The PET@home Toolkit: A Process Evaluation Study

1. Introduction

Clients receiving long-term care at home often indicate that their pets play an important role in their well-being [1,2,3]. Therefore, it is essential to support the beneficial relationships that clients experience with their pets. To assist clients with pets, as well as family caregivers, and professional caregivers in maintaining these relationships, we developed the PET@home Toolkit in the Netherlands (publicly available via: www.ukonnetwerk.nl) using a participatory research approach [4]. The toolkit includes an information booklet, leaflets on animal welfare and communication, an infographic, and a checklist for care plan discussions – designed to enhance understanding, communication, awareness of challenges, and planning for pet care in long-term care at home settings [4].

This article describes a process evaluation that was conducted after a small group of professional caregivers used the PET@home Toolkit in practice. Process evaluations, often using qualitative methods, are valuable for understanding how new healthcare supportive materials work in context and for identifying effective implementation strategies [5,6,7]. While clients, family caregivers, and professional caregivers contributed to the toolkit’s development, a process evaluation after practical use can further help to refine the materials, ensuring they are well suited to the complexities of home care.

The toolkit’s development followed the Medical Research Council (MRC) framework for developing and evaluating complex interventions [8]. This framework emphasises the importance of stakeholder involvement and an iterative process, comprising four stages: 1) developing the intervention; 2) assessing its feasibility; 3) evaluating the intervention; and 4) implementing the intervention [8]. Our previous publication describes the first step within the MRC framework [4], while this study focuses on the feasibility and evaluation phase (phase 2 and 3), informed by practical application and feedback from users.

A process evaluation can provide additional insights into the complexities of home care, which can arise from the involvement of various stakeholders – clients with pets, family caregivers, and professional caregivers – each possessing unique characteristics, such as personality, education level, financial resources, location, social support networks, and healthcare needs [9,10,11,12]. The pet’s characteristics, such as its type (e.g., dog or cat) or physical and behavioural issues [13,14], can add to the caregiving burden, primarily affecting family caregivers [15]. These complexities necessitate tailored support, such as assistance with dog walking or cleaning a birdcage and are further complicated by the varying availability of local support options (e.g., volunteers). Therefore, involving clients and family caregivers in healthcare decision-making using a person-centred care approach is crucial [16]. The PET@home Toolkit can support stakeholders in long-term care at home in this endeavour.

This study aimed to evaluate the practical application of the PET@home Toolkit by assessing stakeholder feedback on four key aspects: 1) satisfaction; 2) relevance; 3) feasibility; and 4) integration of the PET@home Toolkit materials in long-term care at home. By focusing on these areas, the evaluation may provide insights for further improving the toolkit to better address the complex needs of stakeholders in long-term care at home.

2. Materials and Methods

2.1. Study Design

This study was based on a process evaluation framework for long-term care settings [17]. The primary focus was on the quality of the PET@home Toolkit by focusing on the feasibility, relevance, and satisfaction of the materials, as well as strategies to foster the integration of the toolkit materials into long-term care at home.

2.2. Researcher Characteristics

The research group consisted of two PhD students - one specialising in human-animal bond research (PR) and one in geriatric care research (ID) – and a psychology master’s student intern (JK), who also works at a home care organisation. The research process was guided by two expert supervisors in human-animal bond research (KH and ME) and two in geriatric care research (RL and DG). The research group held regular discussions, providing sufficient opportunities for reflection.

2.3. Participants and Procedures

Participants were recruited between August 2023 and January 2024 through three organisations active in long-term care at home. Professional caregivers, clients receiving long-term care at home, and their family caregivers, all of whom had used toolkit materials, were invited to participate in individual semi-structured interviews. Data saturation principles were considered when recruiting participants [18]. Professional caregivers received a brief online or in-person introduction to the toolkit materials before using them. Subsequently, the professional caregivers invited clients and family caregivers to test the PET@home Toolkit materials and provide written consent to be contacted by a researcher. Interviews were conducted through Microsoft Teams (N=7), telephone (N=2), or in-person (N=1) and ranged from 19 to 59 minutes in duration. JK conducted 8 interviews and PR conducted 2. Participants received a 20-euro gift voucher (e.g., for flowers) as incentives.

2.4. Process Evaluation Interview Protocol

As followed from the applied process evaluation framework it covered satisfaction (e.g., ‘What was your general impression of the toolkit?’), relevance (e.g., ‘What elements of the toolkit were less relevant according to you and why?’), feasibility (e.g., ‘What challenges did you encounter using the toolkit?’) and implementation (e.g., ‘How do you think the toolkit can best be integrated into healthcare?’). Participants were also asked to rate satisfaction, relevance, and feasibility from 1 (very poor) to 10 (excellent) (e.g., ‘How would you rate the usability of the toolkit materials?’). See Appendix A for the full interview protocol. Demographic information such as gender, age, and type of pet, was collected to describe participants.

2.5. Data Analysis

Transcripts were analysed using open coding and an iterative-inductive approach by PR and JK with ATLAS.ti for Windows. Initially, the two researchers independently analysed eight transcripts and then discussed codes until reaching consensus on the themes. Two additional interviews, one with a family caregiver and one with a professional caregiver, were conducted to determine data saturation. Subsequently, the two researchers independently clustered the themes deductively within the four interview topics, followed by a second discussion to reach consensus on the clustering.

2.6. Ethical Considerations

The study protocol was approved by the research ethics committee of the Open Universiteit of the Netherlands (U202206075). All participants provided written informed consent. Audio and video recordings were deleted once the project was completed, and transcripts were pseudonymised and stored securely, separate from personal information, on the Open Universiteit drive.

3. Results

3.1. Participant Characteristics

Professional caregivers (N=6), clients receiving long-term care at home (N=2), and family caregivers (N=2) participated in this study. Among the professional caregivers, four were case managers, five were female, and five had completed higher education and one held a university degree. Both participating clients were male and had owned a dog for approximately nine years. The family caregivers included one male and one female; one of their care recipients owned a dog, while the other owned a cat. Additional participant details are provided in Table 1. An overview of the themes identified within the interview topics is presented in Table 2.

3.2. Satisfaction

Satisfaction (scale from 1 to 10) ratings ranged from 4 (N=1) to 9.5 (N=1), with a mode of 8 (N=5). The person who gave the lowest rating indicated that the toolkit contained too much information and too many materials. Two themes were identified within this topic: general impression and suggestions for improvement.

3.2.1. General Impression and Suggestions for Improvement

Overall, participants responded positively to the toolkit materials. They appreciated the design, images, and clear language that was easy to understand. The large font size and A4 format of the information booklet (A4) were appreciated, making it easy to read for individuals with poor eyesight.

CL1: ‘What is written is all fine. It’s all very clear, easy to read, and it’s even a nice little book as well.’

Participants provided suggestions for improvement. For instance, a professional caregiver expressed discomfort with the negative phrasing of the statements in the care plan discussions checklist (e.g., ‘The client has physical disabilities that can impact pet care).

PC1: ‘Only that it was occasionally uncomfortable [for me] because those questions were formulated negatively umm... negative might not be the right word.’

3.3. Relevance

The ratings of the relevance (scale from 1 to 10) ranged from 6 (N=1) to 9 (N=2), with the mode being 7 (N=3). Four themes were identified within this topic: awareness, mutual understanding, pets in healthcare practice, and healthcare quality.

3.3.1. Awareness

Participants noted that the toolkit materials raised awareness about pets and the associated challenges. Even when not using the materials, they more often discussed pets with their clients and colleagues.

PC5: ‘Well, I think it’s about raising awareness… so also with the client, how do you care for [the pet]. Of course, we also sometimes see neglect [of pets] … For us, it’s also a reminder of… Well, that we should be able to discuss this too… and do something about it.’

3.3.2. Planning

Conversations and planning, such as using the poster in the information booklet to record and share agreements about pets, fostered mutual understanding and provided reassurance to participants, reducing worries about potential misunderstandings.

PC3: ’If you fill out one of those posters to record agreements with [in the information booklet] it might be clear for everyone that this has been discussed … For instance, if the pet becomes sick... who will take it to the vet? Or if someone [the client] must go to the hospital, then who will [care for the pet]? She said... Yes, the neighbour has done it before, and she did, and I think she will do it again… But you never really know if she will come back from the hospital, and then you have a problem.’

3.3.3. Pet-Related Aspects in Practice

Several examples of challenges concerning pets in healthcare practice were provided. Additionally, professionals, clients, and family members acknowledged the importance of pets to clients and their mental, social, and physical benefits, and emphasised the need to pay attention to clients’ pets. A client expressed that she would not allow a professional caregiver who was not fond of pets into her home. While a professional caregiver indicated rehoming one of her client’s pets was very time consuming and, although it was not part of her job description, she felt responsible for the wellbeing of both the client and the pet. These examples highlight the importance of accounting for the presence of pets in practice.

FC2: ‘We got a case manager. He stood at the door and remained at the door. He didn’t come in because we had two dogs, and they didn’t want that. They wanted us to lock them up. I’m not going to do that. I said to him: You can come in or you can leave. Then he left. That’s an example where I think that’s not right.’

3.3.4. Impact on Healthcare Quality

Participants indicated that using the toolkit had a positive impact on healthcare quality, particularly in building relationships between professional caregivers and clients with pets. This suggests that discussing the presence of pets with clients and their relatives it is relevant. One professional caregiver noted that discussing a pet with a client provided additional insight into the client’s functioning, providing an opportunity to improve healthcare quality. For instance, the client usually would not let caregivers check her refrigerator, but when asked about her cat’s food, she opened it, allowing professional caregivers to check the contents (e.g., for expired food). The checklist for care plan discussions may be useful in this context.

PC3: ‘It also struck me how, how little she could actually tell about [the care of the pet], well, just in general when I asked questions about [the pet]. That really struck me, I thought oh, then it’s not going as well [with her health] as I… Well, as I previously thought.’

3.4. Feasibility

Eight participants rated the feasibility (scale from 1 to 10) of using the toolkit, while two participants did not provide a rating. Ratings varied between 4 (N=1) and 9 (N=1), with the modus being 8 (N=4). The low rating of 4, was attributed to the amount of information in the toolkit, which was considered excessive. Three themes emerged within this topic: competence, quantity, and healthcare practice.

3.4.1. Competence

Participants generally felt competent to use the materials. However, one family caregiver expressed confusion due to a lack of guidance from the professional caregiver who provided the information booklet. This suggests that the information booklet may require additional instructions in the booklet’s introduction.

FC2: ‘It is not confusing. It is a beautiful little book, children can read it, but I was not sure what to do with it. That was the point.’

3.4.2. Quantity

Some participants felt overwhelmed by the number of materials and expressed concern that using everything with every client with pets would be time-consuming. However, most participants selected only the relevant materials for each client.

PC4: ‘I found it a lot. It was quite a stack. I've sorted out what's for the client … and what's for me. That was already a task. And I found it a lot.’

3.4.3. Healthcare Practice

Some participants mentioned that understaffing and time management issues in daily healthcare practice could hinder the use of toolkit materials. One participant indicated that their day mainly consisted of managing daily issues and crises, making the use of the toolkit a lower priority for many professional caregivers. Another important issue raised was the difficulty of communicating with clients living with dementia, therefore ideally a family caregiver should be present when discussing the pet’s care. The care plan discussions checklist and the information booklet can be used to record agreements between stakeholders.

FC1: ‘Well, things often disappear with a person living with dementia, and none of the children have seen it lying around, so I think, I fear it might have ended up with the wastepaper.’

3.5. Integration in (Long-Term Care at Home) Practice

Professional caregivers shared their insights on integrating the toolkit in the long-term care at home practice, revealing four themes: piloting, timing of application, digitalisation, and responsibility. The outcomes of this interview topic were used to update the implementation guide that accompanies the toolkit.

3.5.1. Piloting

Participants confirmed that new materials are often piloted with a small team of enthusiastic caregivers before being scaled up within the organisation.

PC2: ‘Yes, usually this is set up by policy or by project leaders who then come up with a plan and first discuss it with us. Then, of course, you start with a few areas where the pilot takes place, and then it gets rolled out further.’

3.5.2. Timing of Application

Professional caregivers emphasised the importance of using the toolkit early on with new clients with pets. Ideally, it should be introduced during the initial intake or shortly thereafter.

PC2: ‘So maybe I wouldn’t bring it up during the first conversation, but somewhere early on. Like, hey, we’ve had our first conversation, we’ve set some actions in motion, and now that things have calmed down a bit, I see, I’ve noticed before, but [pet’s name] is also around. Should we talk about that as well?’

3.5.3. Task Owner

Participants noted that case managers and home care workers may not always be the best suited to use the toolkit materials. They suggested that support workers, who are often involved earlier and look after the individual needs of clients, may be better equipped for this role.

PC5: ‘We also work with support workers, so we have a dedicated support team, and they sometimes get involved earlier than we are … if it’s really about things like how to organise your life, how to deal with family or finances, we are not the first to be called in. I think, for example, the support team often quickly encounters a pet.’

3.5.4. Digitalisation

Participants suggested integrating relevant information concerning pets into the digital care planning systems to make it more accessible. They recommended using the care plan discussions checklist as a foundation for this addition to the digital care planning system.

PC6: ‘We are incredibly digital, so I think digitalisation is very important. We are moving away from paper. I think the paper booklet is very nice, but we should just have it on hand to take with us whenever we see that clients have pets.’

4. Discussion

4.1. General Discussion

The aim of this process evaluation was to gather feedback from stakeholders on the quality of the toolkit materials focusing on 1) satisfaction; 2) relevance; 3) feasibility; and 4) strategies to integrate the toolkit materials into the long-term care at home practice. These insights have been used to adapt the toolkit materials to better align with daily home care practices.

Overall, participants expressed satisfaction with the toolkit and its materials, though some they also suggested some improvements. One participant indicated feeling uncomfortable with negative statements in the PET@home care plan discussion checklist. Positive or negative statements may lead to framing effects, potentially influencing clients’ responses [19]. Therefore, we considered it important for the care plan discussion checklist to contain neutral questions. The checklist’s statements were consequently reformulated. For instance, we changed the statement ‘The client has physical disabilities that can impact pet care, such as problems with walking, feeding, cleaning or caring for the pet’ to ‘Is the client sufficiently physically capable of independently caring for the pet?) where applicable.

Participants noted that the toolkit raised awareness about the benefits and challenges related to pets, which could be a starting point for improving the quality of the healthcare provided to clients with pets. An important aspect of this is the communication between stakeholders about pets, using a person-centred care approach [16]. This supports the relevance of the toolkit to long-term care at home. Since many people consider their pet as family members [20], most clients will likely appreciate having their pets considered in their care.

Agreements and planning concerning pets can bring clarity to clients, their families, and professional caregivers, potentially fostering mutual understanding, improving healthcare quality, and reducing the burden on those involved. Therefore, healthcare organisations should consider documenting pet-related agreements in a digital care plan. This can enhance communication, decision-making, and accountability among stakeholders [21]. Moreover, using the toolkit for clients with pets aligns well with the person-centred care paradigm, which is considered a benchmark for healthcare quality [22]. Person-centred care tailors caregiving to clients’ needs and wishes, actively involving them in their care [16,23].

The results suggest that it is important for clients to receive guidance from a professional caregiver when using the information booklet. However, time constraints were mentioned by professional caregivers as a barrier to utilise the toolkit materials. Time pressure is a common issue in home care [24,25,26], which may affect the amount of guidance a professional caregiver can provide when offering a client the information booklet. To address this, we added additional instructions in the booklet’s introduction and table of contents. These changes may offer clients and family caregivers extra support in using the materials independently. Additionally, some professional caregivers indicated that the toolkit included a lot of materials. However, some of the materials such as the communication and animal welfare leaflets are designed for professional caregivers rather than clients. Therefore, not all materials are required to be used with clients. We trust that caregivers can assess and select the materials that are necessary for each specific situation.

Time pressure may also hinder integrating the toolkit in home care settings. While, using the toolkit does not necessarily require much time, professional caregivers under time constraints may be reluctant to adopt innovations. According to the ‘Diffusion of Innovations’ theory [27,28], successful implementation often relies on early adopters - those enthusiastic about the anticipated benefits [27,29]. To encourage wider use of an intervention or new materials it is essential to showcase positive user experiences [27,29]. Therefore, piloting the PET@home Toolkit with enthusiastic early adopters could promote its adoption across home care organisations, before wider and more sustainable adoption in long-term care at home [30]. To support the integration of the toolkit in home care services, we developed an implementation guide to facilitate its use.

4.2. Limitations, Strengths, and Future Research

We identified a few limitations in this study. The first limitation was that only 10 interviews were conducted, with limited participation from clients and family members. However, we applied data saturation principles during the analysis. Additionally, the involvement of clients, family caregivers, and professional caregivers was crucial throughout the entire project, leading to the development of the toolkit [1,4].

A second limitation was that the toolkit materials may not be generalisable to long-term care at home settings in other countries, as they were developed specifically for the Dutch context. Different countries have varying healthcare systems and challenges related to living with pets, therefore the materials would need to be adapted accordingly.

Nevertheless, this study also has notable strengths. We successfully used a process evaluation framework designed for randomised clinical trials (RCTs) of clinical interventions in long-term care settings [17]. Since we did not conduct an RCT or create a clinical intervention, in this study we used a part of the model that focused on the quality (specifically on satisfaction, relevance, and feasibility) and strategies for integrating the PET@home Toolkit into practice, various relevant suggestions were provided and used to improve the materials, ensuring better alignment with daily long-term home care practices.

Future research is needed to evaluate the effectiveness of the toolkit in home care practice, particularly its impact on client health outcomes, such as perceived quality of life. It would also be useful to compare the experiences of clients in organisations that implement the toolkit with those that do not. Furthermore, interviewing professional caregivers about their experiences with using the toolkit could offer additional insights.

The current interest from organisations outside the Netherlands suggests potential for adapting the PET@home Toolkit for international use. Research, such as focus groups with clients, family caregivers, professional caregivers, and animal welfare experts in other countries, would be needed to identify any necessary adaptations for use abroad.

5. Conclusions

Overall, participants expressed positive feedback about the PET@home Toolkit and its materials, while also providing various insights that led to improving the toolkit to better align with long-term care at home settings. Additionally, our study demonstrated that a process evaluation framework initially designed for RCTs can be adapted to assess the practical application of a non-clinical intervention in long-term care at home settings.

The role of pets experienced by clients receiving long-term care at home and their potential to improve healthcare quality underscore the importance of considering clients’ pets with the PET@home Toolkit. The Dutch versions of the materials are publicly available through the University Knowledge Network for Older Adult Care Nijmegen (www.ukonnetwerk.nl) and the Open Science Framework (https://doi.org/mxh2).