Healthcare visits can be anxiety provoking and distressing for children (Craig et al., 2019; Delvecchio et al., 2019; Stenman et al., 2019). Many healthcare institutions incorporate programs to mitigate the negative impact of stressful healthcare encounters for pediatric patients (Humphreys & LeBlanc, 2016). Animal-Assisted Therapy (AAT) is a planned and structured intervention that incorporates animals to address a therapeutic goal (Jegatheesan et al., 2014). AAT can reduce anxiety and behavioral distress in pediatric patients and positively impact the physiological measures associated with arousal (Correale et al., 2022; López-Fernández et al., 2024). Lowered blood pressure, increased pain control, and decreased fear and anxiety are outcomes seen in pediatric patients who have received AAT (Feng et al., 2021; Spikestein et al., 2024).
Facility dog programs utilize AAT to enhance their therapeutic work. Facility dog handlers are clinical team members who integrate the use of a facility dog into their interactions with patients. Handlers incorporate the facility dog, who works alongside them, into their existing clinical responsibilities to augment their interventions and support the goals they have for a patient. The use of facility dogs paired with clinical handlers within the pediatric healthcare setting is rapidly expanding (Chur-Hansen et al., 2014; George et al., 2024). Healthcare staff have described facility dogs as helpful for building rapport, providing a comforting presence, and a positive resource, which normalizes the hospital environment for pediatric patients and their families (Rodriguez et al., 2022).
Certified Child Life Specialists (CCLS) are increasingly taking on the role of being facility dog handlers (George et al., 2024; Goldstein et al., 2022; Spikestein et al., 2024). CCLS are trained and educated healthcare professionals who help children and families deal with the stress associated with healthcare encounters (Romito et al., 2021). CCLS provide developmentally appropriate interventions such as therapeutic play, procedural preparation, procedural coping support, and education to patients (Romito et al., 2021). Limited literature has detailed how facility dog programs function in pediatric healthcare institutions, specifically when facilitated by CCLS. One mixed methods study examined the role and impact CCLS facility dog handlers have on the support of pediatric patients (Goldstein et al., 2022). In this study, descriptive programmatic data was captured for ten days. The data indicated that CCLS handlers were most frequently utilizing their facility dogs to provide general anxiety and coping support for patients three-to-five or six-to-11 years old who were in oncology or inpatient settings (Goldstein et al., 2022).
Setting the foundation and promoting success and retention of a facility dog program in a pediatric healthcare setting takes time, funding, and expertise in providing canine support. Sharing programmatic data is crucial to informing the implementation of facility dog programs. This retrospective, descriptive study provides details on one pediatric hospital’s facility dog program within a child life department, utilizing data to demonstrate how facility dog support is integrated into the work of CCLS, the impact on the day-to-day function, highlight successes, and identify opportunities for growth. The following research questions were used to ground the study: 1) What service areas and types of patients receive support from a facility dog? 2) Which interventions are provided most by CCLS handling a facility dog? 3) How does incorporating a facility dog into the work of CCLS impact direct patient care productivity? This study will expand on current descriptive studies of child life facility dog programs by describing a one-year capture of programmatic data that will detail patient populations, patient Psychosocial Risk Assessment in Pediatrics (PRAP), locations of services, interventions provided, time spent in each intervention, as well as CCLS facility dog handler direct patient care productivity.
Materials and Methods
Data Collection
All patient encounters at a large regional pediatric hospital from January 1, 2024, to December 31, 2024, in which CCLS documented the presence of a facility dog in the electronic medical record (EMR) were included in the dataset. As part of standard practice, after providing an intervention to a patient, CCLS facility dog handlers recorded whether a facility dog was present, the service location, time spent in the intervention, type of interventions provided, goals for the patient, and Psychosocial Risk Assessment in Pediatrics (PRAP) score and risk level. Patient age and date of CCLS intervention were also extracted from the EMR. To assess productivity, total hours worked was collected from the timecards of 46 CCLS, including both facility dog handlers and non-handlers. Handlers with leadership responsibilities were included when describing the patient support provided but excluded from the productivity analysis due to reduced clinical duties. This study was approved by the hospital’s institutional review board, and a waiver of consent was provided.
Program Structure
This facility dog program started in 2019 with one CCLS facility dog handler and one facility dog. By 2024, the facility dog program expanded to include seven facility dogs, seven primary and six secondary CCLS facility dog handlers. At this facility, all primary and secondary handlers are CCLS. Primary handlers typically have their facility dog about 80% of the time both in and out of the work setting. Secondary handlers generally dedicate approximately 20% of their weekly clinical work to providing AAT with the facility dog. Outside of work, secondary handlers are responsible for one overnight stay each week and one weekend per month with the facility dog to maintain the necessary bond for providing effective support to patients and their families.
This child life department has an established goal that all CCLS spend at least 60% of their time in direct patient care. Secondary handlers are included in this expectation, while primary facility dog handlers are expected to spend at least 55% of their time in direct patient care. The 5% decrease is to account for the time away from patient care needed to take care of the facility dog’s needs (e.g. exercise, breaks, special events, bathroom breaks, etc.). It is also important to note that the true impact of a facility dog on CCLS productivity may take time to assess accurately. Becoming a facility dog handler and adding a facility dog to clinical practice takes time to orient and learn a new skillset within the hospital. To account for this adjustment period, new facility dog handlers are not held to department productivity expectations for the first three months in their new role.
The program also includes float CCLS facility dog handler positions, which are not assigned to a single service area and can provide hospital-wide coverage. Float CCLS support and cross-coverage support are provided to a service area until the CCLS facility dog handler has passed their orientation stage. Facility dogs are not permitted in sterile procedures or with patients at risk for aggression. As part of prioritizing canine welfare, the program maintains dedicated respite spaces, structured rest breaks, and adaptations for aging dogs.
Initially, all facility dogs were paired with primary and secondary handlers in fully clinical roles. However, this facility dog program had several primary handlers move into leadership roles over their time handling their facility dog, which has impacted the facility dog’s time allocated to direct patient care. Handlers with leadership responsibilities (e.g. program coordinator, supervisor, manager) have reduced clinical expectations. Additionally, this program has two facility dogs who are considered senior dogs, and it is understood that they may not fulfill the same patient care load as the younger facility dogs in the program.
This program has a facility dog program coordinator role whose clinical allocation varies to accommodate their responsibilities. The program coordinator oversees policies, donor engagement, handler orientation, and evaluation. Currently, the program has facility dogs working in a variety of roles and service areas. Department expectations for direct patient care productivity vary by role. Table 1 breaks down the staff and handlers’ roles, service areas, and departmental expectation for the percentage of time spent on direct patient care.
Measures
Psychosocial Risk Assessment in Pediatrics (PRAP)
The PRAP assesses pediatric patients to evaluate which patients are at risk of experiencing distress during their healthcare encounters (Staab et al., 2014). The PRAP measures patients on eight variables: communication, anxiety/coping, temperament, special needs, parent/caregiver stress, past healthcare encounters, invasiveness of encounter, and developmental impact. CCLS administered the PRAP by interviewing parents using a series of standardized questions. Based on the information obtained during the interview, each variable is scored 0–3 with a total score of 0–24. Higher scores indicate more risk for experiencing distress. Cronbach’s α for internal reliability was .83 (Staab et al., 2014). PRAP score was strongly correlated with procedural distress scores, measured using the Children’s Emotional Manifestation Scale (CEMS) with r = .82 (p < .001) (Staab et al., 2014). The PRAP is utilized and documented as part of the routine care provided by CCLS at this institution.
Study Design
This is a retrospective, descriptive, cross-sectional study analyzing data already documented into the EMR as standard care delivered by CCLS facility dog handlers. Investigators exported data from January 1, 2024, to December 31, 2024, using pre-existing report in the EMR system. Protected health information was removed from this data set before performing statistical analysis.
Statistical Analysis
Demographics and key variables were summarized with counts and proportions for categorical variables. Continuous variables were summarized using means and standard deviations (SD) if normally distributed, or medians and interquartile ranges (IQR) if not normally distributed. One-way analysis of variance (ANOVA) was used to evaluate associations between variables, and significance was set at p < .05.
The PRAP score’s ability to predict time spent with the facility dog/handler was also examined. Visit length was dichotomized at 60 minutes, and logistic regression was used with PRAP score as the predictor. Model discrimination was evaluated using the area under the ROC curve (AUC), and the optimal cutoff score was identified using Youden’s J statistic. Significance was set at p < .05.
Hours per patient encounter (HPPE) was calculated for both CCLS facility dog handlers and non-handlers. HPPE is the total worked hours divided by total patient encounters. The direct patient care productivity was also calculated for each CCLS by dividing the total hours spent in direct patient care by the CCLS’s total hours worked. Data from CCLS handlers who were in leadership roles were excluded in the analysis because their productivity data would skew the dataset due to their diminished clinical load. Direct patient care productivity is displayed as a percentage of total worked hours.
Results
A total of 6,039 facility dog encounters were recorded. The median age of patients was 10 years (IQR = 6–13), with a mean of 11.11 years (SD = 4.60). Adolescents represented the largest age category (43%), followed by school-aged children (41%) (Table 2).
Location
The primary locations patients were seen by a facility dog were the outpatient (37%) and acute inpatient (30%) settings (Table 3). Facility dog handlers spent the most time in acute inpatient (38%) and outpatient clinics (32%).
Assessment
Facility dog handlers completed 510 PRAPs for patients. The median PRAP score for patients seen by the facility dog handlers was eight (IQR = 6-11). Most patients were reported as moderate risk (51.4%) for distress based on their PRAP score (Table 4).
Goals
The most frequently reported goals were to gain sense of trust (86%), gain sense of normalcy (80.4%), minimize stress (79.1%), utilize coping skills (72.9%), and gain sense of control (72.2%) (Table 5).
Interventions
The most frequent interventions provided by CCLS facility dog handlers were therapeutic play (33%) and developmental support (27.7%) (Table 6).
Productivity
Productivity data for primary and secondary facility dog handlers were included in the analysis to compare the productivity of eight of the facility dog handlers to 38 CCLS non-handlers. A one-way ANOVA demonstrated there was a significant difference in direct patient care productivity when comparing CCLS non-handlers to CCLS facility dog handlers, such that facility dog handlers spent less of their total worked hours in direct patient care (61.1%) compared to non-handler CCLS (66.2%), F(1,44) = 4.07, p < .05. Daily average patients seen and HPPE differences were not statistically significant, but facility dog handlers averaged seeing one less patient daily (M = 6.88, SD = 1.88) when compared to CCLS who were not handlers (M = 7.80, SD = 2.27).
The time spent by facility dog handlers differed significantly based on the location where the patient was seen. A one-way ANOVA demonstrated there was a significant impact of service location on CCLS facility dog handler time spent, such that facility dog handlers spent more time with patients seen in inpatient, critical care, and the emergency department (ED) compared to outpatient, radiology and surgery settings, F(5, 5168) = 146.24, p < .001 (Table 7).
A one-way ANOVA demonstrated there was a statistically significant difference in the average time CCLS handers spent with a patient based on the patient’s risk level on the PRAP, with increased time spent with higher risk patients, F(2, 494) = 7.31, p < .001 (Table 8). Post-hoc analyses examined whether PRAP score predicted the likelihood of extended time (> 60 minutes) with the facility dog and handler. A logistic regression model indicated that PRAP score was a statistically significant predictor of extended time (OR = 1.07 per 1-point increase, p = .016). However, the model’s discriminative ability was low (AUC = 0.58). Using ROC analysis, the optimal cutoff occurred at a PRAP score of approximately 10, above which children were more likely than not to require more than 60 minutes of interaction.
Discussion
This study contributes to the limited literature describing facility dog programs led by CCLS. Adolescents were the most frequently supported age group, which likely reflects deployment patterns to outpatient and inpatient mental health services. Facility dog handlers most often provided therapeutic play and developmental support, consistent with the goals of establishing trust, normalcy, and reducing stress for pediatric patients. Interestingly, distress management interventions were less common despite evidence that AAT can reduce pain, fear, and anxiety (López-Fernández et al., 2024). This may reflect institutional policies restricting dogs from sterile procedures, concerns about patient safety, or deployment away from areas where acute pain is more prevalent.
Findings demonstrated that being a facility dog handler decreased CCLS’s direct patient care productivity compared to CCLS who are not facility dog handlers. In this study, handlers averaged seeing one less patient a day compared to their non-handler counterparts. A previous mixed-methods study highlights the need for CCLS facility dog handlers to consider the needs of their facility dog throughout their workday (Goldstein et al., 2022). This difference in patients seen per day is likely explained by the additional responsibilities of managing the facility dog during the workday, including ensuring the dog’s welfare (e.g., exercise, bathroom breaks, rest periods), attending to donor or program responsibilities, and adapting interventions to patient needs with the dog present. These factors reduce available clinical time and provide a plausible explanation for the observed productivity gap. Although modest, this finding highlights the need for departments to plan for realistic productivity adjustments when implementing facility dog programs.
This study also demonstrates that certain factors can influence the time that facility dog handlers spend with patients. Service location and psychosocial risk level on the PRAP was significantly associated with the amount of time CCLS facility dog handlers spent with a patient. In post-hoc analyses, higher PRAP scores were modestly associated with longer interventions, with a threshold of a PRAP score of approximately 10 predicting a greater likelihood of interventions exceeding 60 minutes. However, the predictive strength was weak, suggesting that while PRAP scores contribute to visit length, other contextual and clinical factors (e.g. child preference, clinical scheduling, staff judgment, or concurrent care needs) likely play a larger role in determining the length of the intervention.
Patients seen in critical care, emergency, and inpatient settings may require more time for a successful intervention with a facility dog due to the variety and complexity of medical care and overall acuity of patients in these areas. This finding is supported by a previous study, which indicated that a higher percentage of patients seen in critical care, emergency department, and inpatient settings screened positive for needing child life support when compared to other hospital settings (Staab et al., 2025). Together, these findings suggest that facility dog handler roles affect both the patient populations served and the time spent on interventions. They also highlight the importance of considering psychosocial acuity and service location in planning and evaluating facility dog programs. By expanding on Goldstein et al. (2022), the present study provides a more detailed, year-long description of how handlers integrate facility dogs into child life services and the implications for clinical productivity.
Limitations
The design method used in this study was retrospective and descriptive, primarily using descriptive statistics for analysis. There is a paucity of research investigating facility dog programs, outcomes, and interventions facilitated by CCLS. This study can serve as a precursor to prospective research studies to better understand causal impacts of facility dogs on patients, their families, and on staff productivity. This study has potential limitations that should be noted. Data extracted from the EMR were self-reported by CCLS facility handlers and CCLS non-handlers. Therefore, there is a possibility of missing data if CCLS did not document a patient encounter, did not complete their documentation in its entirety (e.g., service area, patient intervention), or did not select all applicable sections in their documentation (i.e., did not select all relevant patient goals, or all the interventions used with the patient).
There was not enough CCLS facility dog handlers to statistically evaluate several outcome variables we hoped to compare, such as the average number of patients seen per day, HPPE, and differences in productivity by service location. Multi-site studies could provide more statistical power to evaluate productivity differences across service areas and to refine PRAP thresholds for anticipating longer visits. CCLS handlers who led group child life interventions likely skewed the average number of patients seen per day to be higher and HPPE to be lower than it would be if handlers were primarily seeing patients individually. Specifically, two of the CCLS facility dog handlers offer adolescent mental health group sessions, which is likely why this study found adolescents were the age range to receive support most often from a handler. CCLS who see patients in group settings are instructed to document for each patient, but only apply their time spent to one patient in the group. This is to ensure the count of number of patients seen by the CCLS is accurate while not inflating their total time spent in patient care.
Future research should build on this study’s findings by examining how program structure (e.g., float vs. primary handlers, leadership responsibilities) and contextual variables interact with patient characteristics to shape outcomes. Qualitative studies may also be valuable for capturing staff and family perspectives on the unique contributions of facility dogs that are not fully represented in productivity metrics.
Conclusion
This study utilized retrospective, descriptive, and cross-sectional methodology aimed to define a facility dog program led by CCLS at a large, regional pediatric hospital. Findings demonstrated that facility dog handlers most frequently supported adolescents and school-aged children, with interventions centered on therapeutic play and developmental support. Productivity analyses revealed that handlers saw fewer patients and spent a lower proportion of time in direct patient care compared to non-handlers, likely due to the added responsibilities of caring for and incorporating the facility dog into clinical practice. Both service location and patient psychosocial acuity (PRAP score) influenced intervention time, with higher PRAP scores modestly predicting extended interventions. Although the predictive strength of PRAP score was limited, identifying a threshold of approximately 10 offers initial guidance for anticipating longer visits. Collectively, these findings highlight the unique contributions and challenges of facility dog programming, suggesting the need for thoughtful planning around staffing, deployment, and program evaluation. Future research should continue to investigate program impacts across multiple sites and explore qualitative perspectives to better capture the holistic value of facility dogs in pediatric care.