Exploring aspects of significance when arranging dog visits to home-dwelling patients: An action research approach

Municipalities have been encouraged to collaborate with volunteers to facilitate social and cultural activities for patients. Dog visits have been primarily arranged as a group activity in nursing homes. The aim of the present study was to pilot a dog visit program for home-dwelling patients delivered through a collaboration between nurses and volunteers, and to explore aspects of significance when arranging such visits. The project used an action research approach. The action was the implementation of regular dog visits to home-dwelling patients for 6 months, through collaboration between nurses and volunteers. The empirical investigation included respective focus group interviews with nurses and volunteers. Transcribed data were analyzed thematically. Standards for Reporting Qualitative Research guidelines were followed. Influence of motivation, vulnerable relationships, and the perception that various factors contributed to a ‘comprehensive puzzle’ were aspects of significance when arranging dog visits to home-dwelling patients. One crucial factor in the conduction of the dog visits was having coordinators for both the nurses and volunteers. Future dog visits should emphasize thorough mapping of patients and equipages, and appropriate information flow through collaboration between coordinators for nurses and volunteers.


Introduction
For decades, an important political goal has been to support older adults to live at home as long as possible. 1,2According to the Health and Care Services Act, 3 the municipality's residents shall be offered health and care services related to somatic or mental illness, injury or suffering, substance abuse problems, and social or reduced functional capacity.Home care nursing is a 24-h municipal service that provides nursing care to patients in their own homes.The service is mainly staffed by registered nurses and auxiliary nurses.In recent years, home care nurses have experienced more complex health problems among care recipients, mainly due to an increasing number of elderly people, earlier discharge of patients from hospital, and a lack of available nursing home beds. 4The public's responsibility includes the social and cultural needs of service recipients, and healthcare services shall promote social security, prevent social problems, and ensure that the individual is given the opportunity to live an active and meaningful life together with others. 3This goal is challenged by the growing number of home-dwelling patients with complex health problems, and a lack of nurses. 4,5Medical care has been prioritized at the expense of the patients' psychosocial and existential needs. 1,6,7Many patients are left alone for large portions of the day, which can lead to loneliness and social isolation. 8There is a need for emphasizing social and cultural activities in home care, 6,7 and municipalities and volunteers are encouraged to collaborate to achieve this goal. 9,10lunteering is defined as unpaid efforts that are provided to individuals or groups outside personal networks. 11The Red Cross is a major player in volunteer work. 12In recent years, their services have included dog visits.These visits are offered to those who want to spend time with dogs but cannot have one of their own.The volunteers and their dogs undergo training at an educational institution or volunteer organization.After a suitability test, the dog and handler are certified as an equipage. 13og visits, as conducted in this study, are part of animalassisted activities. 13Interaction with dogs can have several positive outcomes.Spending time with a dog can lower blood pressure and heart rate, 14 reduce depressive symptoms, 15,16 promote positive emotions, prevent loneliness, 17 increase social activity, [18][19][20][21] and evoke memories. 18,21Most studies of dog visits have been carried out at institutions such as nursing homes, 22 and a 2017 review 23 revealed that limited research has addressed dog visits to home-dwelling patients.While facilitators and inhibitors of successful collaboration between public health services and volunteers have been identified, 11,[24][25][26] to our knowledge, no study has focused exclusively on such collaboration processes related to dog visits in home care.
The purpose of this study was to pilot a dog visit program for home-dwelling patients delivered through a collaboration between nurses and volunteers, and to explore aspects of significance when arranging such visits.

Methods
The project was conducted with an action research approach, which includes systematic, empirically based attempts to improve practice. 27Action research approaches consist of an action portion, in which suitable measures are developed to implement the intended change, and an empirical portion, in which measures, results, and experiences are evaluated and compared with existing knowledge. 28Action research emphasizes flexible planning, iterative cycles of action and reflection, and simultaneous improvements adjusted to the unique context and participants.The researchers in this context have a dual role: contributing to both increased knowledge in the research area and implementation of practice changes. 29The Standards for Reporting Qualitative Research 30 guidelines were followed.The project was initiated in autumn 2018 in collaboration with the Red Cross.A home care department was invited to participate.The researchers had initial meetings with the respective nursing and volunteer leaders, to clarify the conditions for their participation.We also participated in a staff meeting at the home care department, presented the project, and invited them to participate.One professional nurse, two registered nurses, and two auxiliary nurses accepted the invitation.Together with nine volunteer dog handlers (seven equipages) recruited by the Red Cross leader, we established a project group.One of the auxiliary nurses and one of the volunteers signed up as coordinators.We also created a private Facebook group to share ongoing information and experiences during the project period (see points 1-5 in Table 1).

Action process
The action process was inspired by the seven steps prescribed by Malterud. 28Step 1 consisted of a situational analysis with a background description and selection of topics to be worked on.According to the nurses, a significant number of their patients needed assistance to fulfill social needs.The nurses' main challenge was that they did not have the capacity to assist.They knew that several patients had previously had dogs of their own and might benefit from dog visits.The home care department and the Red Cross had to collaborate to facilitate suitable matches between dogs and patients.There were no established routines related to dog visits in the home care department, or for volunteer activity in general, as this was usually conducted without the nurses' involvement.
In step 2, we summarized previous experiences relevant to the study's purpose.The nurses had no previous experience collaborating with volunteer dog handlers.Several volunteers had a successful experience with dog visits in nursing homes.We conducted literature searches relevant to the topic being studied.Several studies identified facilitators and inhibitors of collaboration between public health services and volunteers, but no study specifically addressed dog visits in home care.
Step 3 consisted of goal formulation.Our project goal was to pilot a dog visit program for home-dwelling patients delivered through a collaboration between nurses and volunteers, and to explore aspects of significance when arranging such visits.
In steps 4 and 5, the action was planned and described in detail.The nurses wanted to offer visits to patients who had expressed affection toward dogs and could receive dog visits without assistance from a home care nurse.They stated that they could facilitate, for instance through patient mapping and recruitment, but not participate in the visits.The researchers made an information folder and a simple mapping form that were distributed to patients who had been strategically selected by the nurses.The patients were asked whether they were interested in receiving dog visits once a week or every 2 weeks for a period of 6 months.They were also asked about their previous experiences with dogs, any allergies, and preferences for visiting dogs (e.g.large or small).Seven patients (3 men, 4 women) were invited to receive dog visits, all of whom accepted the invitation.One male patient participated with his spouse because he had cognitive impairment.The rest of the patients lived alone.One patient was in his 30s, and the others were in their 80s.All seven had previously owned dogs.Before the implementation, the two coordinators met to match patient preferences and equipage, and to create a schedule for the dog visits (see point 7 in Table 1).
The plan included that during the visits, ID cards and Red Cross logo scarves would be worn only after entering the home, to avoid the attention of passersby.The visits were planned to last about 1 h.The volunteers' focus was to facilitate interactions between the patient and the dog.If something unforeseen occurred related to the dog visits, the coordinators were to be involved.
In step 6, the action was implemented.The visits were conducted during a 6-month period (October 2018 to March 2019).In line with action research, which emphasizes that the target groups should have influence in all parts of the project, [27][28][29] the patients shared their experiences of the dog visits continuously with home care nurses, who passed this on to the project group members.Many of the dog visits proceeded as planned, although they were delayed or canceled more often than anticipated, due to patient, volunteer, or dog illness.During implementation, one equipage dropped out because of persistent illness in the dog, and one volunteer chose to leave the project without giving a reason.Two patients dropped out because of health deterioration, and one patient did not want to continue with a new equipage.One new patient was added to the program; however, unlike the initial patients, the new patient had little experience with dogs.Among other deviations from the plan were incidents in which a volunteer needed assistance to get into the patient's residence, as the patient did not hear the doorbell or did not manage to open the door.This led to frustration among nurses and a demand for predictability in the timing of the dog visits.These incidents were discussed in the project group, and the adjustments that were agreed upon were implemented by the coordinators.
In step 7, the initial topics were redefined in light of patients', nurses', and volunteers' experiences.The provided insights from step 7 are valuable when creating new strategies for the continuation of the program, 28 and how this should be taken into account when arranging future dog visits to homedwelling patients is elaborated in the Discussion section.

Empirical evaluation
At the end of the project, the nurses and volunteers were interviewed in respective focus groups.Focus group interview is a data collection method in which participants' opinions and experiences are solicited simultaneously, through dialogue. 31A semi-structured interview guide was developed, with respective adaptions for the nurses and volunteers.Each was asked background questions about their age, professional experiences, and motivation to participate in the project.Both nurses and volunteers were asked to describe the perceived patient benefits from the dog visits and how the patients had expressed this.They were also asked about their experiences and perceptions related to the dog visits, and what kind of adjustments they would recommend for continuation and expansion of the program.

Ethics
The research followed the ethics rules under the Declaration of Helsinki, and the study was approved by the Norwegian Social Science Data Services (reference no.101544) and the ethical committee at the faculty of the university.The nurses and volunteers signed an information folder with a project description specifying that participation was voluntary and that they could withdraw their consent at any time.They were also informed that identifiable information would be kept confidential and only used in an anonymous form.
Action research projects should address topics of mutual concern, enable all those involved to actively participate in any way they desire, and produce outcomes that are mutually beneficial for all participants. 27The project group agreed to not include patients in the project meetings, as the main focus was on collaboration processes between the nurses and volunteers.However, the importance of a person-centered approach to the visits was emphasized.Patient involvement was safeguarded by the nurses' knowledge about each of the participants and their continuous sharing of experiences from the dog visits.An individualized approach was also safeguarded by the volunteers, and adjustments to the visits were made according to patients' initiatives and needs.In addition to receiving an information folder, the patients were informed verbally about the project by the nurses and could express their wish to receive dog visits, and they signed a consent to participate.As members of the Red Cross, all the volunteers had signed a duty of confidentiality.To maintain confidentiality, all information concerning the patients would be shared only between the nurses and the volunteers directly involved in the dog visits.No patients' names or pictures in which they could be identified were shared in the Facebook group.The patients were considered vulnerable and, when dilemmas occurred, the coordinator for the nurses was involved immediately.The major ethical dilemma that occurred during the project was visit cancellations initiated by the volunteers.Such challenges were discussed in the project group to find optimal solutions.

Focus group interviews
The two registered nurses and the two auxiliary nurses were interviewed; the professional nurse was unable to participate.The focus group interview was conducted by the last author at the nurses' workplace and lasted for approximately 60 min.Eight volunteers representing six equipages were interviewed directly after the last project group meeting (Table 1).This interview lasted about 90 min.The first author was the moderator and the last author an observer.Both interviews were audio recorded and transcribed.

Data analysis
The interviews were analyzed thematically, inspired by the reflexive approach of Braun and Clarke. 32,33This approach consists of six phases: familiarization with the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; and producing the report. 32Both researchers participated in the entire analysis process.First, all interviews were read to form an overall impression of the data material.We chose to include the interviews from nurses and volunteers in a common thematic analysis to ensure that the constructed themes comprised experiences from both groups.In the next phase, we searched for interesting text sections and labeled them with initial codes that captured unit meanings.From the codes, we constructed preliminary main themes and subthemes.Together with the codes, the themes were repeatedly reviewed and redefined until they reflected the informants' experiences.We also extracted illustrative quotations, to substantiate the analytic findings.Table 2 presents examples from the analysis process.The results are presented in Figure 1.

Results
The four interviewed nurses were women in their 50s with long-term experience with home care services.All were, or had been, dog owners.To get an impression of the patients' immediate response to the dog visits, the coordinating nurse had shadowed some volunteers at patient homes at the beginning of the project, staying for the first 10 min of the visit.
The eight interviewed volunteers consisted of two men and six women (mean age = 31 years; five were in their 20s and the oldest was aged approximately 50 years).Their experiences as Red Cross equipages ranged from 6 months to 4 years.Six had previous experience with dog visits in nursing homes.Their dogs were of different sizes and breeds, including husky, border collie, Portuguese water dog, Japanese spitz, and English staff.
The results are presented according to the main themes and subthemes (see Figure 1).

Influence of motivation
Individual dog visits in the patients' homes were influenced by motivation and provided benefit on a personal level for all involved.A recurring theme was the perceived joy associated with the dog visits.According to the volunteers, the patients expressed joy in various ways: through smiling and laughter; talking to and cuddling the dog; and expressions such as 'damn nice dog,' 'the world's nicest dog,' and 'my golden girl.'The nurses noted that the patients lit up when talking about the dogs and that they spoke more and with enthusiasm, both before and after a dog visit.Some bought dog food and treats.One nurse expressed: 'I just think it's a lot of fun.'The volunteers described that the joy patients expressed also spread to them: 'I thought we were going to be the ones who made others happy, but I see that they make us happy toothat they give something back to us as well.We are very happy when we have been there.'Dog affection was a strong motivating factor for both the nurses and volunteers.The nurses' own experiences with dogs made them care more about the dog visits, through conversations with the patients: 'It is probably those of us who have a dog of our own who talk with the patients about this a lot.'The volunteers were motivated by both the patients' affection toward their dog and the dog's eagerness and signs of well-being during the visits: 'I see that she [the dog] enjoys it, and she does things that she hasn't done with anyone else.Jumping on her [the patient's] lapshe has never done that before in her career, and she is 6 years old.'The volunteers who had experience with dog visits in nursing homes appreciated the increased feedback from the home-dwelling patients.They described occasions when their dogs had fallen asleep at the patient's feet or hidden under the patient's coffee table when it was time to leave.One of the volunteers had been demotivated by visiting a patient who failed to show interest in the dog: 'She was very busy and not interested in the dog.If I had come without a dog, she would not have reacted.'The volunteers pointed out the importance of nurses recruiting patients who were fond of dogs and eager to participate.
The nurses were motivated to facilitate the dog visits by a desire to increase their patients' quality of life by benefitting from social activities that matched their interests.They appreciated the volunteers' contributions to making this happen.Several patients spent most of their time in their residence.The dog visits gave them something to talk about, both with their families and the nurses.The volunteers felt useful through the positive impact the dog visits had on the homedwelling patients: 'She didn't get out much.She was very interested in what the dog had done since the last visit, especially if it had done any mischief.She thought that was so funny.And then she always came up with a story about her dog doing mischief 50 years ago.' Several volunteers experienced changes in the patients, who shifted from being a bit sullen to talkative.The dog visits evoked memories and led patients to tell stories about their previous dogs.Some patients had expressed Table 2. Examples from the analysis process.

Participant
Text meaning units Codes Subthemes Main theme Nurse She brightens up and talks a lot about the dog.The nurse observed that the dog visits made the patient excited and talkative.

Patient impact
Influence of motivation Volunteer They give something back to us as well.We are very happy when we have been there.
The volunteer experienced happiness after the visits.Nurse He's not out that often, so then he has something to talk about.
The dog visits gave the patient experiences to share.Volunteer It's nice that our dogs can matter to others.
The volunteer appreciated that the dog visits had an impact on patients.
a sense of worthiness to the nurses, through developing a special closeness to the visiting dog: 'The patient expresses that there is something special between him and the dog, because it does not react like that with others.And that has lifted him a lot.'

Vulnerable relationships
Individual dog visits entailed some vulnerable aspects, which challenged continuity in the relationships.Some scheduled visits had been canceled because of a patient's health issues, and some dog visits ended because the patient had transferred to another health service.One nurse said: 'Many of our patients are very, very fragile.They have serious diseases.'However, the nurses claimed there had been even more changes in the schedule because of illness among the volunteers and dogs.They worried about the consequences of such cancellations for patients who had been looking forward to the visit: Those who carry out dog visits, they are of course allowed to be sick.But they must be aware that there are old people sitting and waiting for the dog.And when they call the day before, or the same day and say, 'we cannot come today,' it can cause negative feelings in the patient who has been waiting for maybe 14 days for a dog that does not show up.
The volunteers found visiting patients with different health issues unpredictable, and they experienced pangs of conscience when needing to cancel visits due to their own or their dog's illness.
Most of the volunteers felt more comfortable visiting homedwelling patients than conducting dog visits in nursing homes, due to the calmer surroundings.However, for volunteers who felt a bit shy and reserved, it was easier to visit a group than take responsibility for one-to-one conversation.They emphasized the importance of continuity in the dog visits.It took time for the equipage and patient to get to know each other properly, to feel confident, and to get into a routine: 'It was not until the last visits that I really started to feel it, sort of…, then they started to open up more and talk about things.And then it was nice to sit there.Before, it could be a bit quiet and a bit difficult to keep the conversation going for an hour.'The volunteers noted that home visits were largely dependent on the type of person: 'But I think it has a lot to say who you visit, because we have visited very different people.'The nurses also noted that the experiences of the dog visits could differ depending on the chemistry between the patient and volunteer.Patients had told the nurses that the dog visits were tiring when the volunteer was too talkative: 'She had positive experiences from being with the dog, but the volunteer was far too talkative for our patient.She found it very tiring.' The nurses were clear that performing the role of volunteer meant overriding personal emotions: 'When you step into the role of having a visiting dog, it is not about whether you get along with the patient.It's about who you are visiting and making sure it's okay for your dog and the patient.And if the chemistry isn't right, you just have to get over it.'On a few occasions, patients canceled scheduled visits without giving a reason.The nurses pointed out that the volunteers had to handle such situations in their role as representative of a volunteer organization.The volunteers also emphasized the importance of being committed to conducting dog visits over a period and not quitting after a few visits: '…for some it can be easy to get caught up in the moment, very engaged and eager.And then you think about it and understand what it means to be a volunteer.'

Comprehensive puzzle
The nurses and volunteers described a comprehensive set of factors that were significant to successful dog visits.One nurse called it a 'jigsaw puzzle.'They noted the need for a thorough mapping of the most suitable patient-volunteer-dog matches.A volunteer stated: '… select those who, firstly, want it, and secondly, need it more than others.To do a little more research and then find them.'According to the nurses, one patient had expressed enthusiasm about receiving dog visits but then rejected the volunteer at their first meeting.The nurse coordinator acknowledged that a young female volunteer should never have visited this patient and that matching patients and volunteers must be done with care.
Both nurses and volunteers emphasized the importance of being mutually informed in advance about matters relevant to the visits.The volunteers desired more information about the patients, while the nurses were unsure about guidelines for sharing patient information with the volunteers.The nurses also stated that they knew little about the volunteers and the training they had received to become certified as an equipage.Both parties thought that more information exchange would have contributed to better preparedness for the dog visits.The volunteers highlighted the importance of a preparatory meeting before initiating the dog visits.
Collaboration between the Red Cross volunteer and home care department coordinators was highlighted as crucial to successful dog visits.The coordinators proposed the most suitable matches between patients and volunteers with dogs; they also received and forwarded messages.The nurses noted that they had to be careful when recruiting patients.They admitted having been too hasty when adding a new patient without thoroughly investigating the patients' interest in dogs and motivation for receiving visits.
The volunteers were generally very pleased by the collaboration with the home care department.They underlined the importance of nurses overseeing the dog visits, based on their knowledge of the patients' needs and interests.Some volunteers had little contact with the nurses, while others had to ask for assistance to be let into the patient's home.Unforeseen disruptions in their workplan, when a volunteer called for assistance, led to some frustration among the nurses.Information and logistic challenges were linked to the significant number of nurses in the home care department: 'We are probably 50 to 60 employees who work here.Getting out information to everyone can be challenging.'They wanted to find feasible solutions for nurse involvement when offering dog visits to patients who are medically fragile: 'I think it is very unfortunate if dog visits are only for those who are self-reliant in opening the front door.Those who cannot manage may in fact be the ones who need visits the most.So then one must find another solution.'

Discussion
The purpose of this study was to pilot a dog visit program for home-dwelling patients delivered through a collaboration between nurses and volunteers, and to explore aspects of significance when arranging such visits.The dog visits provided personal benefits for all involved.Both nurses and volunteers were motivated by the enjoyment and impact the visits had on the patients.Joy as a motivating factor has also been identified in other studies. 19,21,34In a literature review, Fredriksen et al. 25 found that feeling valued and receiving feedback were strong motivating factors for volunteers, while lack of gratitude was among the factors that could impair motivation.Lack of dog affection and inappropriately matched patients and volunteers were sources of frustration herein, and the nurses were aware of their responsibility to facilitate the best patient-equipage matches.The importance of mapping 35 has been previously documented.Other studies have shown that such processes can be demanding for nurses, 25 which may be related to the everincreasing home care workload. 1,6npredictable changes in plans were described by both volunteers and nurses.This may be related to the specific characteristics of home care services, which Tingvold and Førland 24 explain include organizational matters that affect volunteering.Home-dwelling patients have the freedom to choose who can access their home and to accept or decline activities. 24During the project, there were a few occasions when either patients or volunteers canceled visits, based on personal preferences.By definition, voluntary work comprises providing unpaid efforts at one's own initiative, 11 which means that volunteers have the freedom of choice to participate or quit activities.Vulnerable relationships and ethical dilemmas arose when volunteers stopped visiting patients.Both the nurses and volunteers underlined that by representing a volunteer organization, volunteers have committed to a role in which they prioritize continuity in the dog visits.The importance of clarifying roles has also been recognized in other studies. 9,11,25ne of the challenges that was initially raised in this action research project was that the nurses, due to capacity issues, could not commit to assist in conducting dog visits.Nevertheless, nurses still had to assist some of the volunteers, leading to frustration because of disruptions in their workplan.Lack of time is a well-known problem in home care, and social needs are not prioritized on busy days. 4,5Political guidelines encourage health services and volunteers to collaborate to fulfill patients' social needs. 10It has been argued that it is necessary to implement professional, cultural, and structural measures to promote social care as a key action area in home care services. 7In a previous study, nearly half of healthcare leaders thought that volunteering should be quality-assured by employees. 26Herein, the volunteers also emphasized the importance of the nurses' involvement, which can ensure person-centeredness by eliciting individual needs and preferences. 36Previous reports have described a potential for using retired nurses in volunteer work within healthcare services, offering them opportunities to contribute their experiences and interests. 37,38Retired nurses with affection toward dogs might be a resource to facilitate dog visits to patients who are fragile.Such volunteers could assist by preparing patients for visits, letting the volunteer into the patient's home, and guiding the visit duration according to the patient's health condition.This should be further explored.
The nurses and volunteers described lack of information and logistic challenges.These aspects underscore that home care might be a complex setting for dog visits.Poor information flow and blurred division of tasks between volunteers and staff have been previously documented. 11,24,25The nurses' uncertainty about sharing patient information with the volunteers indicate a lack of communication related to the signed duty of confidentiality of all the volunteers.The volunteers and nurses also pointed out a need to establish collaborative routines.Through the project group meetings and ongoing communications within the private Facebook group, we experienced the importance of having coordinators for both nurses and volunteers.Both coordinators expressed enthusiasm and strived for successful dog visits by communicating directly with one another.Previous research has highlighted the importance of enthusiasts 34 and having a volunteer coordinator in the care services. 9,11,25ased on findings from this study, our suggestions for improving dog visit programs to home-dwelling patients would be as follows: 1) do a thorough mapping for appropriate matching of patient preferences and equipages; 2) make a written description of the responsibility and tasks related to the two coordinator roles; 3) have initial and continuous information meetings for the nursing staff and the volunteers; and 4) invite retired nurses to assist visits to the most fragile patients.

Strengths and limitations
Action research was considered an appropriate method for piloting dog visits for home-dwelling patients, and the involvement of nurses and volunteers in initiating, developing, implementing, and evaluating the project provided valuable understanding of aspects of significance when arranging such visits.It may be considered a weakness that the patients were not represented in the project group, but it was considered a strength that nurses who knew the patients well were responsible for their recruitment.Due to confidentiality, the data materials did not include information about the patients' health status, but it can be considered a weakness that the volunteers did not have enough information about the patients.
In action research, close collaboration between the researchers and participants is considered a strength, as both parties influence the research process and results.It may also represent a challenge, as the participants may want to help the researchers succeed 29 and vice versa.The project design was based on previous research, in which several volunteers also participated. 19his may have added positive preconceptions among both the volunteers and researchers.To compensate for these factors, the informants were encouraged to share nuanced experiences and provide critical input that could contribute to knowledge development and practice changes.The results indicate that this was adhered to by both the volunteers and nurses.
The various steps and aspects of the action research process are specifically and thoroughly described, to increase credibility.Data collection from two groups of informants strengthened verifiability.Inclusion of the interviews from the nurses and volunteers in a common thematic analysis may have led to missing some nuances in the results.However, it is considered a strength that the constructed themes reflected the experiences of both groups.Though the results were based on a specific context with participants from a particular home care department and a local volunteer organization, the experiences may be transferable to other home care service departments and other volunteer organizations.The consistency between the results and previous research and the detailed description of the action process strengthen transferability. 39

Conclusion
Influence of motivation, vulnerable relationships, and the perception that various factors contributed to a 'comprehensive puzzle' were significant aspects when arranging dog visits to home-dwelling patients.Both volunteers and nurses were motivated by the joy and positive impact the dog visits had on the patients.However, offering dog visits to home-dwelling patients demanded thorough preparation, and several of the patients needed more assistance than intended from home care nurses.The visits had to be supervised by nurses and adjusted to the individual patient's needs and preferences.Successful visits also depended on continuity and a volunteer role awareness that overrode chemistry.Having nurse and volunteer coordinators was a crucial factor for appropriate collaboration processes.Future dog visits to home-dwelling patients should emphasize thorough mapping for matching patients and equipages, routines of information flow, and further clarification of the coordinator role.How dog visits might be offered to the growing group of fragile homedwelling patients, with a lack of nurses to assist, should be explored further, for instance by involving retired nurses.This would contribute to government guidelines to support patients' social needs through collaboration with volunteers.

Table 1 .
Meeting schedule during the action process.