In this study, we verified that some of the subjects in the study population showed positive reductions in self-reported feelings of pain following the AAA.
Sobo et al. (2006) indicated that AAA reduces physical and emotional pain in children when used in conjunction with pharmacological treatment. Braun et al. (2009) concluded that AAI could be used as supplemental therapy to reduce pain and stress in children during hospitalization. Marcus et al. (2012) showed that, at a clinic specializing in the treatment of pain, adult patients with chronic pain had a significant reduction in pain and emotional suffering after a quick AAI session with a dog in the waiting room.
Improvement following AAA was also observed in the physiological indicators of pain, such as a reduction in heart rate, blood pressure, body temperature, respiration, and pupillary constriction, which suggests relaxation (Cole and Gawlinski 2000) and a decrease in pain.
In addition, the research suggests that AAI can lead to distraction from/redirecting of a problem, which is a possible explanation for the decrease in pain. One study indicated that the dog diverts the attention of the child who is under emotional distress (Johnson et al. 2008).
In Table 4, we can observe comments such as “I forgot about the pain” and “I got distracted.” Moreover, some subjects made a point to show photos of their own dog, whereas others suggested that their own dog could visit them at the hospital. According to Tsai et al. (2010), AAA is often more effective at easing symptoms of stress and anxiety in hospitalized children than a visit from a person.
It is worth highlighting that both the patient’s companions and the hospital professionals also sought to interact with the dogs, which fostered an atmosphere of ease and relaxation. These data corroborate the findings of Marcus et al. (2012), who stated that AAI benefits health professionals, which are regularly exposed to stressful work conditions. Another study showed that there was a significant decrease in salivary cortisol (stress hormone) in hospital professionals after 5 min of contact with a dog (Barker et al. 2005).
The subjects who changed their attitude prior to interacting with the dog (asking someone to open the window, brush their hair, or change their clothes) corroborate the findings of Souter and Miller (2007), who showed that AAI significantly reduces depression symptoms, and Banks and Banks (2005), who demonstrated a decrease in feelings of loneliness (particularly in individual visits). From this perspective, it is also possible to associate the psychological benefits with the decrease in the feelings of pain.
As for the subject who reported increased pain after the AAA and the one who did not want to see the dog at first, both fit the findings of Kaminski et al. (2002), who verified the positive effects of AAA on the mood of hospitalized children, which might justify the motivation of these subjects to participate in the AAA despite their discomfort and emotional suffering.
In this study, two therapy dogs of different sizes were used. It is worth highlighting that in situations where the subject was unable to leave the bed, Sheep (the small dog) was put on their lap or a chair beside their bed. In this same context, Bruce (the large dog) rested his head on the bed so he could be petted. Both forms facilitated and motivated affectionate and close interactions.
However, the large dog triggered the following important positive identifications: the children admired his strength and size, commenting: “He probably never gets sick, right?”; “One day, I want to take him for a walk!”; and “Does he eat a lot?” In many cases, identificationFootnote 1 and projectionFootnote 2 were noticed, which suggests symbolic elaboration by the subject before the experience. According to Levinson (1969), the child sees the possibility of incorporating the animal’s strength through identification because the animal also possesses feelings such as sadness, anger, and loneliness.
One of the subjects got out of bed and hid objects for the small dog to find, pretending they were hidden treasures. According to Winnicott (1975), playing has an important role in the elaboration of the subject’s internal issues and is a possible way to control anxiety, ideas, and impulses, which suggests that the interaction with the animal can create a potential space that makes it possible to have a creative experience of elaboration and reorganization between the external and internal world.
Regarding the verbalization of feelings of pain, Table 3 shows the answers given before the intervention with the dog. Verbalization, in most cases, revolves around feeling + parts of the body. The subjects described their pain as a “scratchy throat,” “pressure on the belly,” “like a punch in the stomach,” or something more defined and concrete. Table 4 shows the answers given after the AAA. Verbalization centers on the “other comments” category, which indicates vague feelings of pain after contact with the dog. These results suggest that the pain had “diluted” and was not the main focus anymore, and the comments ranged from “It doesn’t hurt anymore,” “It’s gone,” and “No pain.” In these cases, the subject’s verbalization before and after the AAA lead to symbolic elaboration of their feeling and also corroborate the findings of Sobo et al. (2006), whose research subjects, in an interview, identified the dog as something that created a distraction and entertainment.
In the cases where pain was still present after the AAA, the answers were “It still hurts, but I’m better,” “It’s better than before,” or “Playing was enough to make it better,” which suggests that the subjects felt better than before the intervention, as suggested by Cole and Gawlinski (2000). Although the physical pain remains, the dog is able to reduce, neutralize, and potentiate the negative feelings and sensations so that the patient becomes more tolerant to pain and replaces the absence of affection and feelings of neglect and abandonment (Moraes and Melo 2014).
Because hospitalization is one of the most stressful events for a child (Mahat and Scoloveno 2003), we were able to generally observe that based on the accounts of the companions and the observations of the researchers, the AAA resulted in positive psychological effects for the subjects, such as improved mood/smiles (Kaminski et al. 2002), sociability/conversations (Wu et al. 2002), motivation/getting out of the bed (Sobo et al. 2006), and depressed feelings/stopped crying (Kamioka et al. 2014).
Both the subjects and companions made contact with the animal during the intervention, which suggests that the dog promotes increased expression of emotions and provides support during difficult periods such as hospitalization. The parents/companions must also address feelings of powerlessness, changes in their routine, and giving up the comfort of their homes. The dog can also help them face the disease and treatment (Bussotti et al. 2005).
Patients who were informally appointed by the nurses and did not have complaints of pain but were fragile also benefited from the contact with the dog. Through the sessions, we verified that nurses are professionals who are very sensitive to their patient’s condition and seek to improve their well-being and humanize their care (Kawakami and Nakano 2002).
The concept that AAI can be an important tool in the hospital environment is justified by the humanized approach to healthcare, in which dogs, in particular, have offered significant contributions based on numerous accounts of experiences in the field. However, the topic lacks solid scientific evidence, which should be gathered through intensive theoretical and methodological research.
Limitations of this research
The first limitation is the relationship between the nurse and patient. The nurse identified the patients with pain; therefore, we cannot rule out the question of empathy in this relationship, which is completely subjective.
The second limitation is the difference in the route of application (oral or intravenous) and type of analgesics (dipyrone, paracetamol, tramal, or morphine), which could change the effects of the medication on pain and interfere with the results.
According to the results and the finding by Odendaal (2000), the amount of time the patients interacted with the dog (maximum 10 min) did not correspond to the peak release of hormones such as oxytocin (15 to 20 min), which are directly linked to feeling less pain. However, there was a decrease in the sensation of pain sensation. Is this a result of the possible symbolic elaboration during the interaction? Are distraction and changing focus from the pain sufficient to reduce pain in some patients? How long do the effects of the interaction persist after the session ends?
The type of interaction with the dog can also be considered a limitation of the study because we did not specify the activity to be performed. The type of interaction can also be influenced by whether the patient has a pet at home, which was not considered during this study.
The sample size can also be considered a limitation. Future research should be conducted with a larger sample.