet companionships. Special attention should be given to the training of animals who are placed in an environment where residents have difficulty walking, and may use walkers, and wheelchairs. Abuse of the animal from the patients who may take out their frustrations or aggressions on the animal is a potential problem. Animals used in pet therapy should not be exposed to extremely agitated or confused people. Kongable, Stotsky, and Buckwaiter (1990) in their study of Alzheimer's patients and pet therapy wrote "the most commonly cited risk of using pet therapy for Alzheimer's disease residents is related to the safety of the animal" (p. 20). They reported residents grabbing at the animal, 26 pulling it's tail, and kicking it which produced a stress overload for the animal. The animal through training learned to sense cues of aggressive behavior and began to avoid potentially abusive situations minimizing the potential for injury (Kongable et al., 1990). A potential problem for the animal that may develop is obesity. The pet, especially a resident animal, may be bribed with treats. Residents may save their food for the animal which causes a weight gain of unhealthy proportions (Bustad, 1980). For this reason a person(s) may be designated as the one responsible for feeding the animal. Neutered animals tend to make better companion animals. They tend to be more stable, dependable, gentle, and affectionate. Since the tendency to roam is diminished, neutered pets tend to live longer (Bustad, 1980) . Financial responsibility for securing and maintaining a pet may be costly. Costs for training the animal and health care may be incurred. Veterinarians may contribute their services for the health care of the animal. Food and grooming needs may be provided by funds from the institution or from contributions of the staff and patients (Bustad, 1980). Also decisions on who takes responsibility for bathing, grooming, feeding, exercising, toileting, and playing with the animal is important. Traditionally, the activity director of an 26 pulling it's tail, and kicking it which produced a stress overload for the animal. The animal through training learned to sense cues of aggressive behavior and began to avoid potentially abusive situations minimizing the potential for injury (Kongable et al., 1990). A potential problem for the animal that may develop is obesity. The pet, especially a resident animal, may be bribed with treats. Residents may save their food for the animal which causes a weight gain of unhealthy proportions (Bustad, 1980). For this reason a person(s) may be designated as the one responsible for feeding the animal. Neutered animals tend to make better companion animals. They tend to be more stable, dependable, gentle, and affectionate. Since the tendency to roam is diminished, neutered pets tend to live longer (Bustad, 1980) . Financial responsibility for securing and maintaining a pet may be costly. Costs for training the animal and health care may be incurred. Veterinarians may contribute their services for the health care of the animal. Food and grooming needs may be provided by funds from the institution or from contributions of the staff and patients (Bustad, 1980). Also decisions on who takes responsibility for bathing, grooming, feeding, exercising, toileting, and playing with the animal is important. Traditionally, the activity director of an 27 institution is often delegated the responsibility for the care of a resident animal but a person in another position may assume the responsibility. Certain responsibilities for the care of the animal may also be assumed by capable residents. Suggestions have been made that the care of the animal be written into the job description of an employee (Cusack & Smith, 1984) . From the review of the literature the presence of pets can produce positive influences on the physical and mental health of the elderly. Friedman et al. (1984) suggested that the companionship, communication, purpose, and meaning to life provided by pets act to decrease loneliness and depression. Pets may be an effective intervention for some lonely elders. Pet therapy is not for everyone and should not be considered a cure for all, but consideration should be given to the initiation of this intervention as a means to improve the quality of life. CHAPTER 3 Introduction This study was done to compare a resident pet program and a visitation pet program and their effect on the loneliness experienced by nursing home patients. Conceptual Framework Erik Erickson's eight stages of human development provides a theorical framework for this study. developmental stages. His theory outlines eight With each stage is an issue or psycholog­ ical conflict (crisis) which is of primary importance during that stage of development. Erickson's stage of integrity vs. despair and disgust has the greatest significance for the older adult. Success in resolving the conflicts of this stage, as with all the others, is not possible unless the conflicts of the preceding stages have been successfully resolved. Erickson (1959) defines integrity as 'the acceptance of one's own and only life cycle and the people who have become significant to it as something that had to be and that, by necessity permitted no substitutions.' The person who successfully achieves integrity accepts the experiences which 28 29 have occurred during the person's lifetime and take full responsibility for his or her own life. Persons who were significant in the course of life experience are accepted without any wish that they might have been different. When the indi­ vidual does not achieve integrity, despair follows, often accompanied by dismay that there is not enough time remaining to start all over. In some cases, disgust is substituted for despair (Yurick, et al., 1980, p. 192). Many elderly, particularly these who reside in nursing homes have suffered dramatic changes in their lifestyles. They have relinguished most of their personal possessions, the security of their home, family and friends, and often a relationship with a pet from their previous environment. They have cognitive and physical deficits which limit their ability to interact with others and also limit their response to the environment. There are seldom opportunities to leave the nursing home and personal visitors are few. This often leads to feelings of anger, inadeguacy, boredom, low self-esteem, and hopelessness due to a lack of sense of purpose and absence of a satisfying goal-directed activity in their lives. despair develops. Ultimately, The detrimental effects of institutional care on the well-being of the resident are many and well documented. Pet therapy is one of the interventions that nursing can use to stimulate awareness, interaction, and provide pleasure These residents require activities for nursing home residents. that fulfill the need for purposefullness, and a feeling of 30 being worthwhile by providing a driving life force, Pet therapy is a treatment modality that can be utilized to counteract the isolation and loneliness, increase social interaction and sensory stimulation, and improve self-esteem. The pet 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. Pet therapy is an activity that positively effects the mind, body, and spirit of the institutionalized elderly. Research has documented its therapeutic use in assisting the elderly to restore and maintain the integrity of old age. Sample of Setting The setting for this study was in two nursing homes in Northwestern Pennsylvania. Approval for study was obtained from the institution's nursing administrator. to complete the study was placed in Appendix A. this study was and the A letter of request Permission for granted with understanding that the institutions participants would be anonymous. Only the investigator observed the raw data. consisted of residents of a nursing home with The sample 31 a resident pet therapy program and nursing home residents with a visitation pet therapy program. All subjects voluntarily agreed to participate in the study and signed a consent to participate (Appendix B) . Before data was collected, subjects were asked three designated items from the modified Short Portable Mental Status Questionnarie (SPMSQ). Only those subjects who could provide, without assistance, appropriate answers were included in the sample. Type of Pet Programs A resident pet and a visitation pet program were in place at the time of this study. The resident pet program was established in a private nursing home. The resident pet was a five year old Sheltie dog, named "Morgan", who routinely came to the nursing home five days a week for eight hours a day. The dog was owned by the activity director at the facility. The resident dog was allowed to roam in all areas except the dining room, laundry, and food preparation areas. meal time she was confined to a holding pen. During The dog was not the residents beds or chairs. allow to sit or sleep on The 32 staff of the activities department were responsible for the feeding and grooming of the dog. The dog received veterinarian checkups every three months in addition to the required vaccinations. The nursing home residents were permitted to interact with the dog as desired. The activities department personnel would routinely take the dog out to all areas of the nursing home and encouraged the residents to pet or brush the animal as desired. In the visitation pet program, domestic animals such as dogs and cats were taken by volunteers to the nursing home for approximately two or three hours on the first and third Saturday of each month. The pets were screened for appropriate temperament and behavior before being brought to the home. These pets also received routine veterinarian checks and vaccinations. The pets were escorted through the hallway with the volunteers. Each resident was approached for their consent before the pet was introduced. The nursing staff provided the volunteers with a list of nursing home residents who were allergic to animals before the pet visitation program started. 33 Instrumentation A demographic questionnaire was used to describe the characteristics of the sample (Appendix C). Two instruments were used in this study: a modified form of The Short Portable Mental Status Questionnaire (SPMSQ) and the UCLA Loneliness Scale (version 3). The SPMSQ, a ten item tool, was used to assess for organic brain impairment in the elderly by testing the memory, orientation, and serial mentation operations (Pfeiffer, 1975) . Three items of the tool that questioned time, place, and President of the United States were used to determine the subjects ability to make a reliable response (Appendix D) . The three items of assessment were: What is the name of this place?, What day of the week is it?, and Who is the President of the United States now?. The UCLA Loneliness Scale (version 3) (Russell, Peplau, & Cutrona, 1980; Russell, Peplau, & Ferguson, 1978; Russell, 1994) was used to measure loneliness (Appendix E). A letter granting permission for the loneliness scale used in this study is in Appendix F. The scale consisted of 20 questions describing the experience of loneliness. (lonely) questions and ten questions (Russell, 1994). There were 10 negatively-worded positively—worded (non-lonely) Ratings on a four-point scale range scoring ranged from 20 (nonfrom "never" to "always" and the 34 lonely) to 80 (very lonely) (Russell, Peplau, and Cutrona, 1980). Early research with the UCLA Loneliness Scale involved college student samples. In more recent research, involving elderly samples, a problem regarding the complexity of the question became apparent. In statements containing double negatives (e.g., answering "never” to the response, ”1 do not feel alone") the elderly had difficulty understanding the statement. (Russell, 1994). A simplified version of the scale was developed to correct the problem. The content of one item was reversed from positive to negative making 11 negatively-worded questions and nine positively-worded questions. Version 3 of the UCLA Loneliness Scale had been used on a number of samples: college students, public school nurses, hospital-based nurses, and the elderly (Russell, 1994). Studies on four samples indicated Version 3 is a valid and reliable measure of loneliness. The coefficient alpha ranged from .89 to .94 across the four samples. 1994). (Russell, In studies on the elderly, loneliness scores were "strongly related to the perceived quality of the persons interpersonal relationships." (Russell, 1994). Data Collection at both nursing homes were The activities directors make arrangements for meeting with the initially contacted to 35 subjects. The pet therapy programs were the responsibility of the activities director at both institutions. Individual meetings were conducted with all residents who were able to accurately answer the items on the mental status questionnaire. First, a description of the study's intent was given to each subject. It was explained that participation was voluntary, all information would be confidential, and at any time they could refuse to answer any question or refuse to continue to participate in the study. Time was allotted for subjects to ask questions and determine if they wished to participate. each subject. A written consent to participate was obtained from These signed consent forms were given to the institution's administrator. interviews. The investigator conducted all Subjects were then interviewed following the UCLA Loneliness Scale and the demographic data form. To assist subjects with their response a bold printed response card was used. After the investigator read the question aloud, subjects were asked to indicate their response on the response card. The subjects responses were then recorded by the investigator on data records. After completion of the instruments, the subjects were thanked for their participation. 36 Procedure for Analyzing Data Since scored data was obtained in the study a two-tailed t-test was performed to determine if there was a significant difference in the loneliness experienced by nursing home residents with a resident pet program compared to the loneliness experienced by nursing home residents with a visitation pet program. Significance was determined to be at the .05 level. Requirements for the two-tailed t-test were one independent variable, two levels, between-subjects design, and number of the sample need not be equal (Linton & Gallo, 1975). Since comparisons were made among different groups of nursing home residents, it was a between-subjects design. The two levels of the independent variables were resident pet and visitation pet programs. For independent samples, the formula for degrees of freedom is df = nA + nB 2. A table of values for the distribution of the t probability was provided by statistical references (Linton & Gallo, 1975; Polit & Hungler, 1987). With 1 degree of freedom, the value that must be exceeded in the study population in order to establish significance at the .05 level was the value of 12.71. 37 The pearson correlation coefficient was used to determine if there was an interrelationship between the patient' s loneliness scores and different variables such as gender, pet ownership, length of time in nursing home. Requirements for the pearson r include two variables, both score data, and one score on each variable for each subject (Linton & Gallo, 1975). CHAPTER IV Presentation and Analysis of Data The purpose of the study was to compare a resident pet program and a visitation pet program and their effect on the loneliness experienced by nursing home residents, The hypothesis was: The residents of a nursing home with a resident pet program will experience less loneliness than the residents of a nursing home with a pet visitation program. Demographics The total sample was comprised of 52 subjects from two nursing homes in Northwestern Pennsylvania; 23 from nursing home A and 29 from nursing home B. The average age of both male and female subjects from nursing home A and B was 82.17 and 77.35, respectively. Two subjects from nursing home B were in their forties, lowering the average age. never owned pets before. Six of the 52 subjects had Two subjects currently owned pets which other and visited routinely at the were kept by a significant the ratio of male to female nursing home. Table 1 shows subjects in the study. 38 39 Table 1 Gender Ratios in the Sample Population Sample Population Row Total Male Female Nursing home A 6 17 23 Nursing home B 11 18 29 Column Total 17 35 52 40 Analysis of Data A pearson correlation coefficient was calculated on the subject's loneliness scores and pet ownership, gender, and number of years at the nursing home (Table 2) . Table 2 Variables Correlated With the Loneliness Scores Variables Pearson r P Pet ownership .093 >.05 Gender .0003 >.05 Number of years in nursing home -.273 = .05 41 The results of the correlation of loneliness scores with the variables indicate that pet ownership and gender have no correlation with loneliness scores. A correlation equal to the .05 level of probability was indicated between the number of years in the nursing home and the loneliness scores. This correlation was inversely related indicating that the longer a subject resided in the nursing home, the lower the score on the loneliness scale. The assessment of loneliness was completed using the UCLA Loneliness Scale (version 3). The scores for the subjects from Nursing Home A ranged from 21-58 and from Nursing Home B 21 66. The mean loneliness score for nursing home A and B was 37.87 and 38.93, respectively. A two-tailed t-test was calculated on the data to determine if there was a difference in the mean loneliness scores according to the type of pet program. Table 3 illustrates the results of the t-test. 42 Table 3 Two-Tailed t-test of Loneliness Scores and Type of Pet Program Type of pet interaction Loneliness N Resident pet program 23 Mean 37.87 S.D. t 29 38.93 P 10.73 -3.54 Visitation pet program DF 50 .999 10.77 t (.05, 50) = -3.54, p > .05 This study concluded that there was no significant difference found between the two pet programs and the subject's loneliness scores. Therefore, the hypothesis failed to be rejected at the .05 level of significance. CHAPTER 5 Conclusion Summary The elderly, particularly those facing placement in an institution such as a nursing home, encounter losses, separation, isolation, and loneliness. Pets have long been considered an effective intervention of increasing social interactions, improving self-esteem, and reducing loneliness. The purpose of this study was to investigate the effect of a resident pet program and a visitation pet program on the loneliness experienced by nursing home residents. The results did not demonstrate a significant difference in the loneliness scores and the two types of pet programs. Discussion The literature review focused on loneliness, pet therapy, the psychological and social effects of pet therapy, and the physiological effects of pet therapy. inherent to institutionalization. Loneliness is a problem Nursing home residents are at risk for developing the feelings of helplessness, hopelessness, 43 44 isolation, and loneliness. Life events such as loss of job, income, spouse, children, and physical or mental health may precipitate loneliness (Stotsky, 1968; Burnside, 1981). Studies have reported the positive influence of pets