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Evidence-Based Practice Paper: Animal Therapy’s Impact on Stress Levels

Leah Ault

Daphne Dorame

Ashley Graffice

Rebecca Pargas

University of Arizona
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Pet therapy (PT) is a connection between a patient and an animal that is specialized in

emotional therapy for patients. The purpose of PT is to help someone through stressful or

traumatic situations whether that be past experiences or current. This topic is significant in

nursing practice because as integrative nurses we must learn to incorporate nonpharmacologic

therapies to help our patients heal naturally. There are six integrative nursing principles and they

all relate to the well being of the patient by separating the different ways we can care for the

patient holistically (Wilkinson, 2019). PT relays to Integrative Nursing Principle (INP) #4

because we all must build relationships that are based around the person to benefit them and give

them the needed support. This type of therapy also relates to INP #1 being inseparable from our

environment because it is important to make strong connections with our patients and to have

them utilize tools from their environment to avoid feeling isolated, therefore, making it easier to

go through illnesses, diagnoses, etc. PT is a worthy topic of being examined further because it

gives patients another form of connection that can help them heal in the least invasive way which

can be beneficial in the way that we don’t have to use medication which can have many different

effects on the body. An integrative nurse uses evidence-informed interventions to determine

what is the best way to care for the patient in the most efficient way (Brown, 2016). We came to

the consensus that PT is an interesting topic to research because we are all animal lovers and

have had personal experience in reducing our levels of stress with our pets. Given our interest in

PT we will examine the evidence surrounding PT to determine its impact on stress levels in

comparison to no intervention.

Background and Purpose

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Individuals may experience levels of high stress and anxiety due to physiological and

environmental stressors. There are many different alternative therapies which can be employed

replacing invasive or pharmacological interventions. PT introduces a nonpharmacological

alternative that is less invasive but may be beneficial in reducing stress and anxiety.

Incorporating PT promotes social interaction, increases self-esteem, and communication

(Moreira et al., 2016). PT is an established intervention that is used for healing purposes and to

improve people's well being (Ein et al., 2018). Animals provide emotional and social support

during difficult situations and moments in distress. PT may distract people from a sensory

overload which may ease their anxious feelings (Kowalski et al., 2021). This is important for

future nursing practice because it provides options that are effective, cost-efficient, and

beneficial to the people (Hall & Duke, 2021). PT aligns with INP 1 and 4 because it’s

relationship-based and is centered on the person's response to the presence of a pet in their

environment (Kreitzer & Koithan, 2018). The purpose of the paper is to critically appraise four

articles to examine the utility of PT on stress levels. This paper explores how PT, an integrative

intervention, affects stress levels.

PICOT Question

The purpose of a PICOT question is to attempt to answer a clinical question in a way that

is unbiased and effective (Gallagher Ford & Melnyk, 2019). A PICOT question addresses the

population, intervention, comparison, outcome, and time in which we are researching. Our

PICOT question is in people experiencing stress, what is the effect of animal therapy compared

to no intervention on stress levels change within 3-months? Our PICOT question is an

interventional/therapy format (Brown, 2016).The research databases we used included PubMed

and CINAHL. Our searches included publications within the past five years and were filtered for
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english. To conduct our search we used animal therapy, pet therapy, integrative nursing, and

stress levels with animal therapy as our key terms.

Critical Appraisal of the Articles

Critical appraisals are used to help systematically examine research to see how reliable,

trustworthy, and valuable the information presented is (Brown 2016). We critically appraised

four separate articles pertaining to PT and how it relates to stress. Below are our individual

appraisals for each.

Article One 

The investigators (Ein et al., 2018) conducted a meta-analysis study to examine if pet

therapy is an efficacious method for reducing physiological stress levels (BP & HR) and

subjective stress and anxiety scores (self‐reported stress/anxiety). They used a meta-analysis that

included 28 articles with 34 independent samples. Overall, it contained a total of 1,310

participants. Data were analyzed using Comprehensive Meta-Analysis software (CMA) version

3.0 software. Using a random-effects model, the results of this study include: significant

differences in HR, self‐reported anxiety, and stress after PT. The strengths of this study were the

findings were consistent with the literature, it was peer-reviewed, and provided a large range of

participants. The limitations of this study were that they were unable to run some of the

moderator analyses due to the small sample size and the inability to include more active PT

programs. This study is relevant to this EBP paper because it showed that PT significantly affects

HR, self-reported stress, and anxiety levels.

Article Two

The investigators (Hall & Duke, 2021) conducted a mixed method-study to examine the

efficacy of therapy dogs on campus with nursing students' stress levels. A survey measuring
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stress levels with Cohn’s perceived stress scale and heart rate of undergrad nursing students

provided data via a phone application. Data were analyzed using the SPSS software and

thematic analysis. The results of this study include: overall decreasing stress among nursing

students and increasing positive mood. The strengths of this study were recording qualitative

data as well as heart rate to measure stress and using technology to get accuracy of heart rates.

The limitations of this study were only limited to nursing students and picking mostly people

who owned dogs before because they mostly liked dogs. This study is relevant to this EBP paper

because it shows how PT can be a therapeutic method to help nursing students experiencing

stress.

Article Three

The investigators (Kowalski et al., 2021) conducted a quasi-experimental interventional

comparative study to examine if an animal-assisted activities (AAA) visit from a registered

animal during hospitalization would reduce anxiety for older adults. A convenience sample of

141 participants from eight different medical centers which included patients over the age of 65

provided data via a short form of the Spielberger State-Trait Anxiety Inventory 6-item survey

used to measure anxiety. Data were analyzed using an excel sheet with survey results to

compare data on a spreadsheet for each variable at each medical center. The results of this study

include: significant improvement in depressive symptoms and reduction in anxiety with higher

support after 15 minutes. The strengths of this study were added to research knowledge about

non-pharmacological intervention that reduced anxiety in elderly patients with minimal risk.

The limitations of this study were that it consisted of a self reported survey, population consisted

of mostly a white ethnicity, and because it wasn’t randomized it limits evidence of anxiety
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reduction. This study is relevant to this EBP paper because it supports the use of PT in persons

experiencing depressive symptoms or anxiety.

Article Four

The investigators (Moreira et al., 2016) conducted a qualitative study to examine the

stance of nursing staff and parents regarding their children having assisted therapy with dogs.

Data was collected by 16 participant observations and in-depth interviews at a pediatric oncology

setting. Data was analyzed by interpretive content analysis. The results of this study include:

that they noted that their children were more motivated to do their treatment for their cancer with

having the therapy dog around. The strengths of this study were that they had long monitoring

periods and not too many participants to where it allowed them to look more in depth at these

things. The limitations of this study were that they only used dogs and not other animals that

maybe some of the children would have liked to see to make them feel better. This study is

relevant to this EBP paper because it tells us how children experiencing cancer can relieve some

stress and how PT can positively affect oncology treatment motivation in the pediatric

population.

Summary

Overall the critical appraisals directly support our question concerning how stress levels

are impacted with PT compared to no intervention. Heart rates slowed down within many of the

patients (Ein et al., 2018). The reports from the patients were also mostly positive. They all

showed content with the therapy and reported reduced levels of stress. Depressive symptoms,

stress, and anxiety were all improved with PT (Kowalski et al., 2021). We know the critical

appraisals directly support our question because in every article, PT showed positive benefits to

people experiencing stress. Data that we need to look at in more detail is the types of animal
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therapies that work better (such as working with virtual animals, smaller animals, or bigger

animals) and the amount of time that should be offered to fully capture the effects of PT. With

this information, we could fully understand how and what tactics we should use to help people

with their stress. This evidence can be used to support our question concerning stress and PT by

showing how each resulted in both objective and subjective data of stress levels decreasing with

PT. PT is better to use than no therapy to help patients deal with their stress and can be used in

intervals of weeks, months, or even years (Kowalski et al., 2021). PT in the nursing setting could

provide loads of comfort to many patients now and for years to come.

Implications for Nursing Education, Research, and Practice

The critical appraisal summed up the information needed to provide nurses with proper

education to implement PT into their care plan. Nurses used evidence based research for their

practice and the critical appraisal showed evidence for four different sources of how nurses can

implement PT to make a difference in patients.

Nursing Education

It is known from research that PT lowers heart rate and releases hormones that cause

happiness and it would be most effective to have them incorporate PT themselves to experience

the outcome (Hall & Duke, 2021). Clients have the potential to deny this opportunity, in which

nurses should explain the research behind using PT for stress levels. Different techniques with

PT are playing or petting and are most effective, others who have used PT in the past can talk

through and explain their experience to others to educate them. Nurses may also suggest an

educational video to show the increase in mood associated with incorporating PT.

Nursing Research
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Research was done with using dogs for this type of PT but more research should be done

to incorporate different animals in the study as some may find discomfort in being around just

dogs (Moreira et al., 2016). Research suggests more studies with animals such as horses is

recommended because of the teaching nature of the horse and the ability to influence humans. It

is known that PT has improved stress with nursing students, decreasing pain in cancer patients,

and decreased anxiety. Those are all great benefits and the more research that is done, the more

benefits will come to light.

Nursing Practice

The evidence is clear and concise that supports PT and its effectiveness, it is important to

implement this integrative therapy technique into regular nursing practice. It is up to the nurses

to suggest this kind of therapy when it may be useful to patients with pain or anxiety (Ein et al.

2018). Clients with high levels of stress who find comfort in animals and don’t have the family

support needed, would find use in this treatment and patients need to know it is an option in their

care plan. The more that it is used the more others will see PT and be more inclined to implement

it themselves.

Conclusion

Given our interest in PT, we examined four articles with evidence surrounding PT to

determine its impact on stress levels in comparison to no intervention. We learned that pet

therapy positively affected anxiety and stress levels in various studies. It was found to decrease

levels of stress by bonding with animals and feeling more comfort with them. There was also

improvement in depressive symptoms that showed higher support from pet therapy animals.

Lastly, we found that patients were more motivated to participate in their ordered therapies with

having the support of an animal. Our critical appraisals did answer our PICOT question because
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overall we found pet therapy was highly beneficial to patients under stressed, anxious, or

depressive situations. Although there is more research to be done in this specific type of therapy,

from the articles we have looked into we can see that pet therapy is a great nonpharmacologic

intervention and can bring many benefits to patients with higher stress levels.

References

Brown, S. J. (2016). Evidence-based nursing: The research practice connection (4th Edition).

Jones & Bartlett Learning. https://online.vitalsource.com/books/9781284129120

Ein, N., Li, L., & Vickers, K. (2018). The effect of pet therapy on the physiological and

subjective stress response: A meta‐analysis. Stress and Health: Journal of the

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International Society for the Investigation of Stress, 34(4), 477–489. https://doi-

org.ezproxy4.library.arizona.edu/10.1002/smi.2812

Gallagher Ford, L., & Melnyk, B. M. (2019). The underappreciated and misunderstood PICOT

question: A critical step in the EBP Process. Worldviews on Evidence-Based Nursing,

16(6), 422–423. https://doi-org.ezproxy4.library.arizona.edu/10.1111/wvn.12408

Hall, D., & Duke, G. (2021). Therapy dog effects on nursing student stress: A mixed methods

study. Nurse Educator, 46(4), E70–E74.

https://doi-org.ezproxy3.library.arizona.edu/10.1097/NNE.0000000000000953

Kowalski, M., Smith, C., Cole, D., Bersick, E., Keleekai-Brapoh, N., Panfile, P., & Abate, S.

(2021). A multicenter study of animal-assisted activity and anxiety among older adults

hospitalized in acute care settings. Applied Nursing Research, 60, https://doi-

org.ezproxy1.library.arizona.edu/10.1016/j.apnr.2021.151447

Kreitzer, M., & Koithan, M. (2018). Integrative nursing. Oxford, UK: Oxford

University Press. Retrieved 19 Oct. 2021, from https://oxfordmedicine-

com.ezproxy3.library.arizona.edu/view/10.1093/med/

9780190851040.001.0001/med-9780190851040.

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing &

healthcare: A guide to best practice (4th ed.). Lippincott Williams & Wilkins.

Moreira, R. L., Gubert, F. D., Sabino, L. M., Benevides, J. L., Tomé, M. A., Martins, M. C., &

Brito, M. A. (2016). Assisted therapy with dogs in pediatric oncology: Relatives' and

nurses' perceptions. Terapia assistida com cães em pediatria oncológica: percepção de

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pais e enfermeiros. Revista Brasileira de Enfermagem, 69(6), 1188–1194.

https://doi.org/10.1590/0034-7167-2016-0243

Wilkinson, J. M. (2019). Fundamentals of Nursing (Two Volume Set) (4th Edition). F. A.

Davis Company. https://bookshelf.vitalsource.com/books/9781719642132

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Table of Evidence - Table 1

Table of Evidence

Author(s) & Study Purpose Design Results Relevant to Level of Evidence

Date Sample PICOT Question
Setting
(Ein et al., To examine if PT is They used a meta‐ The researchers used CMA software
2018) an efficient method analysis, guided by the and a random effects model, they
for reducing PRISMA criteria, that found significant differences
physiological stress included 28 articles with occurred in HR, self‐reported Level V, (Melnyk &
levels (BP & HR) and 34 independent samples. anxiety, and self‐reported stress after Fineout-Overholt,
subjective stress and Overall, it contained a PT. They didn’t detect significant 2019)
anxiety scores (self‐ total of 1,310 differences in BP after PT
reported participants from a
stress/anxiety variety of places such as
North America (3+),
Europe (2), Australia
(1), and more

(Hall & Duke, The purpose was to They used a mixed m Results showed that therapy dogs on Level VI, (Melnyk &
2021) see how effective method study in which campus decreased nursing students' Fineout-Overholt,
campus therapy dogs 21 introductory level stress levels. 2019).
are on a nursing nursing students in the
student’s stress level. southwest United states
took a survey on a
phone application
measuring Cohen’s
Perceived Stress scale,
after interacting with
dogs.
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(Kowalski et The purpose was to They did a multicenter Results showed evidence of Level III, (Melynk &
al., 2021) determine if an AAA quasi-experimental improvement in depressive Fineout-Overholt,
visit from a registered
design with a symptoms, stress, and anxiety from 2019)
animal during convenience sample of PT.
hospitalization would 141 patients over the
reduce anxiety for age of 65 from 8
older adults. medical centers in a
north eastern state in the
US.
(Moreira et al., The purpose was to The study was a The results of this study included the Level I, (Melynk &
2016) see how effective qualitative study with a view that they noted the children Fineout-Overholt,
having a therapy dog sample of 16 were more motivated to do their 2019)
on a floor with participants in a hospital treatment for their cancer with
children with cancer with childhood cancer in having the therapy dog around.
would be and how the a hospital in Brazil.
nursing staff and the
parents viewed this
kind of therapy.