Animal-assisted support programs for residents in Canadian long-term care homes: a feasibility and acceptability study

Abstract

Background

Animal-assisted services, specifically animal-assisted support programs (AASPs, pet therapy, animal-assisted therapy, animal-assisted activities), are promising programs that may improve the mental health and overall well-being of older adults living with and without dementia in long-term care (LTC) homes. Few studies have explored the perspectives of residents and LTC staff regarding AASPs for older adults. This study aimed to identify the initial perspectives of LTC staff regarding the feasibility, acceptability, and other factors influencing the implementation of a live AASP within Canadian LTC homes. Our secondary aim was to supplement the perspectives of the LTC staff with interviews from LTC residents and community members.

Methods

Qualitative semi-structured individual and group interviews were conducted in 2022 and 2023 with LTC staff members from one LTC home in Alberta, Canada. Additional interviews with community members and LTC residents supplemented these interviews. The interviews were analyzed using Braun and Clarke’s recommendations for thematic analysis.

Results

Eighteen individuals were interviewed, including 14 LTC staff, 2 LTC residents, and 2 community members (one AASP volunteer and one individual living with dementia). Four key themes were identified: (1) Experiences with animals in LTC, (2) Acceptability and perceived benefits of AASPs, (3) Perceived challenges of AASPs and associated mitigators, and (4) Preferences and recommendations for AASPs in LTC.

Conclusions

AASPs have many potential benefits for residents and staff in LTC homes, including perceived improvements in mood and social engagement. Interview participants provided insights and recommendations for future AASPs, including understanding the challenges to implementing AASPs, such as the fear of animals. The interview findings will inform the design of an AASP intervention and a pilot study to implement and evaluate the intervention in LTC.

Background

Mental health concerns, including depression and anxiety, are increasing in older adults, especially in those living in long-term care (LTC) [1, 2]. The Canadian Institute for Health Information [3] reported that approximately 69% of residents in Canadian LTC homes have dementia, and 87% of residents have some form of cognitive impairment (2015–2016). A recent study of over 514,000 residents in 1319 LTC homes (2002–2018) in Canada also described that nearly 76% of residents had a diagnosed mental health disorder or Alzheimer’s disease and related dementias [2]. These residents with mental health concerns and/or dementia are highly vulnerable as they are less likely to be socially engaged and more likely to receive psychotropic drugs and be physically restrained [2]. They are also at high risk of loneliness and social isolation. Loneliness and high-stress situations can negatively affect the well-being of these older adults by contributing to sensory deprivation, functional decline, symptoms of confusion, and increasing behavioural and psychological challenges [1, 3–6]. Interventions to help address the overall well-being, loneliness, mental health, and social isolation of older adults in LTC homes are needed.

One potential program that may be beneficial in LTC is animal-assisted support programs (AASPs). AASPs are a form of animal-assisted service, which is an overarching term referring to any practice that involves animals in a role to help benefit humans [7]. AASPs are often referred to as animal-assisted interventions, animal-assisted therapy, animal-assisted activities, or pet therapy [7–12]. AASPs are provided by trained or knowledgeable volunteers or paraprofessionals (qualified or registered animal handlers) in partnership with a trained or registered animal (in most cases, a dog) to improve recipients’ well-being. In most cases, AASP volunteers and animals complete a registration process with a formal animal service organization, which often includes training or evaluation (including health screening). An example of one such organization in Canada is the St. John Ambulance Therapy Dog Program [13] . This differs from more informal animal visitation from family members or unregistered volunteers, who are not required to complete these processes. AASPs are a desirable option for improving the well-being of older adults, as they require minimal cognitive capacity and input from the participant, in this case, the LTC resident [7, 8,9,14,15. AASPs help enhance well-being by providing opportunities for socialization and nervous system self-regulation. One well-understood mechanism of these programs is sensory modulation. Using a sensory modulation approach, AASPs promote self-regulation by drawing the participant’s attention to a positive stimulus, such as petting the animal, and distracting and soothing the resident from adverse effects related to (but not limited to) social isolation and mental health concerns [16–18].

Despite several studies of varying designs exploring the effects of AASPs (e.g., improvement in depression in older adults), there is little research focused on the factors that influence the feasibility and acceptability of AASPs for older adults living in LTC homes, especially in the Canadian context [8–12, 19, 20]. Feasibility and pilot studies aim to determine key factors needed to design an intervention study (e.g., a randomized controlled trial) by refining the understanding about if and how interventions and evaluations will work [21–23]. Feasibility encompasses acceptability (whether individuals receiving or delivering an intervention believe it’s appropriate), demand (the likelihood an intervention will be used), concerns surrounding implementation (barriers and facilitators), and practicality (the ability to carry out an intervention) [22–25].

Several pilot and feasibility studies focus on AASPs for older adults in LTC [26–32] and other settings (e.g., hospitals, retirement homes, dementia day care centers, participant homes, and assisted living) [33–41]. Most of these studies focused solely on outcomes related to residents (e.g., depression) and did not examine feasibility-related outcomes (e.g., implementation barriers and facilitators) [27, 28, 30, 31, 33–36, 40, 41]. Only nine studies address feasibility and acceptability outcomes, from six pilots [26, 29, 32, 37–39] and three qualitative studies [42–44]. The pilot studies focused on a variety of healthcare settings, with little focus on LTC. The pilot studies described AASP-related interventions as highly acceptable and bringing pleasure to older adults [26, 29, 32]. They also briefly discussed recruitment feasibility and key learnings from implementation (e.g., the need for animal screening) [37–39]. The three qualitative studies (two in LTC) explored the perspectives of residents, family members, and staff regarding AASP implementation, feasibility, and acceptability [42–44]. The findings included potential facilitators and barriers to interventions (e.g., organizational constraints), adaptations (e.g., tailoring to resident preferences), and recommendations for AASPs (e.g., staff training) [42–44]. One qualitative paper that we located focused on Canadian LTC settings [43]. However, it only discusses acceptability in the context of interventions for loneliness. These pilot and feasibility papers provide initial insights surrounding the feasibility and acceptability of AASPs for older adults. More information is needed as most of these papers focus on specific contexts or uses of AASPs, do not involve the perspectives of all individuals involved, are not conducted in Canada, or provide only a brief overview of acceptability or feasibility.

No studies in the Canadian context have explored the perspectives of key individuals, including residents and staff, on the factors influencing both the feasibility and acceptability of AASPs in LTC to improve the well-being of older adults. To begin to address this research gap, we designed a semi-structured interview study to gain perspectives from LTC staff and supplement these perspectives with interviews from residents and community members (including AASP volunteers) on factors that influence AASPs, specifically in Canadian LTC homes. The findings from this paper will be used to develop an AASP intervention and to design a pilot study to evaluate its implementation (feasibility) and resident outcomes in LTC in Canada [45, 46].

Research question

“What factors influence the feasibility and acceptability of animal-assisted support programs for residents living in Canadian LTC homes?”

Research aims

1. To identify if AASPs are acceptable to LTC staff, residents, and community members (including AASP volunteers) in Canadian LTC homes.

2. To identify from the perspectives of LTC staff the factors that will influence the planning, delivery, and evaluation of AASPs in Canadian LTC homes.

3. To supplement the perspectives of staff by identifying the perspectives of LTC residents, family members, and community members (e.g., AASP volunteers).

Methods

An exploratory study was conducted using semi-structured interviews. The study design and reporting followed O’Cathain et al.’s (2015) guidance for qualitative research in feasibility studies [47]. This guidance was used to design a relevant research question while guiding how we designed and conducted our study from data collection to analysis and reporting in an iterative and dynamic process [47].

Setting, sampling, & recruitment

We recruited residents and staff from one LTC home in Alberta, Canada. The LTC home was chosen based on availability and because they had prior experience with informal animal visits and were keen to develop a potential structured AASP in their home in the future. Interview participants were recruited using information posters in the home, recruitment emails, and discussions with the home manager.

We invited all staff who provided care to residents to participate. This included care aides (nursing assistants), nurses, managers, and allied health (e.g., occupational therapy). Residents were recruited by the care home manager, who distributed information posters and approached multiple residents to participate in the interviews. We attempted to recruit family members of residents using the same methods; one potential participant described interest, but no interviews could be scheduled due to scheduling conflicts. We were unable to recruit any additional family members.

We also recruited one AASP volunteer and one individual living with dementia (community members) based on previous connections to our research program. The AASP volunteer was formerly registered with an AASP organization and provided AASPs in LTC homes in Alberta, Canada. She did not provide AASPs to the LTC home in this study. The older person living with dementia had no association with the LTC home in this study and lives at home in the community. He is a long-time community partner and research advocate for individuals with dementia. He has also had experience working on robotic AASP research projects, unrelated to this research team.

Participants received a $10 coffee gift card. The LTC home received a $500 stipend for its participation.

Data collection

Individual and group interviews were conducted in person and online using Zoom for up to 40 min [48]. Resident and staff interviews were scheduled in collaboration between the participants, the LTC manager, and the project lead (BDeG). Resident interviews were conducted in person in their rooms, and group interviews with staff were held in a conference room allocated by the LTC home’s management. Community members completed their interviews online.

Interviews were led by BDeG; most interviews were also attended by a research assistant (RA). Interviews were recorded using an audio recorder (in-person) or Zoom (online), with field notes taken by an RA or the interviewer. The field notes focused on identifying environmental disturbances (e.g., noise outside the interview room or difficulties accessing Zoom) and non-verbal communication. Group and individual interviews were combined due to time constraints, particularly when accessing the LTC home. LTC staff participated in in-person group interviews to promote collaboration and discussion surrounding the question guide. The group interviews were preferred by the care home and were used to gain perspectives from a larger group of staff participants, as the care home was unable to schedule individual interviews. These interviews were considered group interviews rather than focus groups, as they did not directly examine interaction data or dynamics among the participants, but instead focused on collecting broad information from multiple participants at once. Group interviews (2 interviews) had a maximum of 6 participants. Staff (n = 2) who could not attend in-person group interviews completed online individual interviews.

Interviews began with an introduction to the study and the consent process. Demographic information was collected at the beginning of each interview using a brief questionnaire. Interviews were semi-structured and had an interview guide, with each set of questions tailored to the participant’s specific role (i.e., resident, staff, or community member). Interview questions and the demographic information questionnaire were developed based on our review of the literature and discussions among our research team, which includes individuals with experience in AASP (CD) and LTC (BDeG, CE, HO). We developed our questions to address four main areas of feasibility (acceptability, demand, practicality, and concerns surrounding implementation) using Bowen et al.’s (2009) definitions of areas of feasibility [24]. We adapted the interview guides throughout the interview process using an iterative process in which we concurrently conducted initial data analysis and identified which topics had been addressed more often and which had not [47]. We also adjusted the wording of the questions to enhance delivery and improve participants’ understanding.

Table 1 describes the key components of our question guide. While the effects of AASPs on animal welfare are an important area of study, this was not the purpose of our study and questions related to it were not addressed.

Table 1.

Question guide key components

Component	Feasibility Area [24]	Question Example*	Additional Prompt Examples
Staff Interviews
Experience with pet therapy	Acceptability, Demand, Practicality	1.Tell me a bit about your experiences with or your opinions about pet therapy?	a. Have you seen pet therapy or animals within your LTC home? b. How often and when? c. Are you interested in pet therapy? d. Is pet therapy something you believe residents and other staff members would be interested in? Family members?
Barriers or challenges	Practicality, Implementation Concerns	2.What are your concerns (or barriers) that you have surrounding pet therapy in the LTC home?	a. Barriers for residents? For staff? b. Are there any cultural/language barriers we should consider? c. Any risks you are concerned about? d. How would you suggest we address these barriers?
Potential benefits	Acceptability, Demand	3.What benefits do you believe pet therapy may have?	a. What benefits do you think these programs may have? For staff? For residents? b. Any other potential benefits?
Recommendations surrounding program design	Acceptability, Demand, Practicality, Implementation Concerns	4.What do you believe may help us implement pet therapy in the long-term care homes?	a. What types of activities should be included? b. Where should this take place? c. How long should visits be? d. How often should we bring pets into the home? e. What time would work best? f. How should we recruit the residents? g. Should staff be involved? How so? h. What do you think would make it easier for residents to participate? i. What supports do you think we should provide the home? j. What would the perfect pet therapy program look like in your eyes?
Resident Interviews
Experience with pet therapy	Acceptability, Demand, Practicality	1.Tell me a bit about your experiences with or your opinions about pet therapy?	a. Have you seen pet therapy or animals within your LTC home? b. How often and when? c. What did you like about the experience? d. What did you dislike? e. Is pet therapy something you believe you would be interested in? Or other residents would be? f. Do you believe a pet therapy program is needed in your LTC home?
Barriers or challenges	Practicality, Implementation Concerns	2.What are the concerns (or barriers) that you have surrounding pet therapy in the LTC home?	a. How can we work to address these concerns? b. Do you find pets distressing?
Potential benefits	Acceptability, Demand	3.What benefits do you believe pet therapy may have?	a. What benefits do you think these programs may have? For you? For other residents? b. What feelings do you have around pets? c. What is it about pet therapy you are most interested in?
Recommendations surrounding program design	Acceptability, Demand, Practicality, Implementation Concerns	4.What can we do to make it easier for you [the resident] to participate in this type of therapy?	a. What types of activities should be included? b. Where should this take place? c. How long would you want to visit with the animal? d. How often should we bring pets into the home? e. What time would work best? f. How should we recruit the residents? g. Should staff be involved? h. What would the perfect pet therapy program look like in your eyes?
AASP Volunteer Interview
Experience with pet therapy	Acceptability, Demand, Practicality	Tell me a bit about yourself professionally and your experience with pet therapy?	a. How long have you been doing this work and in what capacity? b. Do you have a certification in pet therapy? c. What got you interested in this area? d. How often do you work with individuals living with dementia (or older adults in LTC)?
Pet therapy structure	Practicality, Implementation Concerns	Walk me through a typical pet therapy session. What is involved?	a. Besides you and the resident, who else may be involved? b. How often might you provide pet therapy for a particular resident or group? How long does a session last? Is this enough time? c. What setting was it? d. What is the role of the LTC home in pet therapy? Was the home able to accommodate for the program to take place?
Pet therapy structure: resident recruitment	Demand, Practicality, Implementation Concerns	Describe how you identify and recruit residents for pet therapy. What does this process involve?	a. Is there anyone besides you involved? b. How easy or difficult is it to get residents to participate? What do you believe made it easy or difficult? c. In a perfect world, what would be the best way to recruit residents?
Potential benefits and barriers	Acceptability, Demand, Practicality, Implementation Concerns	What do you see as the key benefits and barriers to using pet therapy in long-term care?	a. What makes pet therapy desirable to residents, family members, or staff? b. What benefits do you believe pet therapy may present to older adults in LTC? c. Have you encountered any barriers in your sessions? Related to cognitive abilities? Cultural/language barriers? d. How do you believe barriers might be better addressed?
Recommendations surrounding program design	Acceptability, Demand, Practicality, Implementation Concerns	From your perspective what would the perfect pet therapy program look like?	a. What would this involve?
Community Member Living with Dementia Interview
Experience with pet therapy	Acceptability, Demand, Practicality	Tell me about yourself and your interest in pet therapy?	a. What got you into this field? b. What experience do you have with pet therapy and individuals living in LTC? Or individuals with dementia?
Experience with pet and robotic pet therapies	Acceptability, Demand, Practicality	Tell me about your experience as a research partner especially involving pet therapy or robotic pet therapy projects.	a. How did you first get involved? b. What was your experience like when you first started working with animals or robotic animals? c. What did you get out of your involvement in the research projects?
Potential benefits and barriers	Acceptability, Demand, Practicality, Implementation Concerns	What do you see as the key benefits and downsides to pet therapy in LTC? How about for robotic pet therapy?	a. What barriers might we need to overcome for this to be successful? b. What are the main similarities or differences between live and robotic pets? Which would you prefer?
Recommendations surrounding program design	Acceptability, Demand, Practicality, Implementation Concerns	From your perspective what would the perfect pet therapy program look like?	a. What prevents such a program from being developed and delivered? How can challenges be better addressed?

The term pet therapy and an associated definition was used during interviews to allow for easier understanding of all participants

Immediately after the interview, debrief sessions were held. These sessions included meetings between the interviewer and field notes taker (research assistant), and/or recorded reflexive journaling (speaking out loud and recording). These sessions were held to maintain reflexivity, acknowledge any biases or perceptions (positionality) present during interviews, and discuss potential changes to the interview guide.

Analysis

Audio recordings were transcribed verbatim using REV transcription services [49]. The transcripts included the recorded debrief sessions. The transcripts and field notes created an audit trail of decisions during data collection and identified environmental factors influencing the interviews. Participants were assigned an anonymous identification number, and all personal data was removed. BDeG cross-checked all transcripts against interview recordings for accuracy.

We analyzed the demographic questions using descriptive statistics. Interviews were managed and analyzed in NVIVO 15 using Braun and Clarke’s recommendations for thematic analysis [50, 51]. This included (1) becoming familiar with the data by re-reading transcripts and listening to interview audio recordings while writing down initial ideas, (2) generating initial codes and ideas, (3) using the initial codes to identify the themes that ran through each interview, (4) reviewing the themes and ensuring the themes fit with each code and then (5) defining (naming) the final themes. The primary author (BDeG) began the analysis by reviewing the transcripts and field notes in NVivo, writing initial codes and ideas, and sharing them with the research team. The analysis was then completed by BDeG, who summarized initial codes into themes and created a results summary for the research team to review and finalize the themes in multiple meetings. To reflect on potential biases and ensure consistency in the analysis, BDeG wrote reflexive memos and met regularly with the research team.

Results

Eighteen individuals participated in our interviews (individual and group), including 1 AASP volunteer and 1 person with dementia, 2 LTC residents, and 14 LTC staff from 1 LTC home.

The LTC home was a large not-for-profit home in an urban area in Alberta, Canada. Approximately 50% of this home is dedicated to residents living with advanced dementia.

Long-term care staff in our interviews included care aides (8), allied health (2), nurses (1) and managers (3). There was a mix of workers from dementia units and regular long-term care units. Allied health and managers included unit managers, allied health managers, physiotherapists, occupational therapists, recreational therapists, and therapy assistants. All staff were women (n = 14, 100%). The majority were born outside of Canada (n = 8, 57.1%), white (n = 8, 57.1%), worked full-time (n = 8, 57.1%), and had previously owned an animal (n = 13, 92.9%). All staff members described liking animals.

Both residents were female, white, and between the ages of 70–79, had owned pets in the past, and described liking animals. Neither resident had a history of cognitive impairment (as reported by the LTC manager).

The two community members were one older person living with dementia (in the community) who had experience collaborating on robotic AASP research (unrelated to this team), and a previous AASP volunteer who delivered AASP in various LTC and other environments.

Additional demographic characteristics of the participants are presented in Table 2.

Table 2.

Demographic characteristics of interview participants

Staff Characteristics (n = 14)
	Demographic Characteristics by Role
	Care Aide	Nurse	Allied Health	Managers	Total
Role, n(%)1	8(57.1)	1(7.1)	2(14.3)	3(21.4)	14(100)
Sex	n(%)	n(%)	n(%)	n(%)	n(%)
Female	8(100)	1(100)	2(100)	3(100)	14(100)
Age	n(%)	n(%)	n(%)	n(%)	n(%)
18–29 years	0(0)	1(100)	1(50.0)	0(0)	2(14.3)
30–39 years	1(12.5)	0(0)	0(0)	2(66.7)	3(21.4)
40–49 years	5(62.5)	0(0)	0(0)	1(33.3)	6(42.9)
50–59 years	2(25.0)	0(0)	0(0)	0(0)	2(14.3)
60 years or older	0(0)	0(0)	1(50.0)	0(0)	1(7.1)
English as a first language	n(%)	n(%)	n(%)	n(%)	n(%)
Yes	2(25.0)	1(100)	2(100)	2(66.7)	7(50.0)
No	6(75.0)	0(0)	0(0)	1(33.3)	7(50.0)
Place of Birth	n(%)	n(%)	n(%)	n(%)	n(%)
Canada	1(12.5)	1(100)	2(100)	2(66.7)	6(42.9)
Elsewhere	7(87.5)	0(0)	0(0)	1(33.3)	8(57.1)
Cultural Group2	n(%)	n(%)	n(%)	n(%)	n(%)
Black	1(12.5)	0(0)	0(0)	0(0)	1(7.1)
Filipino	4(50.0)	0(0)	0(0)	0(0)	4(28.6)
South Asian	0(0)	0(0)	0(0)	1(33.3)	1(7.1)
White	3(37.5)	1(100)	2(100)	2(66.7)	8(57.1)
Work Full-Time	n(%)	n(%)	n(%)	n(%)	n(%)
Full-time	3(37.5)	0(0)	2(100)	3(100)	8(57.1)
Part-time	5(62.5)	1(100)	0(0)	0(0)	6(42.9)
Shift worked most of the time	n(%)	n(%)	n(%)	n(%)	n(%)
Day shift	5(62.5)	1(100)	1(50.0)	3(100)	10(71.4)
Evening shift	2(25.0)	0(0)	0(0)	0(0)	2(14.3)
Night shift	0(0)	0(0)	0(0)	0(0)	0(0)
Other3	1(12.5)	0(0)	1(50.0)	0(0)	2(14.3)
Pet owner (past or current)	n(%)	n(%)	n(%)	n(%)	n(%)
Yes	7(87.5)	1(100)	2(100)	3(100)	13(92.9)
No	1(12.5)	0(0)	0(0)	0(0)	1(7.1)
Do you like animals?	n(%)	n(%)	n(%)	n(%)	n(%)
Yes	8(100)	1(100)	2(100)	3(100)	14(100)
No	0(0)	0(0)	0(0)	0(0)	0(0)
Animal allergies	n(%)	n(%)	n(%)	n(%)	n(%)
Yes	0(0)	0(0)	0(0)	0(0)	0(0)
No	8(100)	1(100)	2(100)	3(100)	14(100)
Years worked in role	Years	Years	Years	Years	Years
Range: Min, Max	3.5, 21	2,2	4,20	2.5,14	2,21
Mean	8.8	2	12	8.8	8.8
Years worked in LTC home	Years	Years	Years	Years	Years
Range: Min, Max	3.5, 21	2,2	4,7.5	2,7.5	2,21
Mean	8.7	2	5.8	5.2	7.0

Resident Characteristics (n = 2)
Characteristic	Total
Total, n(%)	2(100)
Cognitive Impairment4	n(%)
Yes	0(0)
No	2(100)
Age	n(%)
Other5	0 (0)
70–79 years	2(100)
Sex	n(%)
Male	0 (0)
Female	2 (100)
Birth Country	n(%)
Canada	1(50)
United States	1(50)
Other	0(0)
Cultural/Racial Groups2	n(%)
White	2(100)
Other	0(0)
English as a First Language	n(%)
Yes	2(100)
No	0(0)
Time lived in LTC home (years)	Years
Range, Min, Max	2,3
Mean	2.5
Pet ownership (past or current)	n(%)
Yes	2(100)
No	0(0)
Do you like animals?	n(%)
Yes	2(100)
No	0(0)
Animal Allergies	n(%)
Yes	0(0)
No	1(50)
Unsure	1(50)

Community member characteristics (n = 2)
Characteristics	Total
Total n(%)	2
Cognitive Impairment, n(%)
Yes	1(50%)
No	1(50%)
Age
30–50 years	1(50%)
70 + years	1 (50%)
Sex
Male	1 (50%)
Female	1(50%)
Pet Ownership (past or current)
Yes	2 (100%)
No	0(0%)
Place of residence (at time of interview)
Own home (community)	2 (100%)

¹Two individuals (in the manager group) identified themselves as both allied health and managers. Based on discussions with these individuals, they were categorized into the manager group

²Multiple options were provided on our demographic form; however, the individuals involved in the project only selected the options of “White”, “Filipino”, “Black” and “South Asian”

³The care aide and allied health individual in the other section described working various shifts

⁴This question was not asked on the demographic forms but was confirmed by staff before the interview and again with residents prior to the interviews

⁵Participants were provided with multiple age options such as 50–59 years, 60–69 years, 70–79 years etc. These responses have been presented as 70–79 and other in the chart as only was selected during the interviews

Thematic analysis results

From our interview analysis, four themes directly related to AASPs were identified: (1) experiences with animals in LTC, (2) acceptability and perceived benefits of AASPs, (3) perceived challenges of AASPs and associated mitigators, and (4) preferences and recommendations for AASPs in LTC. The identified themes were parallel to the semi-structured interview questions and subsequent probing questions.

Please refer to Table 3 for a breakdown of the themes, associated codes, and quotes from the thematic analysis.

Table 3.

Themes and exemplar quotes

Theme	Code	Exemplar Quotes
Experiences with animals in long-term care	Pet ownership	“A number of years ago, we had a Chocolate Labrador, and that was pre-[Alzheimer’s’] diagnosis. And then after, after my diagnosis, then it was interesting how he adapted to my being disoriented sometimes on our walk. And so…I have seen animals used for people who are blind and so on. So, I understand the power, the effect of having a pet.” – Community member living with dementia
	Pet visitation and volunteers	“So, I work in recreation, so we help to arrange the dogs to come in with the volunteer services. We also have a pet therapy society that comes in as well…we have two dogs that come in regularly… one on Tuesday and one on Thursday and see certain people that they built a relationship with…like some of the residents don’t come to any programs and they really enjoyed the dog, so the dog spends one on one time with certain people as well.” – Manager 5
		“We have some volunteers, they are bringing the dogs here, so I can see like residents, they can, you know, smile when they see the dogs. Some of them, they are afraid, but most of them, they like to touch the dog, pet them.” – Care Aide 3
	Animals living in LTC	“What I’ve seen over the years in recreation therapy… I’ve been at homes where there are, like, resident dogs that, they go home with somebody at night. There have been resident cats that live there all the time. You know, birds, I’ve seen goats, there’s one place that had goats… I’ve seen a lot… I think it’s good for the residents. I think it’s good for the staff.” – Allied Health 11
	Bringing in former pets (residents, staff, and families)	“Oh, I like visiting with my [roommates' son’s dog] and I like it when he gets treats and he does little activities first. He’ll lift his paws up, or he’ll come and sit in the chair here, and you give him something from there…that’s why he’s the head of everything around here. He has the full attention.”- Resident 1
		“There are some family members that will bring their dog or sometimes a cat… even though they’re just focusing on one, like grandma or whatever, but some residents encourage them. Like they just like it. So, you know, they get their… attention instead.” – Care Aide 9
	AASP in LTC	“Like I really do think [pet therapy] does [break down barriers] because you know… sometimes we’d be in a unit where everyone had really very advanced dementia. And so, they’d be kind of more in a group and there would be a nurse there just to help out. And you know, they would just make eye contact with you. Like I want to pet that dog, and so the dog would go up and sit next to them. And I just like I remember a woman who just like sat there just smiling just like gently touching my dogs head, like playing with its fur. And she just seemed so relaxed. Like she just was just kind of like breathing alongside him and touching him….This way you sit with them and you kind of have that dog there too and it’s just kind of creating something... and you know you can kind of pet your dog at the same time so it’s like something that you’re kind of sharing together” –AASP Volunteer
	Other	“I find, too, with a lot of the residents, like you, you talk with them and they get to know you and stuff, especially [on the regular LTC unit], and they know about animals that you have…showing them pictures and stuff. Like, I always show them pictures of my cats and…they get really happy, and they always ask questions about them.” – Allied Health 10
Acceptability & perceived benefits of AASP	Acceptability and demand for AASPs in LTC	“I’m quite excited about it because I want to make sure that we have everything possible for people to be happy with the animals…I just happen to be in the same room [as a visiting animal] and I’m privileged because it really has made my life much better as a resident.”- Resident 1
		“So, I mean for the most part we were almost always like in demand… rarely could we say, oh we saw everybody that wanted to…”- AASP Volunteer
	Excitement and demand for AASP research	“I’ll say it again. Hurry up…get this plan underway. I think it’s a really good idea and I would love to see it happening sooner rather than later.” – Resident 2
		“I’m glad that you’re studying this type of thing, and I’m glad that people are willing to listen to the results of this and make some decisions based on what you find out, so that’s a good thing.”- Resident 2
	Resident benefits: Mental health	“It calms them down, petting them and just the oh they’re so cute. it just brings them back to maybe when they had their own…animals” – Care Aide 15 “Well, if it’s anything like me, [pet visits are] nothing but rejoicing” – Resident 1
	Resident benefits: Social	“And to have the dog come back and whatever, and to see the dog remembered me, that’s a big thing for a lot of people, they remember me, they know me, who does that? They go pretty much, nobody knows who they are anymore. And then all of a sudden comes this pet who seems to know them, who’s got a waggy tail, and its neat. Its comforting… Its like meeting an old friend again and oh wow you know?” – Resident 2 “[Animal-assisted support programs create] this kind of space for a really comfortable and easy conversation between two people…I think that’s kind of why it was so positive, that it’s just like a really easy, comfortable interaction. And for residents that are non-verbal or even residents who didn’t speak English”- AASP Volunteer
	Resident benefits: Physical	“I’ve read a lot of things on this, a lot of different reports and things and it seems like they all say that one thing an animal does for a senior is to bring down the blood pressure…because it soothes them and calms them…I don’t know all the scientific facts behind it, but…I know I feel better when the dog comes there. I pet it for a little bit, and then I’m happier for the rest of the day. It just does something for you.” – Resident 2
	Family benefits	“I used to work for [another LTC organization] before I joined here, and they also used to bring a therapy dog for compassionate care. [It] was for a palliative resident, but not [just] for…[the] resident, more for the family members who were… there in the room and for the staff who cared for the senior and was going through the motions just for them… to help calm down and feel better.” – Manager 8
	Staff benefits	“Some staff also really liked the dogs so they would like, kind of interact with us as well. So sometimes it was like a little treat for them too.” – AASP Volunteer
	AASP Volunteer benefits	“Every time I’d leave it was always like, I felt good. Like, it was like there was always something that was really like a positive memorable moment, so it was extremely, extremely rewarding” – AASP Volunteer
Perceived challenges and mitigators of AASP	Barrier 1: Allergies & fear of animals	“Maybe if someone has got an allergy, but I haven’t seen anybody in my unit because I don’t see anyone being allergic to pets yet.” – Care Aide 15
		“We have some volunteers, they are bringing the dogs here, so I can see like residents, they can, you know, smile when they see the dogs. Some of them, they are afraid but most of them, they like to touch the dog, pet them.” – Care Aide 3 “Fear is a big thing” – Resident 1
	Mitigator (Barrier 1): Getting to know the staff and residents	“By asking the staff, yes. Ask the resident, because the residents know what they want, and know what they need, right? They still are able to express themselves in my unit. They’re still very good at it.” – Care Aide 15
	Barrier 2: Resident safety and infection control	“Dog has to be trained…You don’t want them to nip or to jump up or you know skin tears with claws…or even, you know, just [be] gentle…[the residents] have…a lot of skin issues.” – Allied Health 11
	Mitigator (Barrier 2): Animal and AASP volunteer training	“Sometimes when other younger people would come [as AASP volunteers] I don’t think they had any experience in long-term care…so it was quite sad. And I think they didn’t know what to expect, and they were uncomfortable with it…they didn’t stay on our particular long-term care team for very long. And I think sometimes working with residents who maybe do have really advanced dementia, they just didn’t really know how to interact or what to do, and so they wouldn’t be as comfortable.” – AASP Volunteer
	Mitigator (Barrier 3): Orientation on infection control and proper animal hygiene	“Making sure the dogs are…well manicured and making sure they don’t have sharp nails as well, in case cause even if they just like, put their paw by [the residents] or something and their nails are sharp, you never want skin tearing” -Allied Health 10
Preferences and recommendations for AASPs in LTC	Resident recruitment	“And the rec therapist who worked at the particular home that I visited actually, like kind of talked to all the residents who were there and found out whether or not they’d be interested in having an animal visit when they came. And if they were interested in that, they like dogs, they wanted that interaction, they had, like a little blue sticker that was on their door…So we knew, like those were the doors that we would knock on. And of course, you’d get to know residents who really like the dogs and those who are like a little bit too scared. So, you’d get to know them as well, but we’d … [give] them a little sign” – AASP Volunteer
	Animal and AASP volunteer experience and training	“I think [AASPs are] needed cause it brings so much positivity to residents [and] the staff…qualified [AASP volunteers], making sure that backgrounds are checked and that you guys [the research team] meet the dogs prior to bringing them in and assess them for their temperament.”-Allied Health 10
	Duration, frequency, and consistency of scheduling sessions	“I would just say if you were to start, which you would, but if you were to start something, then make it an assigned time and the same time every week or something, like I said, so they know that it’s coming, to look forward to. And yeah, and just go find out who really really wants [it].” – Care Aide 16

Theme 1: Experiences with animals in long-term care

Staff, residents, and community members discussed multiple experiences with animals in LTC, including pet visitation and volunteers, animals living in LTC, bringing in former pets, and trained AASPs (provided by registered volunteers and dog pairs) within the care homes. Animals living in this LTC home included a fish tank on every unit. Many staff and residents also discussed how family members of residents brought pets into the LTC home, and they encouraged various residents to interact with the animals. Staff also described previous experiences working in other LTC homes with live-in cats. Another recurring topic was that this LTC home had previously had a petting zoo set up outside by an external organization for the residents to interact with the animals.

The most frequently discussed experience was informal animal (pet) visitation with untrained or unregistered volunteers and dogs. Staff and residents talked primarily about two volunteers who brought their dogs into the home almost weekly. Registered AASPs were discussed primarily by the AASP volunteer and two managers with experience in other LTC homes.

Staff members highlighted the difference between AASPs and the current informal animal visits within the home, noting that the current visits are informal and the animals are untrained. While current volunteers attempted to come routinely, this was not always the case, and residents were sometimes left without visits for weeks when a volunteer was unavailable. Staff also discussed that AASPs with trained or registered animals would be highly beneficial, as this could strengthen safety protocols and increase consistency in scheduling sessions, thereby allowing residents to have an activity to look forward to.

“I mean, we do have…animals that visit, but…it’s informal and [the current dog] isn’t trained, but she’s cute, and she can sit on somebody’s lap, and you know. I would always call that more a visit than a therapy, but…dogs that are trained. I don’t see how it wouldn’t be beneficial.” -Allied Health 11

Theme 2: Acceptability & perceived benefits of AASPs

Acceptability and demand

Acceptability and demand of AASPs were discussed by staff and residents, who expressed their excitement about AASPs and discussed how they would be in demand in the LTC home.

“I think it’s needed [be]cause it brings so much…positivity to residents [and] the staff.” - Allied Health 10

The AASP volunteer described this acceptance and excitement when discussing her experience volunteering in LTC. During her AASP visits, most LTC staff, family members, and residents requested visits or expressed their appreciation for the program. The volunteer and residents in our interviews also expressed excitement about AASP research. They discussed this research as having the potential to inform future decision-making and help understand how AASPs work to improve the well-being of older adults.

“I’m glad that people are looking at this in a more systematic way because I think a lot of people can say…there is a lot of benefit to having those visits and how it improves older adults’…quality of life. But…we can’t really measure it, and we can’t quantify it, so I think it’s really great that you’re doing that.” -AASP Volunteer

Resident benefits

Staff, residents and community members described the benefits of AASPs to residents as physical, mental, and social.

Mental health benefits included potentially helping calm, comfort, and relax residents, improving their mood and reducing feelings of loneliness. Staff said they knew these visits were beneficial from multiple indications. These included the residents’ faces looking happy or lighting up, or seeing the moods of residents who were having a bad day improve when the dog was present. The AASP volunteer described similar experiences in which residents seemed happy, relaxed, and calmer when interacting with her dog.

“Sometimes, we’d be in a unit where everyone had advanced dementia. And so, they’d be kind of more in a group, and there would be [a] nurse there to help out, and you know [the residents] just like would make eye contact with you [the AASP volunteer]. Like I want to pet the dog, and… I remember a woman who just like sat there just smiling…gently touching my dog’s head, like playing with its fur. And she just seemed so relaxed. Like she was just kind of like breathing alongside him and touching him. And yeah, it was very sweet.” -AASP Volunteer

Social benefits included examples of how current volunteers who visit with their dogs (untrained and unregistered) have helped provide engaging activities, facilitate conversations with residents, and give residents a sense of purpose and identity. Residents also discussed how the dog visits made the LTC home feel more like home. Specifically, having the dogs around reminded them of their previous animals or their family members’ animals and provided them with social visits to look forward to. Residents also shared that the dog visits can give them a sense of purpose, something to do, and an activity that makes them feel accomplished. These residents also shared that they believe other residents may benefit from AASPs in this way.

Additional physical and mental health benefits. The residents described how the dog visits could improve both physical and mental health. For example, one resident who had previously read about the benefits of dog therapy discussed how it might improve blood pressure and stated that visits always made her feel better.

“I think pet therapy is extremely important…because it does things like lower the blood pressure, it perks people’s spirits up. It gives them something to look forward to in the day if they know when an animal is coming. It’s comforting, and it’s company for these people that maybe don’t have much of any other visitors. And that’s an important thing. A lot of times, their children don’t come, or they don’t have children, and a pet is an important part of their life that, even if it only comes once a week, it’s something to look forward to, something to touch, something that they get comfort from. And that touch is important.

If they can touch, if they can pet, if they can feel the soft fur, that [is] a comfort to them and it gives them something to do. They feel like they’ve done something throughout the day. And sometimes, there are people who are sort of stuck in their own little world, and they don’t come out into this world until they touch an animal. And that is a really important thing, to bring these people back to a place in life where they can actually do something or be something, a comfort to an animal…” - Resident 2

Components enhancing AASP benefits. Similar to the above quote, when discussing the benefits to residents and their personal experiences with AASPs, participants described two components of animal interactions that enhanced the benefits of AASPs: the importance of touch and the animals’ role in facilitating conversations among residents, staff, family, and AASP volunteers.

Family member benefits

Benefits to family members were described as calming and comforting, while facilitating conversations among staff, family, and residents. One manager described witnessing an interaction between a volunteer and a dog with a family during palliative (end-of-life) care in another LTC home, specifically noting how it helped family members calm down and feel better. The AASP volunteer also provided examples of how the family members reacted to AASP visits:

“[The family members] would always be very appreciative…commenting on how much a parent liked it. Sometimes…we would be visiting… and there would be a family there…[and they] would say, yeah come in…In some ways it just creates this ease and something kind of nice and just something new and different to talk about…you’d visit all of them and that was always nice too.” - AASP Volunteer

Staff member benefits

Staff member benefits were discussed in depth by managers, care aides, allied health, and the AASP volunteer. Perceived benefits include improved mood, reduced workload, and increased happiness due to the distraction of the residents, as well as the resulting improvement in residents’ moods. By improving residents’ well-being and providing staff with assurance that residents are safe and being watched over, the dog visits allowed staff to focus on other tasks. Staff also felt happy while visiting with the dogs.

“On the [advanced dementia unit], we have lots of residents with dementia and their [behaviours]. I wouldn’t say maybe that it necessarily helped with all the behaviours, but it kind of provides a distraction for them…And it lets the staff kind of see that they’re safe, like leave them with this volunteer and the pet, and we know that they’re happy and usually not aggressive.” - Manager 6

“ The [visiting dog] does not even stop only for the resident but will also stop for the staff if they want to spend [a] couple of seconds or minutes. It just helps us too.” -Manager 8

AASP volunteer (handler) and dog benefits. The volunteer also discussed how providing the AASP in LTC helped to improve her mood.

“Every time I’d leave, it was always like, I felt good…there was always something that was really like a positive, memorable moment, so it was extremely, extremely rewarding.” - AASP Volunteer

The volunteer also discussed how her dog was excited to attend AASP sessions within the LTC home. Her dog would get excited when she would bring out the bandana that the dog would wear to AASP sessions, and “he’d know…we’re going to work.”

Theme 3: Perceived challenges of AASPs and associated mitigators

Several participants discussed having little to no concerns over holding AASPs in LTC. However, some participants mentioned challenges related to implementing an AASP. The main challenges identified included (1) Allergies and fear of animals, and (2) Resident safety and infection control.

Allergies and fear of animals

Fear of animals was the most described potential barrier to AASPs. The AASP volunteer, community member, care aides, and residents contributed to discussions surrounding this barrier. These participants reported that some staff members and residents may be afraid of the animals, but most of the individuals they know enjoy them.

“We ran into people who were…quite scared…staff had identified who they were, and so we [the AASP volunteers] would [know] for sure, don’t go to that person’s room. Like they’re scared of the dog…so we were…respectful of their place. I remember staff members…who were terrified of the dogs…and you know you’d just work out how to go around them.” - AASP Volunteer

Staff members (allied health and care aides) and the AASP volunteer also discussed allergies as a barrier to AASPs. Specifically, they discussed ways to address allergies during AASPs, such as avoiding the rooms of residents with allergies.

“You have to think about…fear factor and then safety. So maybe knowing which residents are scared or allergic to animals, so then you can tell the people bringing in the animals, maybe avoid [this] room or avoid this resident.” -Allied Health 10

The most common mitigator of fears and allergies was getting to know the staff and residents. This included understanding the history of residents’ relationships with animals, including fears, allergies, and whether they had previously owned or worked with animals. One resident provided an example of how, when her family member brought in her dog for a visit, they encountered another resident in a public area who became upset because she was scared. This resident stated that if she had known about the fear in advance, she would have been able to avoid the interaction and respect the other resident’s boundaries.

“We hear how residents in long-term care or staff in long-term care benefit from knowing who the residents are, where they’ve come from, and a little bit of their background. In most cases, they have never been asked have they had a pet? And maybe that’s part of the questions that a care home would like to find out in discovering [who] Mrs. [X] is.

You know, did she work? What was her background?… You know all of those things, and did she own a pet? Otherwise…I think it’s more visual. Its staff paying attention to interactions, resident to resident. And knowing that, oh look Mrs. [Y] is pushing Mrs. [X] because of the cat… and you take that as a hint that OK, now we know that Mrs. [Y] may have a problem with the cat. Maybe at one point in a conversation, you want to ask Mrs. [Y] about her experiences with animals.” - Community Member with Dementia

The AASP volunteer also needs to get to know the staff, develop a relationship to facilitate sessions, and understand the staff’s fears and preferences. One resident also discussed how staff from different cultures have had to adapt to animal visits and how cultural considerations should be considered in AASPs.

Resident safety and infection control

Resident safety and infection control were additional challenges discussed primarily by the staff and the AASP volunteer. These concerns included examples of potential injuries or adverse events due to the dog being untrained, jumping on residents, tearing the residents’ skin, or infection risks.

Staff and the AASP volunteer discussed two primary mitigators to ensure the safety of residents and proper infection prevention: (1) ensuring the proper training of the AASP volunteer and animal (including experience in LTC), and (2) providing an orientation on infection control and ensuring animal hygiene.

Training of the AASP volunteer and the animal. Proper training was discussed as needed to ensure the animal did not harm the resident and that the volunteer remained in control of their animal. This also included experience in LTC to ensure AASP volunteers were comfortable with individuals with dementia and knew how to respond appropriately.

“I think everything is good, cause the only concern we had if they’re here is just only the safety of our residents right. So, if the dog[s] are well-trained and you know everything is okay and somebody [will] be with the dog that is all trained too, you know, I think we’re…okay.” - Care Aide 9

Infection control orientation and animal hygiene. The AASP volunteer described receiving minimal infection control orientation before the COVID-19 pandemic. She described believing that AASP volunteers in LTC homes would need a greater orientation in infection control. Other infection control measures mentioned by the staff and AASP volunteer included ensuring dogs were well-manicured (nails trimmed) to prevent skin tears and that the animals had all their vaccines.

Theme 4: Preferences and recommendations for AASPs in LTC

All interview participants shared their preferences and recommendations for structuring and planning AASPs by drawing on their previous experiences. Areas of AASPs discussed included: (1) duration, frequency, and consistency in scheduling sessions, (2) setting and structure of AASPs, (3) training of AASP volunteers and dogs, and (4) resident recruitment and staff and family involvement. For additional details regarding preferences and recommendations for AASPs, please refer to Table 4.

Table 4.

Preferences and recommendations for AASPs in LTC

AASP area/component	Past experiences with AASP and perceptions related to these experiences	Future recommendations for AASPs from participant perceptions
Duration, frequency, and consistency of scheduling sessions	• Duration and frequency of sessions are dependent on (described by the staff, resident, and AASP volunteer):  o The preferences of the person receiving AASPs.  o The supports required by the person receiving AASPs.  o The fatigue of the dog • Staff and residents discussed current pet visitation volunteers:  o Visit with each resident for 5 min to half an hour.  o Come once to twice a week, however, sometimes they are only there once every few weeks, and residents don’t see the dog when the current volunteers are on vacation.  o Do not have a lot of time to spend with residents (described by one care aide). • AASP Volunteer:  o Only conducted visits for one hour at a time, and visits never went beyond an hour and a half because the sessions are quite a lot for the dogs (or other animals like cats). After this period, the dogs would be exhausted due to the stimulation, so typically, 1 hour a day is all an AASP volunteer and dog team can do.  o Due to this one hour, the AASP volunteers could rarely say they saw everybody who wanted a visit.  o Visited typically in the evenings. Scheduled specifically on Thursday evenings, which allowed staff and residents to get to know them and have consistency.  o In the winter, residents were sometimes in bed by the time sessions were being completed due to the evening schedule.	• Recognize that the duration and scheduling of sessions depend on a person-to-person basis and on other activities in the home. Session length is also dependent on animal wellbeing, such as the dog’s fatigue. • Staff described that they wish AASP sessions could be more often and that volunteers had more time with residents. • Most participants (residents and staff) believed sessions should be 1–2 times per week, or a couple of days a week. One resident said she would appreciate AASP as often as they are willing to come.  o Recommended duration of sessions ranges from ten minutes to fifteen minutes to half an hour.  o Resident 1 recognized that with other activities and programs in the home, residents may only have so much love to give to the animals, and therefore, even once a week may be enough. • Consistency and scheduling were described as critical for future programs in multiple instances. Including:  o Consistently scheduled sessions (same day and time each week) are important for residents to be able to plan their activities and look forward to sessions. • There was a divide between multiple participants surrounding their ideal scheduling of sessions:  o Residents and one care aide described mid-morning before lunch as the most ideal time.  o The same care aide described the early evening as an alternate time, as this is good for staff schedules.
Setting and structure of AASPs	• The AASP volunteer described her previous AASP organization’s policy surrounding going in a buddy system (two volunteers at one time point). This allows for safety for the volunteers to respond to emergent situations and avoid ethical issues. • The AASP volunteer described often going to individual rooms for the AASP visits. These one-on-one interactions were more personalized and allowed her to connect with the residents more, creating more nice moments than the group therapy.  o Resident 2 described her experience with group therapy with AASPs and stated that it felt like she was competing for the dogs’ attention with others, and she preferred one-on-one therapy in her room.  o Both residents described liking visits within their rooms in the LTC home.	• The AASP volunteer and staff (care aide) recommended one-on-one interactions, not group-based AASPs.  o Staff also discussed going room to room to visit the residents. • Residents preferred one-on-one AASP sessions in their rooms.  o Resident 1 also described that the AASP sessions should occur wherever the animal and AASP volunteerare comfortable. • Resident 2 described that she would prefer no built-in activities for the AASP sessions and would rather the dog enter the room and let her pet it. This was echoed by Care aide 16, who described that no specific activities are needed.
Training and experiences of AASP volunteers and dogs	• The AASP volunteer discussed most experiences regarding training. In these discussions, she stated that she was not provided with any courses to obtain her certification. She and her dog completed a short test, where they were watched to see how they interacted with various populations. • While acknowledging that training may have changed by now, the AASP volunteer emphasized the importance of training and experience, including:  o Training, knowledge, and experience in LTC homes prior to starting an AASP. She provided examples of young AASP volunteers and their dogs coming into LTC homes with no experience and feeling uncomfortable or not staying on the teams for very long and not knowing how to interact with individuals with dementia.  o Always be in control of your animal (dog), and this included an example of her experience with a resident consistently trying to undo her dog’s leash during a visit. • The AASP volunteer also discussed that there was very little orientation about infection control during her orientation to the LTC homes (prior to COVID-19).	• An allied health professional and a care aide described the importance of training for future programs. Specifically, how training will help avoid biting or injuries. • Recommendations were made to check the AASP volunteers’ backgrounds and assess the animals’ temperament. • The AASP volunteer described the importance of the following training and experience:  o Orientation on safety  o Orientation on how to talk to individuals with dementia  o Experience with long-term care and being able to read residents’ body language and respect their boundaries.
Resident recruitment & staff involvement	• Recruitment of residents was influenced by staff and family involvement and by getting to know the residents. • Staff helped previous volunteers in orientation to the LTC home and identified which residents would like to receive animal visits that day. This was primarily the role of the recreation therapy team.  o After orientation, staff members only received occasional updates via emails or discussions about who the volunteers visited that week and how visits went. • Staff, residents and the AASP volunteer discussed specific instances where staff members getting to know the residents and informing volunteers/AASP volunteers who needed AASP that day was highly beneficial for their animal visitation programs. • The current pet visitation volunteer in the LTC home:  o“Wanders around the [units] and she stops with whoever wants to see the dog” – Care Aide 16 • The AASP volunteer described a specific situation where the recreation therapist in the home she was visiting would talk to residents in advance to see if they would be interested in an AASP visit, and then the recreation therapist would put a blue sticker on the door, so the AASP volunteer knew which rooms to visit.  o Staff members would also point out to the AASP volunteer who would love a visit, or who had a bad day and who would most benefit from a visit that day.  o The AASP volunteer also described being quite independent, but they knew where the staff were in case they needed anything. • The AASP volunteer described instances where the family members asked her to go see the resident that day.	• The community member living with dementia described how getting to know the resident and their history with animals is important in identifying who would benefit from an AASP. This includes staff paying attention to resident interactions. • Two care aides described the importance of asking the residents, family, and staff about resident preferences, and how this may help with recruitment. • A care aide described calling staff members to get involved if a resident gets distressed during an AASP visit. • Resident 1 also discussed potential recruitment strategies, including doing a little interview prior to the start of the AASP, talking to the staff, or providing a signup sheet for the program ahead of time. This may include having a staff member visit each unit to talk to residents and using a sign-up sheet. • Resident 2 also described that word of mouth for recruitment might be beneficial, or having an AASP session as a group first, then having a signup sheet for whoever wants the animal to visit them in their room.

Duration, frequency, and consistency in session scheduling

Most staff and residents believed that future AASP sessions should be 1–2 times per week, with a duration between ten and thirty minutes for each resident. These recommendations were based on experiences with current animal visitation volunteers who spent five minutes to half an hour once or twice a week with residents. Residents and staff wished that AASP sessions could occur more often and that volunteers had more time with the residents.

Frequency and duration were also found to depend on each resident’s preferences and needs. Specifically, each resident may have different preferences and needs regarding the frequency and duration of their AASP sessions based on multiple factors. These factors include how much they would like to interact with the AASP volunteer and the dog, the activities or social visits they already have in their schedule, their previous history with animals, and the amount of support needed by that resident (i.e., residents with dementia).

“Some people would just kind of be, like, happy with just a few minutes. Some people would be really chatty and like… want to talk for a while. So, those ones you would stay maybe… 10 minutes, and other people were just kind of happy to say hello and kind of maybe pet the dog, and…then just after a few minutes they just kind of wanted to go back and do their own thing. So, it really depended on the resident….

The place that we visited had a combination of residents who needed a lot more support, who were in more kind of secure units… So, whether or not someone was still like verbal or that might indicate how long you’d stay with them as well.” - AASP Volunteer

The dog’s fatigue was also considered a factor influencing the frequency and duration of AASP sessions. Specifically, the AASP volunteer discussed that they could only be in the LTC home for 1 to 1.5 hours because the dog became exhausted. Due to the short timeframe, the volunteer believed that she was rarely able to see everyone who wanted to receive the AASP visits in a single day.

In scheduling sessions, participants emphasized the importance of consistency in scheduling and duration for future programs so that residents and staff can plan activities and residents can look forward to sessions. They would also like more consistent scheduling to avoid schedule interruptions, missed sessions when the volunteer is unavailable, or residents being upset about missing dog visits.

“I would just say if you were to start…something, then make it [an] assigned time and the same time each week or something, like I said, so they know that it’s coming, to look forward to.” - Care Aide 16

Despite this overall agreement on the need for consistent scheduling, a divide emerged regarding the optimal time of day for sessions. The AASP volunteer typically conducted visits in the evening due to their availability. In contrast, the residents and one care aide described mid-morning, before lunch, or early evening as the ideal time due to staff scheduling and resident energy levels. Therefore, when planning AASP session schedules, the availability of staff and AASP volunteers, as well as the needs of the residents, must be considered.

Setting and structure of AASPs

Most participants, including the AASP volunteer, staff, and residents, described that AASP sessions should be one-on-one and should take place in resident rooms. One resident described preferring one-on-one sessions while discussing her previous experiences with receiving an AASP in a group setting. She described that when previously receiving a group AASP in a hospital, she felt like she was competing for the attention of the animal and felt ignored. The AASP volunteer also described her experience providing one-on-one AASP visits in the resident’s room. In her experience, these one-on-one interactions were more personalized, allowed for deeper connections with residents, and offered more meaningful moments than group therapy.

A resident and care aide also described that no specific activities need to be built into AASP sessions. Rather, the residents should be able to interact with the dogs (i.e., pet the dogs) however they may please.

Training of AASP volunteers and dogs

Staff and the AASP volunteer described the importance of training for future AASPs. The AASP volunteer defined the training and experience that volunteers should have before entering LTC. Staff described the need to check the backgrounds of AASP volunteers and assess the animals’ temperaments to ensure the residents’ safety and prevent potential injuries.

The AASP volunteer described her previous experience with training, stating that she received no formal training courses to obtain her certification and only had to complete a brief certification test with her dog. She described training and experience in LTC and working with individuals with dementia as essential for conducting AASPs successfully in LTC. This experience and training will help the volunteer to maintain control of their animal while ensuring the safety of residents, staff, and AASP volunteers. The training will also help AASP volunteers recognize residents’ body language, respect their boundaries, and respond appropriately to individuals with dementia. Additional considerations for future programs from the AASP volunteer’s perspective included planning for scheduling and travel, insurance, veterinarian costs, and expenses related to being an AASP volunteer.

Resident recruitment and staff and family involvement

When recruiting residents for AASPs, community members and care aides recommended getting to know residents and utilizing staff and family as resources in recruitment and during visits. This included contacting staff when a resident became distressed during an AASP visit and using staff as a helpful resource to identify who may need an AASP visit each day. Staff, the community member living with dementia, and the AASP volunteer provided these recommendations based on their previous experiences, describing the processes by which residents were previously recruited and what had worked well in the past. Examples of staff involvement included staff members pointing out residents who would benefit from AASPs because they had a bad day, staff placing a blue sticker on the door of residents who would like AASP visits, or staff circulating a sign-up sheet unit to unit for residents. The AASP volunteer and staff also mentioned that family members would help identify whether their relative would like AASP visits.

“First…if they were cognitive, then they could decide [them] selves. But talk to their family and see because maybe some would be scared of the animals as well, right? But talk to the family and see what they want. Talk to us [the staff and] see what we think. And that’s it.” - Care Aide 16

The AASP volunteer discussed how recruitment and factors influencing AASPs depend on the LTC home context, including the setting, staff, and schedules.

Discussion

Animal-assisted support programs have many potential benefits, including improved socialization and well-being for older adults living in LTC homes. Our interview study is the first, to our knowledge, to identify the perspectives of key individuals with some aspect of lived experience, LTC staff, residents, and AASP volunteers, to explore the feasibility and acceptability of AASPs in Canadian LTC homes. This study addressed feasibility, including acceptability, demand, practicality, and implementation concerns, by identifying perspectives on potential intervention barriers and offering recommendations for intervention implementation based on participants’ experiences. Specifically, this study addressed intervention suitability (intervention demand, current AASP experiences and recommendations), intervention benefits (practicality, acceptability) and factors influencing implementation (intervention barriers, implementation concerns, and recommendations for future AASPs) [24, 47].

Participants in our interviews described AASPs as promising and acceptable programs that have many potential benefits for LTC residents. Potential benefits included improvements in mood, happiness, and loneliness, as well as giving residents something to look forward to. Similar to our findings, O’Rourke et al. [43] and Machova et al. [29] found in exploratory and pilot studies that AASPs are highly acceptable in healthcare settings such as LTC homes and bring pleasure, reduce loneliness, and improve the mood of older adults. Our study is unique in that participants also highlighted the benefits of AASPs in LTC homes for staff, families, and AASP volunteers. These perceived benefits include improved staff workload, facilitation of conversation between family and residents, and improvements in mood for the AASP volunteers.

Participants in our interview study described their preferences for AASPs and the factors they believed influenced the implementation of AASPs, including implementation challenges. Perceived challenges included allergies and fears of animals, as well as concerns about resident safety and infection control. Similar to our findings, AASP studies and local health authorities’ guidelines have emphasized the need for infection control and resident safety through the implementation of appropriate infection prevention measures and the training of AASP volunteers and dogs [15, 37, 42, 44, 52–54]. Getting to know the resident, or acknowledging recipients’ views of animals, has also been identified in our study and associated literature as important in AASPs to help deter difficult situations and manage fear [,44 ]. Our study builds on this literature by identifying how understanding the history, culture, and preferences of residents and staff can be specifically used to mitigate challenges, such as fears. Other studies have identified additional challenges not addressed in our study that should also be considered in AASP development, including residents’ unavailability (e.g., due to health exams), organizational constraints (e.g., staff organization), and residents’ physical well-being (e.g., pain) [39, 42].

Our findings are the first to our knowledge to discuss the preferences and recommendations for AASP implementation specific to those involved in AASPs in LTC homes in Canada, including AASP volunteers, LTC staff, and residents. Various organizations and research studies have provided general recommendations or guidelines for conducting AASP visits. For example, Therapy Dogs International [54] provides guidelines on what to do in the event of injuries, recommendations for grooming, and a general guide on how to prepare for, conduct, and follow up on visits (i.e., how to introduce yourself to clients). Our findings contribute to the current literature by adding specific recommendations from the perspectives of those directly involved in AASPs regarding recommended durations, settings, frequencies, and factors influencing implementation (summarized in Table 4).

When highlighting their recommendations for AASP programs, our interview participants identified that the experience of AASP volunteers and dogs, including experience and training in LTC homes, was essential to ensure the safety of residents and effective interactions. Current guidelines, such as the Therapy Dogs International Guidebook, provide general recommendations for handling age-related challenges during AASPs [54]. Other recommendations by the International Association of Human-Animal Interaction Organizations (IAHAIO) describe the need for training in the context in which AASPs are delivered []. Despite these recommendations, there are no country-wide standards to guide AASP sessions and ensure the training and experience of AASP volunteers in LTC [, 44, 54]. It is also not uncommon for animal visits involving unregistered and untrained animals and volunteers to occur in LTC homes. Future guidelines regarding safety and training can help ensure the safety of residents, staff, and volunteers while standardizing program processes for future AASPs in LTC.

Our participants also discussed their recommendations for the duration and scheduling of AASPs, including the importance of having consistently scheduled sessions. This finding is similar to that of Holt et al. [37], who also identified inconsistent scheduling as a problem in their program and emphasized the importance of systematically scheduled AASP sessions [37]. We recognize that the recommended durations and schedules from our interviews were not based on empirical evidence, but rather on our participants’ experiences and perceptions regarding the dog’s and residents’ fatigue, residents’ engagement, benefits, and knowledge of the preferences of other LTC staff and residents. These recommendations were therefore highly individualized, and many factors could influence these preferences on a day-to-day basis, such as events within the LTC homes, resident moods, and illnesses. When planning AASPs, the adaptability and flexibility of program implementation should be considered due to the varying environmental contexts and needs, and resident preferences should be prioritized in the planning process [43, 44, 55]. Clear guidelines specific to AASP implementation are also needed to enhance research approaches, facilitate comparisons between studies, ensure the development of AASPs that meet the needs of resident populations in multiple LTC homes, and ensure consistent training for volunteers [55].

Our findings not only support the existing literature, which calls for new guidelines and recommendations to ensure the appropriate implementation of AASPs, but also emphasize the importance of considering the environmental context and residents’ preferences when planning AASPs [43, 44]. As discussed in our results, getting to know the residents and personalizing the program to their preferences and needs is critical in planning future AASPs in LTC. Having a standardized duration and frequency of AASP sessions may not be feasible or ideal for all residents, as some residents will require more time with the animals and AASP volunteers than others.

Our findings also have potential implications for LTC staff, such as nurses and care aides in LTC homes. The perspectives and recommendations from our interviews provide initial context on how staff can be involved in AASPs (i.e., recruitment) and how they can benefit from the process (i.e., improved mood and workload). In addition, by acknowledging the role that individual preferences and history play in planning AASPs in LTC, LTC staff can work to ensure that person-centered care approaches are applied to AASP interventions. By encouraging the use of a person-centered approach to AASPs, LTC staff can help to personalize AASPs to ensure a meaningful experience for residents that has multiple benefits, while reducing potential intervention barriers [56].

Limitations

This study had several important limitations. First, it was conducted in one LTC home in Edmonton, Alberta, Canada, and our sample was recruited using convenience sampling. Therefore, the findings are not generalizable and may not represent the full range of participant experiences (e.g., most participants discussed AASPs only with dogs). Second, most of our participants (57% of staff, 100% of residents) identified as white. This is an important limitation, as different cultures may have different views on animal programs, fears of animals, and barriers to AASP implementation. Third, neither of the resident participants had a diagnosis of cognitive impairment. Finally, only one AASP volunteer participated in our study. Future research focused on gaining a broader range of perspectives may be beneficial for further understanding residents’ experiences with AASPs and various perspectives on AASP implementation.

Conclusions

In this feasibility and acceptability study, animal-assisted support programs (AASPs) were perceived to be acceptable and worthwhile for improving the social isolation, mental health, and well-being of older adults living in LTC homes. AASPs have many potential benefits for LTC staff and residents, including improvements in stress and mood. Based on the findings and the supporting literature, we are developing an AASP intervention that will be piloted and then evaluated in a rigorous clinical trial design. More rigorous research into this potentially important non-pharmacological intervention is urgently needed.

Abbreviations

AASP

Animal Assisted Support Programs

AB

Alberta

LTC

Long-Term Care

RA

Research Assistant

Authors’ contributions

BDeG developed the study concept and design under the supervision of CE. BDeG led data collection and participant recruitment. HT, CE, and CD provided feedback on the data collection plan. BDeG analyzed the data and received feedback from CE, CD, and HO. BDeG led the writing and revision of the manuscript. All authors reviewed and approved the final manuscript.

Data availability

To protect the confidentiality of our participants, the original interview data cannot be shared. Upon reasonable request, the corresponding author (BDeG) may share further information surrounding the interview data that does not compromise the confidentiality of our participants.

Declarations

Ethics approval and consent to participate

This study adhered to the Declaration of Helsinki. The study received ethics approval from the Health Research Ethics Board- Health Panel at the University of Alberta (Reference number: Pro00106061). Operational approval was obtained from the LTC home prior to the start of the project. All participants involved in the study had capacity and provided verbal (online Zoom interviews) or written (in-person interviews) informed consent. Participants could stop the interview at any time.

When conducting this project, we had two primary ethical considerations: (1) Ensuring voluntary participation of individuals recruited by the LTC manager and through research connections, and (2) Ensuring informed and continuing consent of individuals with cognitive impairment. To mediate these potential concerns, we held a meeting with a member of our research ethics board and multiple meetings among our research team to discuss mediation strategies.

To ensure voluntary participation, we emphasized in our recruitment materials that participation was voluntary. We also informed participants that participation was voluntary before the interview and that their participation would not be shared with anyone (including the LTC manager). Participants were also given the option to stop the interviews at any time without repercussions.

Ensuring informed consent and capacity to consent were mediated through multiple methods. Neither resident in our study had a history of cognitive impairment or dementia, as identified by the LTC manager, who had an in-depth knowledge of the residents’ histories. The community member in our study living with dementia was able to communicate that his dementia was at an early stage, and is an active research partner in multiple research groups. Prior to conducting the interviews, the interviewer (BDeG), a Registered Nurse with experience working with individuals with dementia, met with the residents and community member to discuss informed consent in detail and the purpose of the study, while providing the opportunity to ask questions. Both residents and the community member, appeared to meet all standards for competent judgement (ability to receive and understand information, process information, appreciate the situation and its consequences, weigh benefits and risks, and communicate decisions) [57, 58]. As recommended in the literature, the participants’ behavior, including nonverbal and verbal cues indicating fatigue, confusion, or refusal, was assessed throughout the interview process. However, no concerns were noted throughout the interviews [57]. Check-ins were also conducted throughout the interviews to ensure ongoing consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.