CONTINUING MEDICAL EDUCATION IN ACADEMIC EMERGENCY MEDICINE CME Information: Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers

Objective: Cognitive stress during shift work contributes to burnout in emergency department (ED) workers. We hypothesize that if physicians and nurses interact with a therapy dog for 5 minutes while on ED shift, both their perceived and their manifested stress levels will decrease. Methods: In this single-center, prospective, randomized controlled clinical trial (NCT03628820), we tested the effectiveness of therapy dogs versus coloring a mandala and versus no intervention (control) on provider stress. Consenting emergency medicine physicians and nurses provided three self-reported assessments of stress and saliva samples at the start (T1), at the middle (T2), and near the end (T3) of shift. Thirty minutes prior to T2, participants were randomized to either interacting with a therapy dog or coloring for 5 minutes; controls had neither. Stress was assessed on visual analog scale (VAS, 0–100 mm) and with salivary cortisol (Salimetrics) and the modified Perceived Stress Scale (mPSS-10). To assess potential change in participant behavior, patients of providers in either group were asked to complete an internally derived survey of empathic behaviors displayed by providers at T1 and T3. Results: We enrolled 122 providers (n = 39 control, n = 40 coloring, n = 43 dog); 48% were residents, and 60% enrolled on an evening shift. At T1, mean ( SD) VAS score was not different between groups (18.2 [ 17.8] mm). At T3, VAS tended to increase with coloring (24.5 mm), remain unchanged in controls (20 mm), and decreased slightly with dogs (13.6 mm, p = 0.018 vs. coloring, Tukey’s post hoc). Salivary cortisol levels were consistently highest at the beginning of each providers’ shift and were significantly decreased versus control in both the dog and the coloring groups (p < 0.05, Tukeyʼs). We observed no difference between groups for the mPSS-10 nor in patient reported survey of empathic behaviors. Conclusion: This randomized controlled clinical trial demonstrates preliminary evidence that a 5-minute therapy dog interaction while on shift can reduce provider stress in ED physicians and nurses. Physician and nurse burnout is common in emergency medicine and appears to be more frequent than other specialties. Approximately 55% to 70% of emergency physicians, nurses, and residents in training are at risk of quitting their profession because of high levels of burnout, the rate of burnout among other specialties is 45% to 55%. Burnout has been associated with loss of empathy and compassion From the Indiana University School of Medicine, Indianapolis, IN; and Butler University, Indianapolis, IN; Lois and Sydney Eskenazi Hospital, Indianapolis, IN; and the Purdue University School of Veterinary Medicine, Lafayette, IN. Received December 24, 2019; revision received February 1, 2020; accepted February 10, 2020. The authors have no relevant financial information or potential conflicts to disclose. Supervising Editor: Mark B. Mycyk, MD. Address for correspondence and reprints: Jeffrey A. Kline, MD; e-mail: jefkline@iupui.edu. ACADEMIC EMERGENCY MEDICINE 2020;27:266–275. 266 ISSN 1553-2712 © 2020 by the Society for Academic Emergency Medicine doi: 10.1111/acem.13939 toward patients, loss of coping ability, reduced career longevity, and lower physician satisfaction with career. Causative factors directly related to the work stated by providers are psychological demands on shift, poor job control, long shifts, night shifts, lack of autonomy, and criticisms on shift. Improving the well-being of providers may increase quality of patient care, inasmuch as happy providers generally evoke higher patient satisfaction. This work therefore seeks to reduce provider stress while on shift in the emergency department (ED). In this clinical experiment, we test the effectiveness of therapy dogs versus a coloring exercise versus no intervention on provider stress. The rationale for therapy dogs is supported by prior literature that demonstrates that human perception of stress and pain can be reduced with exposure to animals in multiple settings, including health care workplaces. The rationale for coloring of mandalas centers on the potential for the exercise to cause a mental distraction from work concerns, potentially overriding cognitive stress responses (i.e., “mindfulness”). The main study hypothesis is that emergency health care workers on shift who interact for 5 minutes with a therapy dog and handler will have lower perceived and manifested stress response compared with use of a time out that includes voluntary use of a coloring mandalas. The work will also address two exploratory hypotheses: The first is that salivary cortisol will correlate significantly with perceived stress and will increase from beginning to end of shift and that exposure to a therapy dog will blunt this increase. The second exploratory hypothesis states that participants who interact with a therapy dog will display more empathic behaviors.