A conceptual framework to address administrative and infection control barriers for animal-assisted intervention programs in healthcare facilities: Perspectives from a qualitative study Letter to the Editor A conceptual framework to address administrative and infection control barriers for animal-assisted intervention programs in healthcare facilities: Perspectives from a qualitative study Kathryn R. Dalton PhD1 , Peter Campbell MHS2, William Altekruse MHS3, Roland J. ThorpeJr. PhD4, Jacqueline Agnew PhD1, Kathy Ruble PhD5, Karen C. Carroll MD6 and Meghan F. Davis PhD1,7 1Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, 2School of Medicine, University of Maryland, Baltimore, Maryland, 3School of Social Work, University of Maryland, Baltimore, Maryland, 4Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, 5Department of Pediatric Oncology, Johns Hopkins University School of Medicine, Baltimore Maryland, 6Division of Medical Microbiology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland and 7Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, Maryland To the Editor—Animal-assisted intervention (AAI) programs, used extensively in healthcare facilities, have numerous reported benefits to patients.1–3 These programs have increasingly been used for healthcare workers, as a targeted intervention to reduce occu- pational stress and burnout symptoms.4 However, barriers, specifi- cally infection control concerns, prevent AAI programs from being used in many hospitals and among their diverse populations. This has become more apparent during the coronavirus disease 2019 (COVID-19) pandemic, and many AAI programs have been sus- pended due to apprehension about coronavirus spread, despite the critical need for proven mental health support programs for patients and employees during this taxing period. This qualitative study aimed to capture opinions pertaining to benefits and concerns related to AAI from individuals directly involved in hospital programs, particularly occupational health benefits for hospital staff and infectious disease concerns. We report on these key stakeholders’ perspectives and experiences and, through these reports, present a conceptual framework to rec- ommend measures to better implement and support these pro- grams. Although we focused our research on infectious diseases broadly, participant responses and our research findings are reflec- tive and applicable to concerns for AAI programs related to the COVID-19 pandemic. As part of a larger study on hospital AAI program-related risks and exposures, we interviewed 37 healthcare workers and therapy animal handlers from multiple hospitals. We thematically coded interview transcriptions based on deductive programmatic frame- work analysis. The study underwent research ethics review and approval. Further details on methodology and study participants have been previously published.5 Participants reported that these programs did benefit hospital staff by reducing stress and bolstering morale. They felt this led to an improvement in job performance through increased employee engagement, and by providing an “additional tool in their toolbox” for improved patient care. Finally, these programs were reported to be a gateway to other therapy programs, such as mental health counseling. In spite of these cited benefits, partic- ipants identified administrative barriers to implementation, such as balancing clinical duties. They conveyed that these obstacles could be overcome with appropriate leadership, and from collabo- ration across the hospital and management “buy-in,” to under- score the value of staff inclusion in AAI. Infection concerns were reported as a frequent barrier to pro- gram implementation, both for patient and healthcare worker use. Participants described their concern of the dog serving as an inter- mediary vector of pathogen spread among patients, staff, and the hospital environment. However, many participants, both pet therapy handlers and healthcare workers, felt this risk was minimal due to effective control measures, which should target the animal, the patients, and the hospital environment, designed with practical input from multiple stakeholders. The primary facilitator to appro- priately enact control measures was the designation of individuals responsible for safety, and relevant training for all individuals involved with these programs about potential infectious risks and mitigation strategies. Based on these reports, we developed a conceptual framework (Fig. 1), adapted from the Consolidated Framework for Implementation Research6 and the Environmental Protection Agency’s Risk Management Framework,7 which links our major themes in the context of program implementation. Hospital objec- tives and needs feed into program implementation, accomplished by addressing program barriers through facilitators (blue box). Perceived barriers, both administrative and infection risk as described, can be addressed through a risk management frame- work (yellow box): (1) identify the hazard (eg, infection concerns), (2) assess and characterize said hazard, and (3) hazard manage- ment through applying and monitoring control measures. This approach results in an adaptive protocol based on individual pro- gram needs. Critical to the design and execution of program imple- mentation is multiple stakeholder and hospital leadership Author for correspondence: Kathryn R. Dalton, E-mail: Kdalton4@jhu.edu Cite this article: Dalton KR, et al. (2021). A conceptual framework to address administrative and infection control barriers for animal-assisted intervention programs in healthcare facilities: Perspectives from a qualitative study. Infection Control & Hospital Epidemiology, https://doi.org/10.1017/ice.2021.24 © The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Infection Control & Hospital Epidemiology (2021), 1–2 doi:10.1017/ice.2021.24 Downloaded from https://www.cambridge.org/core. 06 Apr 2021 at 01:19:04, subject to the Cambridge Core terms of use. https://orcid.org/0000-0002-0105-7098 mailto:Kdalton4@jhu.edu https://doi.org/10.1017/ice.2021.24 http://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1017/ice.2021.24 https://crossmark.crossref.org/dialog?doi=10.1017/ice.2021.24&domain=pdf https://www.cambridge.org/core engagement (red boxes) to ensure diverse, comprehensive input on protocols. Implementing adaptive AAI programs, through targeted facilitators, results in program benefits for both patients and staff, such as those listed in the figure, since many program barriers and facilitators apply to both. This ultimately creates a reinforcing feed- back loop improving program implementation by substantiating hospital needs. Our qualitative study provided insight into appropriate AAI program implementation, both directed towards patients and HCW, based on the unique experiences and perspectives from individuals actively involved in these programs with crucial roles in their administration. Through participant reports and develop- ing our conceptual framework, we identified 3 major areas for pro- gram improvement. First is the need for a tailored risk assessment to understand barriers unique to individual programs, hospitals, departments, and patient populations, to develop adaptive proto- cols. Secondly, leadership roles, or “champions,” are essential to advocate for the programs’ worth, plus communicate and ensure adherence to policies critical to success. Lastly, collaboration across the hospital is needed to design protocols for AAI with input from multiple stakeholder groups to ensure that program guidelines are comprehensive and practical. This conceptual framework can serve as a scaffold for hospitals wishing to start or extend AAI programs, and it is noteworthy for hospital administrators, healthcare epidemiologists, and occupa- tional health specialists. More currently, this framework can be used to design plans to restart suspended AAI programs due to COVID-19, as well as potentially other patient well-being volun- teer programs. The detailed level of contextual qualitative data obtained from our participants can be utilized to develop a prac- tical quantitative survey to collect data from a wider scope of hos- pitals and participant groups to increase our recommendations’ generalizability. The results of this, and future work, will have significant implications in the utilization and preservation of these valuable AAI programs. Acknowledgments. The authors thank Drs Kaitlin Waite and Sharmaine Miller for their assistance. We also thank the research participants for their cooperation. Financial support. No financial support was provided relevant to this article. Conflicts of interest. All authors report no conflicts of interest relevant to this article. References 1. Bert F, Gualano MR, Camussi E, Pieve G, Voglino G, Siliquini R. Animal assisted intervention: a systematic review of benefits and risks. Eur J Integrat Med 2016;8:695–706. 2. Kamioka H, Okada S, Tsutani K, et al. Effectiveness of animal-assisted therapy: A systematic review of randomized controlled trials. Complement Ther Med 2014;22:371–390. 3. Waite TC, Hamilton L, Brien WO. A meta-analysis of animal-assisted inter- ventions targeting pain, anxiety and distress in medical settings. Complement Ther Clin Pract 2018;33:49–55. 4. Abrahamson K, Cai Y, Richards E, Cline K, O’Haire ME. Perceptions of a hospital-based animal assisted intervention program: an exploratory study. Complement Ther Clin Pract 2016;25:150–154. 5. Dalton KR, Altekruse W, Campbell P, et al. Perceptions and practices of key worker stakeholder groups in hospital animal-assisted intervention programs on occupational benefits and perceived risks. medRxiv 2020. doi: 10.1101/ 2020.12.18.20248506. 6. Consolidated framework for implementation research. Center for Clinical Management Research website. https://cfirguide.org/. Published 2017. Accessed Janaury 21, 2021. 7. Framework for human health risk assessment to inform decision making. US Environmental Protection Agency website. https://www.epa.gov/risk/ framework-human-health-risk-assessment-inform-decision-making. Published 2014. Accessed January 21, 2021. Figure 1. Conceptual Framework for Hospital Animal-Assisted Intervention Program Implementation Adapted from CFIR and EPA Risk Framework (yellow box). Blue box = program barriers and facilitators, grey box = program implementation, red boxes = external influences. Circled arrow with R = positive reinforcing feedback loop, where appropriate program implementation leads to an increase in program benefits, which validates and increases hospital needs for these programs. * Most commonly documented patient benefits from systematic reviews of previous literature (Bert et al., 2016; Kamioka et al., 2014; Waite et al., 2018) 2 Kathryn R. Dalton et al Downloaded from https://www.cambridge.org/core. 06 Apr 2021 at 01:19:04, subject to the Cambridge Core terms of use. https://doi.org/10.1101/2020.12.18.20248506 https://doi.org/10.1101/2020.12.18.20248506 https://cfirguide.org/ https://www.epa.gov/risk/framework-human-health-risk-assessment-inform-decision-making https://www.epa.gov/risk/framework-human-health-risk-assessment-inform-decision-making https://www.cambridge.org/core A conceptual framework to address administrative and infection control barriers for animal-assisted intervention programs in healthcare facilities: Perspectives from a qualitative study References