Introduction
According to the Centres for Disease Control, 1 approximately 1 million American children are living with a cardiac defect or condition, each of which requires specialised monitoring and care to different degrees. Echocardiography is one of the most widely used imaging techniques for diagnosis and evaluation in paediatric cardiology, Reference Camarda, Patel, Carr and Young2,Reference Prakash, Powell and Geva3 thus many children both with and without cardiac conditions will experience an echocardiogram at some point in their childhood years. Younger children are commonly sedated for this procedure, as it may be developmentally challenging for them to remain still enough for diagnostic-quality images to be obtained. Reference Roach, Husain, Zabinsky, Welch and Garg4,Reference Stern, Gauvreau, Geva and Benavidez5
Sedation for paediatric echocardiography, however, is undesirable both due to costs—which may range from hundreds to thousands of dollars Reference Roach, Husain, Zabinsky, Welch and Garg4—and increased risk of adverse events related to sedation itself. Reference Cravero, Blike and Beach6,Reference Sanborn, Michna and Zurakowski7 In addition, receiving sedation or anaesthesia has been shown to be an overwhelming, stressful, and potentially traumatic event for some paediatric patients; Reference Brewer, Gleditsch, Syblik, Tietjens and Vacik8,Reference Perry, Hooper and Masiongale9 it is now recognised how negative experiences of medical encounters during childhood influence lifelong attitudes towards healthcare. Reference Burns-Nader, Whitten and Davis10 Thus, to both minimise costs and minimal risks associated with sedation use, and decrease anxiety and reduce the risk of unnecessary trauma, it is important to consider non-pharmacological strategies that may achieve these goals simultaneously and benefit all stakeholders.
One rising area of intervention implementation and research concerns the work of facility dogs. Hospital facility dogs and their handlers are trained to provide goal-oriented, structured interventions that increase patient and family psychosocial well-being and help them meet specified therapeutic and developmental goals. Reference George, Keller, Goldstein, Grissim and Boles11–Reference Fine, Garcia, Johnson, UK, Winkle and Yamazaki13 Ranging from animal-assisted therapy to animal-assisted intervention and animal-assisted activity, these intentional supports might include procedural preparation and support, diversion from the healthcare environment, pain management interventions, and motivation (such as encouraging ambulation after a surgery). Reference George, Keller, Goldstein, Grissim and Boles11,Reference George, Keller, Goldstein, Grissim and Boles12 Prior research has documented high levels of paediatric staff satisfaction with these skilled dog-and-handler teams, reporting perceptions that their interventions improve patient experience and increase cooperation. Reference Murata-Kobayashi, Suzuki and Morita14,Reference Rodriguez, Bibbo and O’Haire15 Moreover, care provided by trained psychosocial professionals and facility dogs has been shown to reduce healthcare-related costs and reduce the need for sedation during procedures requiring paediatric patients to remain still. Reference Boles, Fraser and Bennett16–Reference Kinnebrew, Dove, Midwin, Olson and Guimaraes18
Less known, however, have been the specific relationships between facility dog intervention and children’s anxiety, especially in younger patients, and in the context of non-oncology chronic populations. Therefore, the purpose of this study was to examine the relationship between facility dog intervention and young children’s anxiety during non-sedated echocardiography in an outpatient cardiology clinic. The study was guided by these research questions:
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1. What is the relationship between facility dog intervention and participants’ pre- and post-echocardiogram anxiety levels?
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2. How do parents/caregivers of participants perceive and experience facility dog intervention during their child’s echocardiogram?
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3. How do cardiology clinic staff perceive and experience facility dog intervention during participant echocardiogram?
Methods
Given the limited availability of facility dog time and services at the research site (only one dog-and-handler for over 300 inpatient beds), and the high visibility of this study in a highly socially connected chronic illness patient population within that site, a quasi-experimental design was chosen. The research site was a freestanding children’s hospital that is a nationally ranked full-service paediatric cardiology centre. The centre is known for its heart transplant and multi-stage surgical repair programmes, serving both local families and those who travel for its renowned surgical services. Demographically, the hospital is affiliated with a non-profit academic medical centre and is situated in an urban area in the southeastern United States. This study received full Institutional Review Board approval from the research site under protocol #[231071].
Participants
Eligible participants were children between the ages of 18 months and 8 years scheduled for an echocardiogram without sedation in the paediatric cardiology clinic during the data collection period (May 2023 to July 2024). Children who did not speak English or who were currently in state custody were excluded from this study. The facility dog-and-handler team dedicated Wednesday mornings to study recruitment and data collection; therefore, eligible patients and families were identified in advance from the clinic schedule to plan for obtaining consent and assent, having a trained nurse observer present, and communicating with clinic staff that data collection would be occurring. When eligible participants on designated data collection days were identified, the team attempted to contact parents/caregivers by phone the day before to give information about the study in preparation for approaching to obtain consent and assent in the waiting room prior to the child’s appointment. In addition, this was an opportunity to assess if the child met any of the dog-related exclusion criteria, which included a reported allergy to or fear of dogs, or if parents/caregivers had concerns about the possibility of their child displaying aggressive behaviour towards dogs.
Procedures
Once consent and assent were obtained in REDCap Reference Harris, Taylor and Minor19,Reference Harris, Taylor, Thielke, Payne, Gonzalez and Conde20 on an iPad in the clinic waiting room, the parent/caregiver completed a brief demographic and medical history survey also using REDCap. Next, the participant and family were greeted by the facility dog-and-handler and escorted to a private clinic room, as was standard practice during any other clinic or procedure visit. After a brief wait and playful introductory conversation (as the rapport-building phase of the intervention, as described in more detail below), the technician came to the room along with the trained nurse observer to escort the child, family, and dog/handler team to the echo room. As the child entered the room and was transferred to the bed, the nurse observer scored the modified Yale Preoperative Anxiety Scale in REDCap on an iPad as the pre-procedural timepoint. The nurse observer then left the room, the door was closed, and the facility dog/handler team remained throughout the procedure to provide supportive intervention.
The nurse observer waited outside the room listening for audio cues that the procedure was ending, and as the facility dog handler opened the door, the modified Yale Preoperative Anxiety Scale was scored once again as the post-procedural timepoint. As the child calmed and dressed, a parent/caregiver was asked to complete a brief parent/caregiver perceptions/experiences survey in REDCap on the iPad. The facility dog-and-handler then escorted the family back to the waiting room at the conclusion of their visit and provided support for this final transition. After this, the participant’s involvement in the study ended. Finally, the technician was asked to complete a brief staff perceptions/experiences survey using REDCap on an iPad. However, since technicians were not the only staff impacted by this study, all cardiology clinic staff were invited to complete this survey via email once all participant data collection was complete, so their experiences could be represented.
Intervention
The procedural support intervention participants received during their echocardiogram was performed by a single dog-and-handler team, which helped to maintain fidelity to the maximum extent possible while also allowing for the flexibility needed to meet individualised coping needs and preferences. The intervention team consisted of a facility dog handler (LG) who was a master’s-educated Certified Child Life Specialist with over 30 years of clinical experience in a variety of settings; the facility dog, Squid, was a five-year-old black Labrador retriever and graduate of the accredited assistance dog organisation, Assistance Dogs International. This team had three years of work experience as the only facility dog team at the research site when the study began and thus were fluent in needs assessment and service provision across inpatient and ambulatory settings.
As facility dog interventions, like many psychosocial interventions, are grounded in the development of a therapeutic relationship between professionals and their clients, the procedural support intervention in this study began as soon as the child and family were introduced to the dog-and-handler. As the dog-and-handler offered a calm and comforting presence, the handler observed the child’s visual and behavioural responses to the facility dog team while introducing themselves and their services. The handler encouraged choice and control by inviting the child to engage with the dog in the ways they felt comfortable, such as petting, gentle interaction, or play.
Before transitioning to the procedure room, the handler showed and narrated a developmentally appropriate picture book featuring the facility dog undergoing an echocardiogram to help familiarise the child with the equipment and sequence of events they would experience. While reviewing the book, participants were given the opportunity to plan how they would like to lay on the procedure room bed, and where they would like the facility dog positioned during this. The handler also encouraged the child and family to make a coping plan for the procedure, which included not only how to interact with the facility dog, but also other sensory soothing supports such as favourite music, parental touch, and comfort items.
In the procedure room and throughout the echocardiogram, participants and families were given the maximum amount of agency possible in interactions with the facility dog-and-handler. This allowed them to interact in any way that would not compromise the quality of the echocardiogram (e.g. through excessive movement), including choosing the dog’s positioning, giving commands, petting the dog, or having the dog provide deep pressure stimulation. The handler was attentive to the child’s verbal and nonverbal cues throughout the procedure so adjustments could be made by the facility dog or other tools could be used to support the child’s coping. For instance, if a child grew restless and needed diversion, the handler could engage them by showing videos of the dog engaging in his everyday activities or demonstrating his commands on the bedside tablet. If more tactile distraction was needed, interactive games could be offered such as a chance to peek inside the facility dog’s vest zippers to search for surprises or play with finger puppets resembling the facility dog for toddler-aged participants.
The presence of the dog-and-handler was intended to complement rather than replace other non-pharmacological interventions, thus patients were encouraged to have other coping tools available as desired, such as playing videos or music for distraction. The facility dog procedural intervention was slightly longer in duration than the echocardiogram itself, which enabled the dog-and-handler to be present prior to the patient needing to sit on the exam bed or remove any clothing, both of which have been anecdotally recognised as possible sources of anxiety. The dog-and-handler remained with the patient for the full length of the echocardiogram, and took care to ensure participants were calm, comfortable, and back to baseline before ending the research encounter fully.
Measures
To assess patient anxiety pre- and post-echocardiogram, the modified Yale Preoperative Anxiety Scale Reference Kain, Mayes and Cicchetti21 was used. This is an observational, behaviour-based measure scoring anxiety manifestations across five domains in children ages two to 12 years old. Reference Kain, Mayes and Cicchetti21 A trained nurse observer not involved in the child’s medical care scored the child’s behaviours on the “emotional expressivity,” “state of apparent arousal,” “activity,” and “use of parents” domains on a scale of 1 to 4, and the “vocalizations” domain on a scale of 1 to 6. Thus, possible composite anxiety scores ranged from a low of 5 to a high of 22. The modified Yale Preoperative Anxiety Scale was chosen for its applicability to a procedural context, manageable training threshold, ease of use, and high reliability with reported Cronbach’s alphas ranging from 0.82 to 0.95. Reference Vakili, Feizi, Salimi, Mottahedi and Rizevandi22
At the procedure’s conclusion, the caregiver and sonographer were asked to complete respective electronic perception/experiences surveys designed by the research team. These surveys consisted of 3 questions answered on a five-point Likert scale, with “1=Strongly disagree” and “5=Strongly agree.” In addition, there was one multiple-choice question and one open-ended comment box.
Analyses
All demographic, modified Yale Preoperative Anxiety Scale, and caregiver and staff perception/experience survey data were analysed using IBM SPSS Statistics version 29. The relationship between facility dog intervention and participant anxiety was explored using paired-samples sign tests, Spearman’s rho, and Mann–Whitney U given non-normal data distribution; parent and staff perceptions were characterised with general descriptive statistics.
Results
A total of 70 children participated in the study (see Table 1). The mean age was 3.77 years (standard deviation 2.22), and the sample was relatively split with regard to gender (52.8% male). Interestingly, the majority of participants had reportedly undergone at least one previous echocardiogram (n = 58; 80.6%).
Table 1. Participant demographics
Note. n = 70. Not all participants answered all demographic questions.
Facility dog intervention and child anxiety
As can be seen in Table 2, participants demonstrated significantly lower m-YPAS scores after their echocardiogram with facility dog presence and support as compared to scores observed at the start of the procedure (Z = –3.974, p < .001).
The majority of participants (n = 58; 80.6%) had previously undergone at least one echocardiogram. When compared to those with no prior echocardiogram experience, this group that had received previous testing demonstrated significantly higher anxiety scores at the pre-procedural timepoint (z = –2.442, p = .015). However, the difference in anxiety between these “experienced” and “inexperienced” groups at the post-procedural timepoint was found to be nonsignificant (p = .071). Likewise, there was no significant difference in anxiety change between the two timepoints noted for these two groups (p = .113).
Interestingly, Spearman’s rho yielded a significant negative correlation between participant age and anxiety scores at both the pre-procedural (r(68 = −0.330, p = .005) and post-procedural (r(68) = −0.564, p < .001) timepoints. However, there was no correlation seen between age and change in anxiety scores across these timepoints (p = .938).
Caregiver perceptions and experiences
A total of 73 parents/caregivers completed the caregiver perception and experiences survey. Of these, 72 (98.6%) agreed or strongly agreed they liked facility dog-and-handler intervention and presence during their child’s echocardiogram procedure. In addition, 71 (97.2%) agreed or strongly agreed the facility dog-and-handler’s presence and support helped their child cope with the procedure, and 72 (98.6%) agreed or strongly agreed they would recommend this intervention to other patients and families.
Staff perceptions and experiences
Fifty-eight participants completed the staff perceptions/experiences survey. The majority (n = 51, 87.9%) agreed or strongly agreed facility dog-and-handler intervention and presence improved the child’s coping ability during their echocardiogram. They also largely (n = 49, 84.4%) agreed or strongly agreed that the intervention did not notably impact their workflow or ability to complete the procedure as needed. In fact, 50 participants (87.7%) agreed or strongly agreed that facility dog-and-handler intervention improved the quality of care they provided during the child’s echocardiogram experience.
Discussion
Non-pharmacological procedural support interventions provided by Certified Child Life Specialists and facility dog-and-handler teams have shown to reduce children’s anxiety in healthcare settings, sometimes decreasing need for and use of sedation. Reference Boles, Fraser and Bennett16–Reference Kinnebrew, Dove, Midwin, Olson and Guimaraes18 This study, however, is among the first to examine the relationships specifically between facility dog intervention and young children’s anxiety during outpatient echocardiography. As in prior literature, participants in this study demonstrated a statistically significant decrease in anxiety from procedure start to finish. The direction and significance of this relationship remained stable across participant ages, although younger children demonstrated higher pre-procedural anxiety levels compared to older children. Thus, toddlers, preschoolers, and young school-aged children all appeared to benefit from the procedural support intervention provided by the dog-and-handler team.
Most participants reported prior echocardiogram experience, with this group showing more anxiety at procedure start than those without; this was perhaps reflective of known links between early healthcare experiences and later perceptions. Reference Burns-Nader, Whitten and Davis10 Regardless of prior procedural history, anxiety levels were observed to decrease at similar rates across timepoints across all participant groups in this study, suggesting the wide utility of facility dog intervention for diverse paediatric patient groups. Furthermore, staff perceptions from this study echoed those of prior work in which facility dog-and-handler team interventions generated high satisfaction levels among hospital staff. Reference Murata-Kobayashi, Suzuki and Morita14,Reference Rodriguez, Bibbo and O’Haire15 Caregivers were also highly satisfied, feeling it benefitted their child’s coping, and was achieved with no noted workflow impact.
Implications
Facility dog-and-handler teams are a growing psychosocial resource at many North American children’s hospitals, recognised as integral members of clinical teams—not just comforting companions—often because of the procedural support they provide. Reference George, Keller, Goldstein, Grissim and Boles11,Reference George, Keller, Goldstein, Grissim and Boles12 As highly trained professionals carefully selected to serve children in healthcare facilities, their background in animal-assisted intervention and animal-assisted therapy allows them to deliver structured, intentional, goal-oriented interventions going far beyond petting a dog for fun. Reference George, Keller, Goldstein, Grissim and Boles11–Reference Fine, Garcia, Johnson, UK, Winkle and Yamazaki13 In this study, procedural support interventions from a facility dog-and-handler team were found to be associated with a decrease in even toddler-aged children’s anxiety between the beginning and end of an often-stressful, non-sedated outpatient echocardiogram procedure. These studies suggest facility dogs may provide a feasible and effective non-pharmacological intervention to reduce sedation needs and offer psychosocial care to young children in procedural settings, inclusive of those with and without chronic illnesses.
However, more research—especially experimental studies—and structured evaluations are needed to continue building and expanding the evidence base for these novel psychosocial support programmes. Specifically, researchers should consider tying facility dog intervention to not only emotional and behavioural outcomes such as cooperation or emotion regulation, but also physiological measures of therapeutic response such as heart rate, blood pressure, or hormone fluctuations.
Limitations
Like all research, this study was not without limitations. Given the importance of avoiding sedation or anaesthesia during paediatric echocardiography for reasons of safety, Reference Cravero, Blike and Beach6,Reference Sanborn, Michna and Zurakowski7 cost, Reference Roach, Husain, Zabinsky, Welch and Garg4 and patient stress levels, Reference Brewer, Gleditsch, Syblik, Tietjens and Vacik8,Reference Perry, Hooper and Masiongale9 patients and families were permitted to utilise any non-pharmacological anxiety reducers such as music or videos they felt were beneficial, thus a control group receiving no interventions was not included in this study. Future research should attempt to accomplish a randomised controlled trial design to more fully compare facility dog intervention with other non-pharmacological procedural support interventions. Moreover, participants in this study were drawn from a single clinic, were English speaking, and were not representative of the entire population that could benefit from or appreciate access to facility dog interventions.
Figure 1.
Conclusion
Living with cardiac conditions can have a significant impact on children’s development and, in particular, their coping with the frequent and recurrent healthcare experiences required to monitor and treat their conditions. Facility dog interventions may be a useful way to support young children during non-sedated echocardiogram, with participants in this study demonstrating decreased anxiety between the pre- and post-procedural timepoints while receiving support from a facility dog-and-handler team. In addition, this intervention was well-received by parents/caregivers and staff without impacting clinic workflow. As paediatric healthcare facilities seek to invest in their psychosocial service offerings and enhance the long-term medical and psychosocial outcomes of their patients and families, facility dogs may be a useful and well-received investment in both aims.
Acknowledgements
None.
Financial support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Competing interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008, and has been approved by the institutional committee at Vanderbilt University Medical Center.
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