A Qualitative Exploration of the Benefits of Pet Therapy and Their Potential Application to Robotics   Introduction Despite technological advancements and ongoing cancer research, rates of some cancer diagnoses continue to rise.  For example, the prevalence of pancreatic cancer has steadily risen over the past five years (Pancreatic Cancer – Cancer Stat Facts, 2015), Figure 1.  As the population continues to age and longevity is improved, cancer intervention will remain a considerable strain on the patient and the healthcare system.  In the hopes of becoming cancer-free, patients are often subjected to surgical, pharmacological, and radiation therapy.  Additionally, patients seek out alternative therapy as a source of symptoms relief.  Such therapies include yoga, acupuncture, music therapy and pet therapy (CDC, 2018).  In regards to pet therapy, the Centres of Disease Control (CDC) notes that pets can have positive effects on our physical health.  They can decrease our blood pressure, cholesterol levels, and triglyceride levels (CDC, 2018).Figure 1: New Cases, Deaths, and 5-Years Relative SurvivalProblem StatementCancer, along with its associated treatments, causes a variety of distressful and life altering side effects.  Symptoms like nausea, alopecia, pain, and loss of appetite manifest both physically and psychologically (“Side Effects of Cancer Treatment,” 2015).  Alternative therapies have proven to be a novel and innovative method for the management of some of these untoward symptoms (10 alternative cancer treatments to consider,”2015.).  Specifically, various research articles have demonstrated the positive impact of pet therapy in the oncological setting (Creagan, Bauer, Thomley, & Borg, 2015).Despite their benefits, little investigation has been completed regarding the specific attributes of pet therapy that provide benefit and to what degree. Even less investigations have been done in regards to the oncological patients’ perceptions of the benefits provided by pet therapy. To address this gap in knowledge, we propose a unique exploration of the patient experience in order to divulge important information regarding pet therapy.  Patients diagnosed with cancer provide a unique opportunity as those that undergo treatment have a specific set of common symptoms.  This research provides an opportunity to explore those symptoms along with the components of pet therapy that coincide with their relief.  The intention is to develop a set of qualities that can be incorporated to other therapies in order to provide the same benefits from a session with a pet care provider.  Thus, by conducting a qualitative examination of patient experiences, we may be able to identify and elicit specific characteristics in order to improve upon the therapy and be applied to other types of regimens of healthcare systems.Significance of the study (Literature Review)While both medical and psychological professionals express a belief in the benefits of pet therapy, there is a lack of continuity in regard to what components provide specific abatement of symptoms. Common symptoms include not only physiological effects, but also psychological manifestations, such as loneliness, anxiety and depression. Similar to pharmacological intervention, The National Center for PTSD suggests benefits such as stress reduction provided by pet ownership (“Dogs and PTSD – PTSD,” 2014), but without clear indicators for success. A literature review also provides examples of research exploring pediatric patients and the intervention of pet therapy, but there is a gap in knowledge regarding its significance in the adult population (Chubak et al., 2017).  In this sense, it should be noted that without further exploration of the adult population significance, we lack the ability to enhance the positive components of pet therapy and possibly extrapolate and apply their benefits to other arms of treatment.  The proposed research is significant because understanding both the positive and negative attributes of pet therapy will lead to an increased understanding of how to lessen discomfort and improve the quality of life for those suffering from cancer. Through our research, we intend to fill this gap in technical knowledge with the hopes of providing a targeted treatment plan for adult oncological patients.  This research is innovative because it addresses the pressing need to identify what components of alternative therapies provide benefit to adult oncological patients.  We intend to identify and characterize these attributes in a rigorous manner in order to provide better outcomes for future patients.Specific AimsQuestion:What are the specifics traits of pet therapy that are beneficial to the patient suffering from cancer-related symptoms?Aim 1. Explore and describe the specific characteristics of pets and pet therapy that patients find beneficial in the abatement of their cancer-related symptoms. Question:What is the degree of benefit or detriment of each pet therapy traits?Aim 2. Assess to what degree each pet therapy’s characteristic is perceived as beneficial or detrimental.Question:Which associations can be made between patient characteristics and pet therapy benefits and deterrents?Aim3.  Analyse the associations between patient characteristics and pet therapy benefits and deterrents.Question:Which positive attributes of pet therapy can be applied to other medical technology?Aim 4.  Determine the positive attributes that could be applied into medical technology .MethodologyIn all research it is important to select the paradigm from which the research was approached. In this regard, we chose an epistemological position facing a reality that looks to know the perceptions of the oncological patients regarding pet therapy. We presumed that this could be a complex but dynamic reality that needs to be approached from the patients’ perspective in order to explore their strengths and weaknesses. After considerations regarding the logic and coherence of our research, we have decided that the paradigm most useful to our study is the qualitative interpretative paradigm. Indeed, in this case, the nature of the knowable consists in exploring the oncological patients’ perceptions and experiences in regards to the pet therapy.As we can observe from an ontological point of view, the reality that we intended to study did not exist outside of me as a researcher, and the connection that we looked to establish was an interrelation between the studied reality and us. As this research aimed to explore the patients’ experiences regarding pet therapy, we believe that a qualitative research approach was important to give a voice to those who are suffering from cancer-related symptoms and how they experienced the relief of these symptoms. It is equally significant to understand the associations that oncological patients made and what are their concerns regarding the pet therapy and the assistance provided from using it.Likewise, research inspired from the interpretative paradigm are based on the assumption that people live in a context and create a culture that is reproduced through their words and actions (Guba and Lincoln, 2005). The intention of the research in a qualitative interpretative paradigm seeks to understand people’s reasons and motivations in their real dimension; as such, this understanding is obtained from within, allowing patients to freely narrate their own lived experiences regarding pet therapy.Additionally, from an epistemological point of view, the results obtained came from the interrelation between the researcher and the group of interviewees. In this sense, we consider that the results are co-constructions between the participants and the interviewer, admitting that subjectivities from all the participants influenced the results. Also, we recognize that my personal subjectivity, my values and beliefs played a role in this research.In summary, we tried to give relevance to the voices of the participants that are people having cancer- related symptoms and currently fighting against this disease. It is about translating the description in order to understand the meanings.Finally, from a methodological point of view, we established that in order to approach the community, we will meet with patients currently affected by cancer-related symptoms, given that we are interested in the understanding of the pet therapy’s dynamic lived and experienced by them while confronting this disease. Thus, the research arose from the researcher value attributed to patients’ understanding of pet therapy, supported by the assumption that their perceptions can shape both their understanding of the relief and their support and belief system regarding this disease.As mentioned from the beginning of this work, we intended to obtain first-hand  stories of the oncological patients who have used pet therapy as an alternative form of treatment in the hopes to abate their cancer-related symptoms. Hence, we come to the conclusion that field research of an explanatory nature is appropriate to the research purposes. Indeed, according to the assumptions of the qualitative-interpretive paradigm that guides this study, the design of the research is flexible and emergent (Creswell, 2009), because it will be constructed progressively, in an open manner and depending on the changes that may arise. This research is an exploratory study and its design will allow the researcher to include new elements based on the findings derived from the analysis of the data. Likewise, the flexibility refers to the possibility of modifying what was already planned in the initial design in terms of the volume and quality of the information, as well as the techniques for obtaining it. Therefore, in the following paragraphs, we will present the characteristics of my participants, as well as those of the place where we will collect the data and the process of selection we will follow.The sample: oncological patients that have experienced pet therapy This qualitative study used a purposive convenience sample.  Participants were selected through the assistance of a prostate cancer support group.  The last two participants were acquaintances.  While cancer patients, as a population, were easy to identify, it was a herculean challenge to find a sample of those that had specific experience with pet therapy. Our participants were five patients diagnosed with cancer that have received treatment and had fist hand experience with pet therapy. The choice of patients was guided by the following inclusion criteria: a) women and men over the age of 18 diagnosed with cancer; b) patients have received some type of traditional intervention such as chemotherapy. Likewise, patients of the same age groups, cancer types, etc. will be identified and categorized.  Finally, the exclusion criteria included those that have not been treated and have some type of aversion to canines.  Patients under the age of 18 were excluded. The next table illustrates the demographic characteristics of the interviewees.Data Collection Instruments and ProcessData collection was completed by face to face interviews that were recorded and later transcribed.  A total of twelve questions were asked in the context of semi-structured interviews to the patients that accepted our invitation. Before each meeting, the anonymity and the confidentiality of theinformation provided was explicitly and clearly manifested to these participants, in order to safeguard their names and other specifics traits.We conclude that interviews were to be seen as an intimate and personal encounter where the interviewees, persuaded of the confidentiality and discretion of the researcher, decided to open up and entrust us with their experiences; information that under other circumstances, they would have not shared with a third-party. In short, it can be affirmed that each interview allowed for a rich interaction with the interviewees. The interviews lasted approximately fifteen to thirty minutes.In regards to the interviews questions, an interview guide covered the two main aspects that we wanedt to explore about the participants’ perceptions concerning pet therapy.  First, the patient experience in regard to their experience having pet therapy.  Second, we looked at the patients’ experiences in regards to the specific cancer-related symptoms. For instance, questions will cover the knowledge they had about the therapy and the different associations they can make between the relief of their symptoms and the pet therapy. In the appendix B, the reader can see the interviews questions.Also, a simply questionnaire will be distributed in order to collect demographic information.  The author also kept a field journal, where all the data collection process was consigned, as well as, all the decision that could be made during the data collection and the data analysis processes. The next table shows the correspondence between the qualitative approach and the aims we have for this study.Qualitative ApproachResearch AimsOncological patients’ semi-structured interviews1, 2, and 3Research’s Field JournalThematic Analysis2, 3, and 4Before the face-to-face meetings, every potential participant was asked about their disposition to voluntary participate in the study. Finally, the face-to-face interviews were conducted at private residences for comfort and privacy.  In one instance, a local coffee shop was determined to be the only acceptable site.Scholars agree that there are four validation criteria for qualitative-interpretative research: credibility or internal validity, transferability or external validity, reliability and confirmation (Guba, 1981; Lincoln, 1995). It is worth noting that the product of this research will be based on the narratives of the interviewees, which are nothing more than the history lived and felt by the people who experienced it. Thus, in the paragraphs that follow, I will display every validation criterion and show how I achieved it.Likewise, the use of a clear and strictly followed analysis process, such as the methodological technique we select, i.e. Thematic Analysis with justified data collection instruments to achieve the objectives, will ensure the confirmation of our interpretations. In this sense, the next section is totally devoted to an extensive description of the data analysis process following the main principles of the Thematic Analysis.Data Analyze TechniqueUpon completion of data collection, data will be stored via a Microsoft Word and Excel spread sheets.  The data analysis will be completed by using Thematic Analysis technique, where it will be identified the emerged sub-themes and themes. The process to develop a Thematic Analysis will be described in the next paragraphs.For the Thematic Analysis, we started by reading one interview in order to familiarize ourselves with the words of the interviewee. After the first reading, we restarted the process more carefully, reading line by line, in order to begin coding.A code must be understood as a label that is assigned to an ‘event’  indicated in the transcript of the interview. Following the research question, this event must seem relevant. I understand an  ‘event’ as the full verbal expression of an attitude or a complete individual or collective act. Each ‘event’ found in the interviews was codified by doing two steps: first, by describing what it was, i.e. what is the code’s definition and second, by adding a textual quote of what was considered to be an event. The textual quotation of the words used by a participant aims to guarantee the fidelity of the description in progress. Thus, the coding stage consisted of two actions: a description and a quote verbatim in order to justify the use of the code we assigned to the event.As we read line by line, we was assigning codes, that is, a word or phrase (label) in the right margin of the document. Then, we took a second interview and did the same process, that is, we gave it a first read and then went on to codify this second interview. For the second interview, we used the same codes from the first interview or we created others, if necessary. The most important thing about this stage is not to miss any important ‘event’ mentioned by the interviewees. We followed this course of action with the third and fourth interviews.After having analyzed 4 interviews, as a second step, we went to study the codes, to review them again and to ask them questions. These questions will allow us to group some codes together before passing to the creation of sub-themes and themes. At the end of the first stage, the original interviews turned into a series of small pieces, each one composed by a description and a text quote with a code associated with it.Our next step was to build and name a category. In order to build a category, one must first define it from the participant’s explanations and then determine the codes that are specific to it. The comparison of the different codes from the first set of interviews made possible to specify the points of resemblance as well as the points of discrepancy that constitute the description of the category. Thus, the categories constructed should allow us the total understanding of the phenomenon. After this, we questioned the data again. This time around, using more complex questions.  The new questions sought to identify a phenomenon or a part of it, considering that one category illustrates just a single part of the total phenomenon. These categories are descriptive ones that account for a part of the phenomenon. Thus, all categories related to each other lead us to the understanding of the phenomenon in its total complexity. In this way, we created categories and, at the same time, we grouped codes within them. To make sure that we choose the adequate codes and category’s names, we used the ‘constant comparison’ between the interviews and the analysis. This constant comparison movement will allow us to ensure that the codes and categories truly correspond with what the data was telling us. In the case of thematic analysis, a category can be considered as a sub-theme. Also, some categories together can be considered as a theme. To create the sub-themes, we repeatedly read the interviews, and at the same time we assigned a ‘code or label’ to the participants’ statements. For example, one sub-theme was named: effects of pet’s visit. This sub-theme can be defined by the participants’ declarations in regards to the exchange with the pet, which was for these purposes, a dog. In this sense, it can be said that the presence of the dog and the relationship patient-dog that was established seems favor or promote the feeling of calm. Indeed, the calmness was signaled as one consequence of the pet therapy: “I liked the companionship and calmness I felt.” (P1). In addition, the companionship mentioned by the patient could be related to the feeling of not to be alone, and that someone makes me feel accompanied. Another participant stated that his feeling of being overwhelmed was modified with the pet therapy: “Before, I was already overwhelmed beyond belief from the whole cancer experience, but I was hopeful that having a pet therapy dog around would be a happy distraction” (P3).  Following with the analysis, participants declared opposed feeling when one of them mentioned: “The friendliness of the dog seemed to make the biggest impact on my mood” while another patient declared: “My symptoms weren’t really impacted, but it made the entire process less daunting.” (P1). As it can be observed, two patients expressed different manners to sense or perceive pet therapy. Even if the second participant considered that pet therapy did not impact his symptoms, he was able to feel a diminution concerning the general discouragement that can appropriate the mood of the patient. Finally, for another participant, the pet therapy was a way to feel comfortable and accompanied without the feeling of guilt or sadness: “I was so lonely going through this process, my family was wonderful, but having them visit me – I knew made them uncomfortable. Whenever the dog came to visit – there was no guilt or sadness, just a sweet pup that wanted to say hi!” (P2).   Thus, to close this sub-theme, we can affirm that every patient is a unique universe that experience cancer in her/his particular manner. We can say that the pet therapy seems to have an discreet effect over all the mood of the patient, and this therapy was able to sensibly modify the feeling (psychological aspect) of the interviewees. The second sub-theme was named: physical modification attributed to the pet therapy. This code refers to the physical modification that the patient associated with the pet therapy. For example, one patient clearly expressed: “Symptoms that got better? I was certainly more awake and less fatigued when the service dog came in. It was almost like having your first cup of coffee in the morning, just a jolt to the system!”. The use of a metaphor is especially useful to understand the impact provided by the pet therapy. However, some preventions were signaled by the patients, as the size of the dog or the effect of dogs in the immune system: “Deterrents from the Pet Therapy experience… hm, I’d have to say the only things I could think of is if someone going through chemo doesn’t have a strong enough immune system. Fortunately for me, that wasn’t the case!”. Thus, as in the first sub-theme, the second one shows us opposite opinions regarding the effects of pet therapy in the physical conditions of the patients. Some of them felt good, while other keep some reserves to accept this kind of therapy. Nevertheless, it can be mentioned that all the interviewees had positive feedback in regards to continuing the pet therapy.The last sub-theme was named: difficulty in discerning which pet therapy’s characteristic influences their symptoms.  It can be defined as the generalized hard task, observed among the participants, to identify a particular pet therapy’s characteristic and relate it to their health improvement. In this sense, one participant expressly highlighted: “I don’t know, it just seemed to help”. Thus, it should be noted that it was sometimes  difficult for participants to identify a particular characteristic of pet therapy that was related to the relief of their symptoms. Reviewing the last three sub-themes, we grouped them into a one theme named: The Impact of Pet Therapy into Oncological Patient. As we can observe, a theme is a denser unit of information that is able to foster the three sub-themes mentioned before. The next figure illustrates our purposes.This theme can be defined by the interviewees’ words regarding the physiological and psychological outcomes of the pet therapy that were mentioned by the participants. According to the data, we can affirm that even if the patients were not able to specifically mention which characteristics of the pet therapy had the best or the worst effect in their cancer-related symptoms, it should be noted that all the participants agreed to manifested that the exchanges with the pet brought them some type of relief, especially a psychological support. However, some physical symptoms as the fatigue were also released.The loneliness, sadness, or burden’s sensations that usually seize the oncological patient were relieved by the presence of the pet.ConclusionPet therapy has been used for nearly two decades in order to provide relief to those suffering from symptoms including anxiety, depression (Henner, & McDade, 2017), pain (Chubak et al., 2017), and loneliness (Matchock, 2015). Pet therapy, like other alternative therapies, have demonstrated the ability to lower blood pressure and increase dopamine levels (Matchock, 2015).  Our research demonstrates a valid process to determine what specific characteristics of pet therapy provide objective pleasure to patients, along with physiological benefits. The outcomes of this research contributed to the existing understanding about the patients’ perceptions regarding pet therapy. Obstacles and Lessons LearnedDespite our new knowledge, limitations were demonstrated throughout the course of research.  First, our sample was extremely homogenous.  This was apparent both demographically but also in regards to the specifies of  treatment.  There was also obvious inexperience in regards to the interview questions.  Despite using tools learned throughout the course such as open ended questions and placing negative questions last, the author was unable to extract the specific answers he was searching for. This would be the biggest lesson I learned.  In the futureI hope to spend the most time developing succinct provoking questions that will elicit the specific type of information you intend to research.  Another lesson learned was that despite all your best efforts, it is impossible to not introduce some type of bias when conducting research.  I found myself wanting to have a conversation with the participants where I also introduced my thoughts regarding pets.  Additionally, being a dog owner myself, it was impossible to mask my stance in regards to the benefits of pet therapy.  Lastly, although I consider myself a master when it comes to time management, it became evident that properly establishing timelines and goals is imperative when it comes to conducting qualitative research. Over the semester, I developed a passion for this topic and for this research approach.  I hope to further explore it in the future.  I feel a mixed method approach could incorporate biometric quantitative insight into what I feel is a solid foundation.  Thank you Dr. Shedlin. Appendix A.Interview Guide           Appendix BReferences  10 alternative cancer treatments to consider. (2016). Retrieved November 4, 2018, from http://www.mayoclinic.org/diseases-conditions/cancer/in-depth/cancer-treatment/art-20047246CDCBreastCancer. (2018, April 19). Complementary and Alternative Medicine for Cancer Patients.Retrieved December 8, 2018, from https://www.cdc.gov/cancer/survivors/patients/complementary-alternative-medicine.htmChubak, J., Hawkes, R., Dudzik, C., Foose-Foster, J. M., Eaton, L., Johnson, R. H., & Macpherson, C. F. (2017). Pilot Study of Therapy Dog Visits for Inpatient Youth with Cancer. Journal of Pediatric Oncology Nursing, 34(5), 331–341. https://doi.org/10.1177/1043454217712983Creagan, E. T., Bauer, B. A., Thomley, B. S., & Borg, J. M. (2015). Animal-assisted therapy at Mayo Clinic: The time is now. Complementary Therapies in Clinical Practice, 21(2), 101–104. https://doi.org/10.1016/j.ctcp.2015.03.002 Department of Health | Wong Baker FACES Pain rating scale. (n.d.). Retrieved November 5, 2018, from http://www.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-pain~triageqrg-wongCreswell, John W. and Cheryl N. Poth. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 4th Edition. Thousand Oaks, CA: SAGE Publications, 2018.Dogs and PTSD – PTSD: National Center for PTSD. (n.d.). [General Information]. Retrieved December 8, 2018, from https://www.ptsd.va.gov/gethelp/dogs_ptsd.asp?_ga=2.45503783.2014798647.1544282503-1696601653.1544282503Guba, E. G., & Lincoln, Y. S. (2005). Paradigmatic controversies, contradictions, and emerging confluence. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (3rd ed., pp. 191-215). Thousand Oaks, CA: SageMarcus, D. A., Blazek-O’Neill, B., & Kopar, J. L. (2014). Symptom Reduction Identified After Offering Animal-Assisted Activity at a Cancer Infusion Center. American Journal of Hospice and Palliative Medicine®, 31(4), 420–421. https://doi.org/10.1177/1049909113492373Matchock, R. L. (2015). Pet ownership and physical health. Current Opinion in Psychiatry, 28(5), 386. https://doi.org/10.1097/YCO.0000000000000183Pancreatic Cancer – Cancer Stat Facts. (n.d.). Retrieved December 8, 2018, from https://seer.cancer.gov/statfacts/html/pancreas.htmlRicciardelli, M., Henner, K., & McDade, K. (2017). Effects of Dogs on Depression Levels of Cancer Patients. American Journal of Occupational Therapy, 71(4_Supplement_1), 7111520298p1-7111520298p1. https://doi.org/10.5014/ajot.2017.71S1-PO5053Side Effects of Cancer Treatment. (2015, April 29). [nciGeneral]. Retrieved November 4, 2018, from https://www.cancer.gov/about-cancer/treatment/side-effects