Abstract
Animal-assisted activity programs are commonly used in long-term care facilities to enhance the well-being of older residents. Although research suggests that older adults benefit from these programs, little is known about the experience from the perspective of older adults themselves. In this qualitative study, we used direct observation and in-depth interviews to gain an understanding of the experience of participating in a unique rabbit-assisted activity program delivered in a Midwestern residential facility. Several benefits were identified, with no negative experiences articulated by the participants. In addition to finding the rabbits soothing, the rabbits served as a source of social support for some participants and encouraged social interaction. Participants generally felt that rabbits are good animals to use for this type of activity, but expressed a desire for more frequent, longer, and more interactive visits. Facilities considering animal-assisted activities (AAA) programs should consider these factors when designing their programs.
Background
Two types of animal programs are commonly used in long-term care facilities to enhance the well-being of residents: animal-assisted activities (AAA) and animal-assisted therapy (AAT). Whereas AAT programs tend to be directed toward the achievement of therapeutic goals, AAA generally refer to informal opportunities for individuals to interact with animals (Marino, 2012; Pet Partners, n.d.). As Marino (2012) noted, however, it is often difficult to discern the two in the scientific literature.
Although AAA and AAT typically involve dogs and cats, rabbits and other small animals may also be used (Burch, 2003; Chandler, 2012; Granger & Kogan, 2006), in part because the day-to-day care of small animals is often less demanding and their smaller size simplifies transport (Burch, 2003; Chandler, 2012). Rabbits, in particular, may be especially effective, as they “are curious and affectionate, and they respond to attention and interaction” (Burch, 2003, p. 70).
While there are methodological limitations in the scientific literature on AAA and AAT (Marino, 2012) and uniformly beneficial effects on health-related outcomes have not been found, several studies involving the use of AAA and AAT in long-term care have reported at least some benefits to program participants. These include reduced loneliness (Banks & Banks, 2002, Banks, Willoughby, & Banks, 2008), improved social functioning (Barak, Savorai, Mavashev, & Beni, 2001), slowed progression of dementia-related agitation/aggression (Majić, Gutzmann, Heinz, Lang, & Rapp, 2013), and favorable effects on depression (Friedmann et al., 2015; Majić et al., 2013).
Although the precise means by which AAA and AAT programs may exert their effects are not known, one potential means is via the provision of direct and indirect social support (McNicholas & Collis, 2006). Some individuals form close relationships with animals and perceive them to be direct sources of support (McNicholas & Collis, 2006). Among a sample of pet owners, for example, McConnell, Brown, Shoda, Stayton, and Martin (2011) reported that the level of emotional support received from pets was similar to that received from siblings and parents. While the support received from a visiting animal may not be equivalent to that of a personal pet, existing evidence indicates that interactions with unfamiliar animals have favorable physiological effects in the context of stress (Friedmann, Thomas, Cook, Tsai, & Picot, 2007; Polheber & Matchock, 2014). This suggests that AAA and AAT visits may offer a direct source of comfort to some individuals. Moreover, some research suggests that AAA and AAT participants bond with visiting animals (Banks et al., 2008; Holt, Johnson, Yaglom, & Brenner, 2015).
With respect to the indirect provision of social support, McNicholas and Collis (2006) contended that animals encourage social interaction, fostering a sense of belonging and creating opportunities for individuals to establish relationships with others. This corresponds with research on AAA and AAT that suggests that animal programs create opportunities for older adults in residential facilities to interact with others (Bernstein, Friedmann, & Malaspina, 2000; McNicholas & Collis, 2006; Roenke & Mulligan, 1998) and that the animal involved can facilitate communication (Roenke & Mulligan, 1998).
Although research suggests that institutionalized older adults may benefit from AAA and AAT programs, little is known about the experience from older adults’ perspective. Greater insight into the participants’ experience is important to understanding how these programs enhance well-being and can serve to inform program design. The objective of this study, therefore, was to obtain insider knowledge of the experience of participating in an existing animal-assisted activity program that provides older adults with an opportunity to interact with rabbits.
Method
Program Description
An existing rabbit-assisted activity program administered in a Midwestern continuing care retirement community was the focus of this study. The activity was conducted by a rabbit team consisting of an activity facilitator and one to two volunteers. The activity facilitator and volunteers run a rabbit rescue organization and are trained and certified by Bunnies in Baskets (n.d.), a national organization dedicated to the humane use of rabbits in animal-assisted programs.
The activity typically involved three rabbits that were informally shared with residents in their rooms and in common areas. The rabbits were presented to individual residents in a wicker basket, which is lined with an “accident” resistant blanket. If desired by the resident, the rabbits were also placed on the resident’s bed or lap. According to the activity facilitator, using a basket allows for easier transportation and handling and helps to ensure the safety of both residents and the rabbits. The full duration of the activity session is one hour; however, interaction time with the rabbits varied from resident-to-resident. Depending on the expressed level of interest, interaction time ranged from several seconds to approximately 10 minutes.
According to the activity facilitator, the rabbits involved in the program are carefully selected and extensively trained for the activity. Initial training is incremental in nature, with the intensity of the training increasing each week. The rabbits are taught hand signals, to remain calm, and to sit in a basket. Ongoing training is conducted several days a month to ensure that the rabbits retain what they have learned. Prior to their involvement in the program, the rabbits’ physical and behavioral health are evaluated by a veterinarian. This activity facilitator further evaluates the rabbits using a modified Canine Good Citizen Test (American Kennel Club, 2016), which includes an assessment of the rabbits’ reaction to sudden loud noises, things rolling past them, things on the floor, and heavy petting as well as general obedience. The human members of the rabbit team complete a six month online training course offered through Bunnies in Baskets.
Data Collection
This qualitative study involved direct observation of the activity and in-depth interviews with residents. The Institutional Review Board at Miami University reviewed and approved the study protocol. Prior to direct observation of the activity sessions, verbal assent was obtained from participating residents by requesting permission to observe and write field notes. In addition, before conducting the interviews, informed written consent was obtained from all interviewees. It should also be emphasized that the rabbit-assisted activity program examined in this study existed prior to the onset of this research study and would have occurred in the absence of any research activity. The members of the research team are not affiliated with the rabbit-assisted activity program, the residential care facility, or the rescue organization.
Direct observation
Direct observation was used to better understand how the program was administered, to provide greater context for the in-depth interviews, and to bolster overall trustworthiness. Approximately 30 participants were observed during two activity sessions conducted several weeks apart, each lasting about an hour. Participants’ reactions, conversations, facial expressions, and interactions with the rabbits, the rabbit team, and other individuals were documented via field notes by the first author using methods described by Bogdewic (1999). Many of the same participants attended both sessions. Field notes were written when the participant was approached with the rabbits either in the common areas or their individual rooms. No residents were excluded from direct observation.
In-depth interviews
Eight face-to-face, in-depth, semi-structured interviews were conducted with residents who participated in the activity. Purposeful sampling was used to select residents who were able to express their experiences and perceptions. The facility’s lead social worker aided in identifying residents who could effectively communicate and who did not have a dementia diagnosis. An interview guide using open-ended questions was used to elicit personal stories and gain an understanding of the residents’ emotional reactions to the rabbits, understand the residents’ perceived benefits of participation, and determine if there were any negative aspects to participation. All interviews were conducted at the facility by the first author and were audio recorded. Interviews generally lasted 45 min.
Data Analysis
For the direct observation component, field notes were read and re-read until mutually exclusive categories of observations could be discerned (Bogdewic, 1999). Following verbatim transcription of the interviews, thematic analysis was performed by the first author. Transcripts were first reviewed several times with the aim of identifying keywords, ideas, and patterns. As explained in Creswell (2007), significant statements or quotes that shed insight into the residents’ experiences with the rabbit-assisted activity program were highlighted in a process known as thematic coding. The data were then used to develop a codebook so that meaningful units of text could be grouped together. Codes were then extracted and re-read several times until clusters of meaning or themes could be identified. To establish trustworthiness, interview data were compared with data obtained via direct observation to determine if findings converged or diverged (Bogdewic, 1999).
Demographic Characteristics of the Interviewed Participants
Of the eight participants who were interviewed for this study, seven were female. Six of the participants were White and two were Black/African American. Two had never been married, five were widowed, and one was married. The age of the participants ranged from 71 to 95 years with a mean age of 84.7 years (SD = 8.4). Educational attainment varied: two participants did not complete high school, two earned a high school diploma, and four completed at least some education or training after high school.
Results
Direct Observation
Three reactions to the rabbits were observed: not interested, mildly interested, and very interested. Not interested included residents who expressed no interest in petting the rabbits and made statements to indicate their lack of interest. Mildly interested encompasses those who petted the rabbits for a few seconds, but did not appear to be enthusiastic. Very interested describes residents who appeared very enthusiastic when the rabbits were present (e.g., smiling, talking to the rabbits). No participant exhibited a negative reaction to the rabbits either in the form of facial expressions or statements.
When the residents petted the rabbits, they often smiled and greeted them. Verbatim quotes included, “I love bunnies,” “I like to pet them,” and “You’re a little sweetheart.” One noteworthy interaction occurred between a resident and her granddaughter. Upon seeing the rabbits, the granddaughter asked her grandmother if she would like to pet them. The resident said “yes,” petted the rabbits, and then continued to converse with her granddaughter.
Several times during the activity, participants spontaneously remarked on past experiences with rabbits: “I had a rabbit once in my house,” “I used to have a bunny when I was young,” and “My granddaughter had a white bunny.” One woman reminisced about a past pet with a staff member, whereas another participant was reminded of her sister when she saw the rabbits. This suggests that participation in rabbit-assisted activities (RAA) evoked memories for some of the residents.
Themes From the In-Depth Interviews
Four themes were identified from the data. These include soothing experience, catalyst for communication and socialization, social support, and restricted opportunities for making meaning.
Soothing experience
Three participants reported that the presence of the rabbits and/or the act of petting them was relaxing or calming. Ms. A, for instance, stated how petting their fur kept her from repeatedly scratching her arms: “It calms me down . . . I rub their fur and it relaxes my mind.” Another stated, “Calm . . . satisfied . . . comforting” when asked how he felt when petting the rabbits. These residents’ comments suggest that one potential benefit of RAA may be that interacting with the rabbits promotes relaxation and decreases feelings of distress.
Catalyst for communication and socialization
Many participants reported talking directly to the rabbits. Ms. H stated, “When they’re here and I’m petting them, I talk to them all the time. [I] tell ’em how pretty they are and everything you know.” Other responses suggest that RAA served as a catalyst for interpersonal interaction. Ms. E described how she would socialize with her friends during the activity: “Well . . . we sit . . . in the lobby together, some of the friends you know . . . when they bring the bunny in and bring it over to us we’ll play with it.” Similarly, Ms. A expressed how she had conversations with a fellow resident about the rabbits: “I would tell [her] if you love animals then the bunnies are the softest, the gentlest, the cuddliest, they don’t scratch. They’re in a blanket.” These quotes suggest that RAA may serve as one means by which to promote communication and socialization.
Social support
Two participants described receiving emotional support from the rabbits. Ms. A described how the rabbits helped her cope with the death of her mother: “Right after my mom died I needed something. So I used the rabbit to heal me and it did. I held the rabbit and we prayed and we talked and talked and I talked to the rabbit.” Her experience suggests that even brief interactions with rabbits can serve as a source of emotional support for some older adults. Ms. D expressed a less intense sense of support from the rabbits: “You can make ah acquaintances with ’em, make friends.” She felt she could bond and communicate with the rabbits because they appeared to be interested in her. It may be that the ability of a live animal to respond to an older adult creates a sense of being emotionally supported.
Restricted opportunities for making meaning
Six participants identified wanting something more from the program, with the majority remarking that they wished visits with the rabbits were longer or more frequent. Ms. F expressed, “I wish they came over [every] other day.” Others commented that they desired a more interactive experience with the rabbits, such as being able to feed them. Ms. A suggested, “Go buy them little tiny carrots . . . and keep ’em in a cellophane bag and give us [a carrot] and let us give them [to the rabbits].”
Half of the participants commented that rabbits themselves were limited in their ability to provide meaningful interactions. Ms. C stated, “I can’t entertain them and they can’t entertain me except give me some pleasure.” Such sentiments appear to be connected to the limitations of the program and to using rabbits. Many expressed wanting to do more with the rabbits. As the program is currently designed, however, interactions with the rabbits are carefully controlled to ensure the safety of both.
Two additional findings also warrant discussion. First, in response to a question about the use of rabbits as an activity animal, all program participants reported that rabbits are good animals to use. Mr. B stated, “I would say they are the best type of animal to have because of their even temperament.” Two other participants compared RAA with another program that utilized dogs. Ms. C commented that she preferred the rabbits: “The dogs will either jump or run away and the bunny will just sit where he is. He is quiet.” Others remarked on the cleanliness of the rabbits: “I would say they are not dirty like other animals. They are pretty clean, clean animals.” These quotes indicate that although some residents may find rabbits limited, others may prefer interacting with rabbits because they perceived them to be clean and calm.
Second, all interviewees were readily able to recall memories about animals when asked about their experiences with pets and rabbits. Ms. H recalled memories about her children and rabbits: “[Someone] gave us white bunnies for the kids. I don’t know how they got loose, but they got loose out of their box so they went all over the yard. They were real pretty.” Although such stories emerged after prompting, it is important to emphasize that spontaneous reminiscing was also observed during the activity sessions. Together, these findings suggest that RAA may be a tool by which to promote reminiscence.
Discussion
The purpose of this study was to gain an understanding of the experience of RAA from the perspective of program participants. Several benefits were identified, with no negative experiences articulated by the residents. One benefit was that participants found their interactions with the rabbits to be soothing. This finding is consistent with literature documenting the stress-buffering effects of animals on humans (Allen, 2003; Friedmann et al., 2007; Levine et al., 2013; Polheber & Matchock, 2014). Consistent with McNicholas and Collis’s (2006) hypotheses, the rabbits served as a source of emotional support for some participants and encouraged social interactions among residents. Given that existing research suggests that positively oriented reminiscence can benefit mental health (O’Rourke, Cappeliez, & Claxton, 2011; Pinquart & Forstmeier, 2012; Westerhof & Bohlmeijer, 2014), an additional means by which RAA could enhance well-being is by encouraging reminiscence. Participants spontaneously recollected memories about their childhood, family life, and past pets and were able to do so when prompted during the interviews. Others have reported similar observations (Banks & Banks, 2002; Holt et al., 2015; Roenke & Mulligan, 1998).
Although no negative aspects of participation were identified, program design may have limited opportunities for the participants to derive meaning from the activity. Several participants expressed a desire for longer and more interactive visits. In addition, some participants commented on the limited capabilities of the rabbits. Interestingly, however, all participants described the rabbits as a good animal for AAA. Longer and more interactive visits may, therefore, serve to enhance the residents’ perceptions of the rabbits and the meaning they derive from the activity.
Several study limitations should be noted. First, the sample included only current and repeat participants. As a result, the benefits of participation may be overstated and negative aspects of participation might have been missed, as residents who derived no benefit from the program or found it unpleasant may not have returned. To gain a more comprehensive understanding of AAA and AAT, studies that incorporate both current and former participants are needed. Second, study participants were predominantly White and female. Since the experience of RAA may differ for men and members of other ethnic groups, efforts should be made to incorporate more diverse samples in future investigations. Third, the period of direct observation was relatively brief. A longer period of observation would increase the number of opportunities to observe the participants interact with the rabbits, the rabbit team, and other program participants. Fourth, although the sample size is within the recommended range for a qualitative study involving in-depth interviews (Creswell, 2007), the small sample limits generalizability of findings. Fifth, this was an exploratory study that does not permit quantification of the effects of participating in RAA or control/examination of factors that may have contributed to the reported benefits (e.g., characteristics of the human element of the rabbit team). Carefully designed randomized controlled trials of RAA would further our understanding of the potential benefits of RAA to older adults. Despite these limitations, this is—to our knowledge—the first published study to specifically examine RAA. It suggests that older adults who opt to participate in RAA derive benefits from their participation. Facilities considering the use of RAA should carefully consider the frequency, length, and nature of residents’ interactions with the animals.
Footnotes
Acknowledgements
The authors thank Dr. Nancy Orel for her contributions to this research project. They would also like to thank the rabbit team, the continuing care retirement community, and the residents who participated in this study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.