Acceptability and Impact of Pet Visitation on a Pediatric Cardiology Inpatient Unit Adam S. Wu, MD Ruta Niedra, MSW, RSW Lisa Pendergast, BSc, RN Brian W. McCrindle, MD, MPH, FRCPC We evaluated the effectiveness of a pet visitation program in helping children and their families adjust to hospitalization on a pediatric cardiology ward. Thirty-one pet visits were observed and followed by interviews with patients and parents. Analysis of data suggested that pet visits relieved stress, normalized the hospital milieu, and improved patient and parent morale. The benefit received by the subjects correlated with the amount of physical contact and rapport developed with the visiting animal. Copyright 2002, Elsevier Science (USA). All rights reserved. HOSPITALIZATION CAN BE a frighteningexperience for children and a stressful time for their families. Both child and parent must con- front an unfamiliar environment sometimes asso- ciated with considerable pain, in addition to the feelings of fear, anxiety, helplessness, and power- lessness that accompany severe illness, and one in which boredom and lack of stimulation increase as the period of hospitalization lengthens. Pet visita- tion is one of the interventions that have been used to alleviate the stress of hospitalization. In recent years, pet visitation programs have been started in hospitals across North America with specially trained animals. Thus far, anecdotal evidence and the critical response of patients and staff have been positive: patients have reported reduced stress and increased levels of happiness and contentment (Cole & Gawlinski, 1995). Thus the evaluation problem was that the expe- rience of hospitalization for children and their fam- ilies can be dislocating and disorienting, and it was identified that there was a lack of knowledge re- garding the potential benefits and risks with regard to the use of pets in this setting. The purpose of this evaluation was to determine the impact of a pet visitation program on patient and parent satisfac- tion, physiologic measurements of stress, and per- ceived normalization of the hospital milieu. The setting was the pediatric cardiology inpatient unit of The Hospital for Sick Children, Toronto, On- tario, Canada. BACKGROUND Animal-assisted therapy is an interdisciplinary approach in which animals are used as adjuncts to other therapies. Pet visitation is its simplest and least structured form (Gammonley & Yates, 1991). Theoretically, the establishment of a human– companion animal bond creates a relationship free of the stress and complexities of judgment and expectations. The exchange of affection between human and animal is not ambivalent, differing from human interpersonal relationships between family members and other loved ones, which are frequently charged with ambivalence and negative emotional states. Human love and comfort, if available at all, frequently must be earned through sacrifice and compromise, whereas pets offer a source of comfort that can be scheduled on demand of the owner in almost any quantity (Bardill & Hutchinson, 1997; Jorgenson, 1997). The animal accepts without condition, loving without care or From the Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada. Address correspondence and reprint requests to Brian W. McCrindle, MD, MPH, FRCPC, Department of Paediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. Email: brian.mccrindle@sickkids. on.ca. Copyright 2002, Elsevier Science (USA). All rights reserved. 0882-5963/02/1705-0005$35.00/0 doi:10.1053/jpdn.2002.127173 354 Journal of Pediatric Nursing, Vol 17, No 5 (October), 2002 consideration, regardless of illness, deformity, or disability, offering security in that love and giving both child and parent a sense of empowerment in a sometimes overwhelming environment. For children, pet visitation is also thought to reduce separation anxiety and offer a pleasant di- version from anxiety-provoking treatments. Inter- action with the animal helps reinforce the child’s sense of self-concept in the face of the adult ther- apist, who is perceived as an authority figure (Davis, 1985). The visiting animal has also been found to provide motivation for children in pain to comply with treatment and behavior modifications (Kale, 1992). It is believed that the presence of the friendly animal helps to redefine the perception of the hos- pital environment by introducing something se- cure, familiar, and associated with the natural world. The friendly animal also provides relief, stimulation, and encouragement, offering a plea- surable experience to look forward to and a recep- tacle for the projection of feelings of fear, pain, and anxiety (Bardill & Hutchinson, 1997). The ani- mal’s presence may help facilitate social interac- tion, ambulation, activity, and compliance with treatment (Davis, 1985; Gammonley & Yates, 1991). The pet becomes a pillar of support and a source of strength, psychological sustenance, and optimism. The idea of “contact comfort,” in which simple physical interaction such as holding, petting, or touching produces changes in heart rate and blood pressure, may also apply to pet visitations. Re- searchers have proposed that petting an animal may produce a direct physiologic effect (Jorgen- son, 1997). Anecdotal evidence suggests that human-animal bonding has a positive influence on human health in both outpatient and inpatient settings. For ex- ample, pet owners with chronic illnesses have less morbidity than those without pets (Gammonley & Yates, 1991). Pet ownership has been found to reduce risk factors of heart disease and to improve social and psychological functioning, and cardiac patients who own pets have been found to survive longer than those who do not (Cole & Gawlinski, 1995; Jorgenson, 1997). Companion animals have also been found to reduce nursing home residents’ need for medication (Zisselman, Rovner, Shmuely, & Ferrie, 1996). In addition to the psychological benefits, quan- titative studies have shown that, in the presence of a good human-animal bond, animal visitation to adult and geriatric patients can lower blood pres- sure and reduce perceived pain (Baun, Bergstrom, Langston, & Thomas, 1984; Harris, Rinehart, & Gerstman, 1993). For example, a randomized, par- allel-group control treatment trial of 58 geriatric psychiatry inpatients with chronic age-related dis- abilities, in which pet therapy intervention was compared with an exercise program for 1 hour a day over 5 consecutive days, found equivalent changes in blood pressure, pain perception, and Multidimensional Observation Scale for Elderly Subjects scores in both groups, as well as a non- significant tendency for subjects in the pet inter- vention group to have less irritable behavior (Zis- selman, Rovner, Shmuely, & Ferrie, 1996). A qualitative study involving 30 adolescents hospi- talized in a psychiatric unit with a therapy dog living in the unit, in which ethnographic methods of analyzing data collected through patient jour- nals, interviews, anecdotal notes, and staff reports were used, found that the subjects identified the dog as a friendly component of the hospital milieu and served as a catalyst for interactions between individual patients, as well as between patients and staff (Bardill & Hutchinson, 1997). The benefits of a pet visitation program are not reserved to the patients; staff and family also ben- efit. The pet has been found to reduce the perceived stress levels of the nursing staff, allowing them to better function in their jobs and giving them more productive time with their patients (Carmack & Fila, 1989). Volunteers have indicated that the presence of companion animals made their own experience more satisfying (Harris, Rinehart, & Gerstman, 1993; Zisselman, Rovner, Shmuely, & Ferrie, 1996). METHODS The Pets at Work Program Pets at Work (PAWS) is a pet visitation program designed to provide an opportunity for therapeutic interaction for patients, parents, and staff at the pediatric cardiology ward of The Hospital for Sick Children. The dogs in the program are trained to come and sit still on command, to fetch a small thrown toy, to climb onto beds and chairs only when commanded to do so, to remain calm and relaxed in the presence of several human beings, and not to bark or bite under any circumstance. These dogs are brought to visit patients and their families privately in their rooms on the ward once a week, with a typical visit lasting 10 to 20 min- utes. During the visit, both the patient and parent are free to interact creatively with the dogs in any manner they wish under the supervision of trained PAWS volunteers. 355PET VISITATION ON A PEDIATRIC CARDIOLOGY INPATIENT UNIT Three dogs were used in the PAWS program during the evaluation period: Blue, a 9-year-old golden retriever; Bertie, a 7-year-old Shih Tzu; and Gioia, a 7-year-old mixed breed. The dogs visit in pairs, an arrangement that allows for flexibility and variety for the patients and their parents. Large, placid dogs like Blue make wonderful cuddlers for children (Kale, 1992), whereas smaller dogs like Bertie and Gioia are ideal for initiating contact with very young children and infants who might be intimidated at first by the presence of a large, unfamiliar animal. The presence of 2 dogs also allows for both child and parent to interact with a dog simultaneously. Patient Population The patient population included the patients and parents who participated in the PAWS program at the cardiology inpatient ward of The Hospital for Sick Children over a period of 6 months. Patients ranged in age from young infants to teenagers. Parents were required to sign a consent form ear- lier in the day before the dogs were allowed into the patients’ rooms, and children in protective or infectious isolation or with allergies to dogs were precluded from participation in the program. For the evaluation, pet visits were observed, followed by an interview with both the parents and the patient. Each patient was observed during the first pet visit. Establishing the Bond Establishment of a healthy and effective bond is an essential first step for patients to benefit from pet companionship (Zisselman, Rovner, Shmuely, & Ferrie, 1996). The complex process of bonding is affected by many factors, including the temper- aments of the child, the parents, and the animal. Other factors include the facilitation provided by the volunteers and the setting and environment of the visit. With the right combination of these fac- tors, the establishment of a healthy bond can be remarkably swift. Visible signs of bonding and rapport were often observed within minutes of the initiation of the visit, and sometimes this process seemed to occur virtually instantaneously. The level of physical activity during the pet visit between the child and the dog and the parent(s) and the dog, as observed by a member of the evaluation team, was recorded and classified into 1 of 6 levels. Activity was considered level 0 if there was no interaction or outright avoidance between the dog and the subject. Interactions limited to eye contact with no attempt at communication were classified as level 1. Interactions that involved an attempt at communication, either verbally or by gesture, but without any physical contact between the animal and the subject were considered level 2. Interac- tions where physical contact occurred between the dog and the subject, but without any attempt at communication, were classified as level 3. Interac- tions that involved both verbal or nonverbal com- munication and simple physical contact such as petting or stroking the dog were considered level 4. When a complex physical interaction involving both communication and active play occurred be- tween the pet and the subject, the activity was considered level 5. The observer also subjectively evaluated the level of rapport achieved between the subject and the visiting animal and classified it into 1 of 5 levels. If the subject appeared uncomfortable with the dog throughout the course of the visit, this was considered level �1. If the subject appeared to be comfortable with presence of the animal and/or showed transient interest in the animal, this was recorded as level 0. If the subject displayed a sustained interest in the dog over a period of time greater than half the total visit and the emotional tone of the encounter was largely neutral, this was recorded as level 1. If the interaction between the dog and the subject was warm, friendly, and re- laxed, this was classified as level 2. If the interac- tion appeared to be loving and intimate, this was classified as level 3. In the subsequent interview, the subject was asked to describe his or her own feelings generated by the encounter and then to choose which of 6 terms represented those feelings most closely. The terms the subject could choose from were strongly negative (level �2), unease or dislike (level �1), indifference (level 0), calm and relaxed (level 1), pleased and content (level 2), and happy and joyful (level 3). The levels of observed activity, the observer’s subjective classification of rapport, and the sub- ject’s own description of feelings generated during the encounter are summarized in Table 1. Milieu Impact To assess milieu impact, the patients and par- ents were asked to describe what they thought and felt about the hospital environment and what kind of impact the pet visit had on these opinions and feelings, if any. They were then asked to choose which of 4 levels most accurately de- scribed how the pet visit affected their percep- tion of the hospital milieu. If they felt that the pet visit changed their perception of the hospital milieu negatively overall, they were asked to 356 WU ET AL select level �1. If they felt that the pet visit did not change their perception of the hospital mi- lieu, they chose level 0. If they felt that the pet visit primarily distracted them from the everyday reality of the hospital milieu, they chose level 1. If they felt that the pet visit helped normalize their perception of the hospital milieu by making it feel more like home or the outside world, they chose level 2. The milieu impact levels are also summarized in Table 1. Measures of Satisfaction Patient and parent satisfaction with the PAWS program was also assessed. Both parents and patients were asked whether they felt they ben- efited from the visitations and, if so, to identify in which way they felt they gained the most benefit. They were also asked whether their ex- perience with the PAWS dogs changed their own feelings about pets and animals. Finally, they were asked whether they would want another visit and whether they would recommend pet visitation to others. Physiologic Parameters A subset of the patients receiving pet visits had vital sign monitors attached for medical reasons. In these patients, physiologic parameters of heart rate, respiratory rate, and oxygen saturation were re- corded, with beginning, end, high, and low values noted. Data Analysis The data were statistically analyzed with the use of the SAS statistical program (SAS Institute, Cary, NC). Kendall � correlation coefficients were calculated between physiologic parameters and measures of activity, feelings, and rapport for both patients and parents. Correlations among the mea- sures of activity, feelings, and rapport themselves were also calculated and frequency tables gener- ated. Table 1. Measurement Scales Level/category Description Activity scale 0 No activity/avoidance 1 Eye contact/watching 2 Communication without physical contact 3 Physical contact initiated or accepted 4 Physical contact with communication 5 Active play Rapport scale –1 Subject uncomfortable with dogs 0 Comfortable with dogs, transient interest 1 Sustained interest 2 Interaction is warm, friendly, and open 3 Interaction is loving and intimate Feelings scale –2 Strongly negative –1 Unease or dislike 0 Indifferent 1 Calm and relaxed 2 Pleased and content 3 Happy and joyful Milieu impact scale �1 Negative impact 0 No impact 1 Distraction—described as “something new,” “a diversion,” etc. 2 Normalization—described as “more homelike,” “something familiar,” etc. Benefit categories 0 No benefit 1 Relief—calming, reduction of fear, stress relief, diversion, etc. 2 Motivation/facilitation—gives motivation to get better, comply with treatment; facilitates social interaction, provides topic of conversation, etc. 3 Unconditional love—makes subject feel loved, accepted, needed, and valued 4 Object of comfort/projection of feelings—gives subject sense of control, offers opportunity to release fears and worries 357PET VISITATION ON A PEDIATRIC CARDIOLOGY INPATIENT UNIT RESULTS Patient Population A total of 30 children, 10 girls and 20 boys, were observed during pet visitation encounters in the course of the evaluation, along with 28 mothers and 17 fathers, with 15 encounters with both par- ents present. The median patient age was 7 years, ranging from 3 months to 16 years. Eight of the patients were under the age of 5 years and were not interviewed. None of the children had been visited by a dog before during any previous hospital ad- missions. Fifteen patients were in the hospital for heart surgery, 4 for cardiac catheterization, 2 for arrhythmias and pacemaker placement, and 2 for adjustment of medications. Four patients were be- ing treated for noncardiac conditions but were on the ward because they had significant underlying cardiac disease that required monitoring, and 3 had noncardiac conditions. Half of the participating families currently owned a pet, 20% had previous experience with a pet, and the final 30% had no experience with pets. As the PAWS program is voluntary, all of the participants were favorably disposed toward animals from the outset: 37% of patients and 46% of parents indicated that they were highly favorable. Thirteen patients had cardiac and vital sign mon- itors attached for medical reasons and had their physiologic parameters recorded. Patient and fam- ily demographics are summarized in Table 2. Physiologic Parameters No statistically significant changes were ob- served in oxygen saturation levels or in heart and respiratory rates between the beginning and end of pet visits. Significant transient changes, however, were observed during the course of the pet visita- tion. There was a significant difference between the highest observed respiratory rate and the be- ginning rate: the mean increase was 17.3 breaths/ min, with an SD of 13.6 breaths/min (p � .001). The degree of this rise in respiratory rate correlated negatively with the degree of rapport established between patients and visiting dogs (r � �0.54, p � .04). Thus the stronger the rapport that devel- oped between the patient and the visiting dogs was, the less intense the increase in respiratory rates during periods of stimulation was. A significant difference between the beginning and low values for both respiratory and heart rates was also observed. The difference between the beginning and low respiratory rates averaged 15.3 breaths/min, with an SD of 10.6 breaths/min (p � .0004), whereas the mean difference between the beginning and low heart rates was 10.3 beats/min, with an SD of 12.1 beats/min (p � .02). Decreases in respiratory rate were noted most frequently dur- ing periods of physical contact between patients and dogs, but there was no significant correlation between the magnitude of the falls in respiratory rate and the activities undertaken by the child with Table 2. Demographic Data Patient demographics Total patient population (n) 30 Males 20 (67%) Females 10 (33%) Median age (range) 7 y (3 mo to 16 y) Patients aged � 5 y 8 (27%) Patients on cardiac monitoring 13 (43%) Reason for hospitalization Heart surgery 15 (50%) Cardiac catheterization 4 (13%) Arrlythmia/pacemaker 2 (7%) Medication adjustment 2 (7%) Noncardiac Underlying cardiac disease 4 (13%) No underlying cardiac disease 3 (10%) Family demographics Total parent population (sets) 30 Mothers present 28 (93%) Fathers present 17 (57%) Both parents present 15 (50%) Families currently owning a pet 15 (50%) Families with previous experience with a pet 6 (20%) Previous disposition toward animals Parents (highly favorable/favorable/unfavorable) 46%/54%/0% Patients (highly favorable/favorable/unfavorable) 37%/63%/0% 358 WU ET AL the dog. This finding may reflect the fact that no distinction was made in the nature and duration of physical contact (e.g., whether it was calm petting or stroking or boisterous play). In conclusion, a pet visitation can have both stimulating and relaxing effects on pediatric pa- tients, and these effects are accompanied by appro- priate changes in respiratory rate and heart rate. The establishment of a strong rapport with the dogs appeared to lessen the intensity of the impact that stimulation had on heart rate. Relaxation effects seemed to dominate over stimulation effects as rapport developed between the children and the PAWS dogs. Activity, Rapport, and Feelings Table 3 shows the frequency distributions of activity, rapport, and feelings rankings for both patients and parents in the PAWS program in cor- relation with each other. Among the patients, all of the children had interactions with the dogs that included physical contact (activity levels 3, 4, and 5). Of these 30 children, 24 established rapport that was observed to be in the positive categories (lev- els 3 and 4) and 26 reported positive feelings generated by and during the pet visitations (levels 4 and 5). A significant correlation was observed between the presence of physical contact and both the establishment of rapport (r � 0.35, p � .04) and the patient’s self-reported positive feelings (r � 0.36, p � .04). Similarly, a correlation was observed between the observed level of rapport and the degree of positive feelings reported by the patients themselves (r � 0.71, p � .0001). Once again, most of the children (23/30) scored in the double positive area, with both positive rapport and positive feelings. Many of the subjects commented on the enjoyment they received from touching and interacting with the dogs. One child reported, “I liked the warmth [of the dog],” and a mother, commenting about her son, remarked that “he loves it when the dogs get on the bed with him.” When the effects of activity on the establishment of rapport and the generation of positive feelings for the parents were analyzed, the correlations were even stronger than for the children (r � 0.72 and p � .0001 for correlations between activity and rapport; r � 0.61 and p � .0002 for correla- tions between activity and feelings). This trend could be a result of the parents having more pre- viously established positive ideas about their feel- ings about animals and the activities they enjoy doing with them. Unlike the children, who were entirely distributed within or near the triple posi- tive ranges (activity including physical contact, positive rapport, and positive self-reported feel- ings), the parents comprised two groups. The first and larger group, like the patients, had triple pos- Table 3. Correlations Between Activity, Rapport, and Feelings Generated by Pet Visitation for Patients and Parents Activity levels 0 1 2 3 4 5 Patient rapport levels (n � 30)* 3 4 3 4 2 4 8 1 1 4 1 0 1 –1 Parent rapport levels (n � 31)† 3 10 5 2 1 8 1 1 2 0 1 3 –1 Patient feelings level (n � 30)‡ 3 4 4 4 2 5 8 1 1 4 0 –1 –2 Parent feelings level (n � 30)§ 3 7 3 2 1 9 2 1 2 4 1 0 1 –1 –2 Rapport levels �1 0 1 2 3 Patient feelings level (n � 30)� 3 1 1 10 2 2 11 1 1 1 2 1 0 –1 –2 Parent feelings level (n � 30)¶ 3 2 8 2 6 6 1 3 3 1 0 1 –1 –2 r, Kendall � correlation coefficient. *Correlation of patient activity level with rapport level: r � 0.35, p � .04. †Correlation of parent activity level with rapport level: r � 0.72, p � .0001. ‡Correlation of patient feelings level with activity level: r � 036, p � .04. §Correlation of parent feelings level with activity level: r � 0.61, p � .0002. �Correlation of patient feelings level with rapport level: r � 0.71, p � .0001. ¶Correlation of parent feelings level with rapport level: r � 0.62, p � .001. 359PET VISITATION ON A PEDIATRIC CARDIOLOGY INPATIENT UNIT itive ranges, but a smaller second group was ob- served to have triple neutral ranges. These were the parents who largely chose not to interact with the pets themselves and instead essentially stood back and watched their child play with the dogs. They tended not to have physical contact with the ani- mals, and their observed rapport and self-reported feelings were at neutral levels. As with the pa- tients, there was a correlation between the degree of rapport and the level of positive feelings for the parents (r � 0.62, p � .001). Interestingly, many parents stated during interviews that one of the most important reasons that the pet visitations made them happy was that they were able see their children be happy with the dogs, but there was no correlation between the child’s reported feelings and those of the parents. No patient or parent scored in the negative ranges for activity, rapport, or feelings. No one who participated in the PAWS program completed a visit feeling that it had been a negative experi- ence. Milieu Impact In total, 35% of the children and 48% of the parents reported that the presence of the dogs helped normalize their hospitalization experience, and 61% of the children and 40% of the parents thought that the pet visitations were a pleasant distraction from the reality of hospitalization. One child commented that the dog visit “makes you feel like you’re at home”; in a similar vein, another child said, “[the dog] makes the hospital feel really homish.” A third patient reported that having the dogs visit “makes you feel kind of normal.” This effect was also noted by the parents: one father commented on how the visits “make the atmo- sphere less clinical,” and one mother added that the dogs were “like something from home.” Other subjects found the pets to be a pleasant diversion, with one mother telling the interviewer that the pet visit “took my mind off my worries and helped me get back into the norm.” Another parent com- mented that the visits were “a nice change from the everyday routine.” A small percentage (4% of pa- tients and 12% of parents) indicated that the pet visitation did not change their impression of the hospital milieu. Again, no negative impact was reported by any of the patients or parents. Distrac- tion was the primary milieu impact, particularly for the younger children. Benefits and Satisfaction Commenting on the dogs, one mother said “they can feel when a child is in pain, or happy, almost as if they can read their minds.” Another subject, referring to one of the dogs in the program, ob- served that “he has a ’love me’ look that makes you feel needed.” Most patients (73%) considered relief the most important benefit of the pet visits, 19% chose the giving of unconditional love, and the remaining 8% said it was the motivation to get better or to stay optimistic. None of the patients believed that they received no benefit from the pet visit. (See Table 1 for the benefit categories.) Among the parents, 52% identified relief as the most important benefit, 16% said the most impor- tant benefit was the giving and receiving of uncon- ditional love, 16% felt that they personally re- ceived no benefit, 12% felt that the most important benefit was the facilitation of social interaction, and 4% identified having the pet as an object for the projection of feelings as the most important benefit. These self-reported benefits were correlated by observation. Both children and parents were seen to take pleasure in receiving unconditional love from the dogs, children were observed being mo- tivated to look forward to another visit, and both children and parents were observed anthropomor- phizing the dogs and projecting feelings, though they did not necessarily identify this process ex- plicitly. In large part the participants in PAWS were highly satisfied with and supportive of the pro- gram. All of them wished to be visited again in the event of a future hospitalization, 24% of patients and 12% of parents reported that the visitation had made their attitudes toward animals (generally al- ready positive) even more positive, and none re- ported that the visits made their attitudes toward animals worse. Eight percent said they would rec- ommend pet visitation for other hospitalized chil- dren, 32% would recommend it for both hospital- ized adults and children who liked animals, and 60% said they would recommend a pet visit to anyone, even those who did not normally like animals. Of those interviewed, 74% believed that the PAWS program as currently run poses no sig- nificant risk to the children and 100% considered the program to be beneficial. Limitations of the Evaluation The sample was self-selected because of the voluntary nature of the program, so most sub- jects were predisposed to react favorably to a pet visitation. The children involved comprised a wide range of ages and maturity levels, and patients and parents were interviewed together: the opinions of one, therefore, may have had an 360 WU ET AL impact on those of the other. Because all of the encounters in this evaluation were first-time vis- its, only the initiation of human-animal bonding could be observed. There were insufficient num- bers of patients who received multiple visits over long hospital stays to analyze the impact of bond strengthening over time. Although the changes in physiologic measurements were sug- gestive of a beneficial effect, we lacked a control group for comparison. Further investigation will be necessary to determine whether pet visitation has any important impact on physiology. We did not use any previously available instruments for assessment in this evaluation. An important lim- itation is that we did not assess validity or reli- ability of our evaluation interview, nor did we perform any formal qualitative analysis. DISCUSSION The benefits of animal-assisted therapy span the spectrum of age, culture, and creed. Studies have shown tangible benefits in patient populations ranging from geriatric (Gammonley & Yates, 1991; Harris, Rinehart, & Gerstman, 1993; Zissel- man, Rovner, Shmuely, & Ferrie, 1996) to pediat- ric (Bardill & Hutchinson, 1997; Davis, 1985; Kale, 1992) in many different areas of clinical medicine, from home care (Harris, Rinehart, & Gerstman, 1993) to intensive care (Cole & Gaw- linski, 1995) to psychiatry (Bardill & Hutchinson, 1997; Zisselman, Rovner, Shmuely, & Ferrie, 1996). Cultural attitudes toward certain types of animals in specific settings likely affect the process of bonding, but these factors were not observed in this project because participation in PAWS was voluntary. The PAWS program has been enthusiastically received by both patients and parents on the car- diology ward, and tangible benefits of this program in both physiologic and psychological factors have been observed and measured. Both stimulating benefits, such as waking a child who is groggy from recently completed surgery, and relaxing ben- efits, such as calming a tense child waiting for a procedure, with concurrent physiologic changes, were evident. The physiologic impact of stimula- tion is reduced as rapport is developed. Relaxation and calming appear to become more common and important as the patient and dog grow more famil- iar with each other. Relaxation effects on heart and respiratory rates were consistent with the results of a study in which petting one’s own dog, with whom a bond had been established, produced a relaxation effect similar to quiet reading in adults (Baun, Bergstrom, Langston, & Thomas, 1984). The fall in heart rate was also consistent with the fall in heart rate observed during pet visitations in geriatric populations (Harris, Rinehart, & Gerst- man, 1993). However, changes in respiratory rate were not statistically significant in the geriatric study, whereas in this evaluation changes in respi- ratory rate were the most notable physiologic ef- fect. This may reflect the physiologic differences between children and elderly adults or the fact that the patient population in this evaluation had a greater incidence of cardiac disease. Establishment of rapport and generation of pos- itive feelings were enhanced by physical contact and close proximity. Maneuvers such as bringing the child down to the pet on the floor, bringing the pet up onto the bed with the child, or letting the child walk the pet around the unit under supervi- sion help establish the warmest relationships in the shortest time and generate the most patient and parent satisfaction. Finally, the benefits of bonding are not exclusive to the patients and parents who sign up for a visit. Anyone on the ward during the time the dogs are making their rounds, including staff, volunteers, and other parents and patients not confined to their rooms, can benefit as well. As in the study by Bardill & Hutchinson (1997), the presence of the visiting animal in the hospital helped make the hospital milieu more homelike, friendly, safe, and protective. Distraction and stress relief were the primary benefits of this interven- tion, with normalization secondary, perhaps be- cause of the brief nature of the visits, as stress relief requires the least amount of bonding. For children with long hospital stays who receive many visits, the importance of normalization may in- crease and the impact of diversionary aspects may gradually become less important. The process of hospitalization can be a stressful, frightening, and confusing time for pediatric pa- tients and their families and may negatively affect the clinical outcome. The effort to make the expe- rience of hospitalization less daunting for children is a continuing one, and the friendly pet can be a valuable ally in this endeavor. Nurses should be aware of the dislocating and disorienting effects of hospitalization on their young patients and their families. Nurses can be strong advocates in the development of similar programs within their in- stitutions. It is hoped that the data provided from our evaluation will assist in this endeavor. Other opportunities for normalization of the hospital mi- lieu might be the subject of further nursing re- search. 361PET VISITATION ON A PEDIATRIC CARDIOLOGY INPATIENT UNIT REFERENCES Bardill, N., & Hutchinson, S. (1997) Animal assisted therapy with hospitalized adolescents. Journal of Child and Adolescent Psychiatric Nursing., 10, 17-24. 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