Search
Search Constraints
New Search Filtering by: Keyword occupational therapy ✖ Remove constraint Keyword: occupational therapy
Number of results to display per page
Search Results
-
- Keyword matches:
- ... OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 1 Developing Evidence-Based Occupational Therapy Assessment and Intervention Binders for an Inpatient Psychiatric Setting Mary Grace Willis May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Taylor Gurley, OTR, MS, OTD, CEIM, RYT-200 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 2 A Capstone Project Entitled Developing Evidence-Based Occupational Therapy Assessment and Intervention Binders for an Inpatient Psychiatric Setting Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Mary Grace Willis OTS, BSHS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 3 Abstract I completed my doctoral capstone project at Sandra Eskenazis Mental Health Recovery Center. The objective of my DCE project was to focus on developing a standardized model of practice for occupational therapy services in this unit. Secondarily, I also aimed to gain advanced practice skills related to advocacy while working in this setting because this facility frequently works with an underserved population, addressing highly stigmatized conditions. My secondary goal was to gain experience in advocating for these clients, as well as in advocating for the best occupational therapy services in this unit. I compiled intervention and assessment binders of evidence-based practice suggestions in order for the occupational therapy staff on the unit to quickly access and utilized evidence-based practice for treatments. I conducted a pre- and postsurvey of satisfaction and documented increased satisfaction with OT services provided on the unit. Primary goals: Increase efficiency of occupational therapy services on the Mental Health Recovery Center (MHRC) through utilization of OT Intervention & Assessment Binders. Increase quality of care for patients by utilizing occupational therapy assessments and interventions that are evidence-based and supported by research. OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 4 Developing Evidence-Based Occupational Therapy Assessment and Intervention Binders for an Inpatient Psychiatric Setting The Midtown Mental Health Recovery Center is the inpatient mental health unit at the main campus of Eskenazi Health in Indianapolis. The ultimate goal of this site is to return patients to their homes and communities as soon as possible (Eskenazi Health, 2016). This site also emphasizes that its staff members are all aware of the stigma and challenges that come with many mental health conditions and they provide sensitive care, emphasizing the rights and dignity of all patients (Eskenazi Health, 2016). This setting is a mixed adult unit, meaning all clients are over the age of 18, and it has 30 beds. This setting provides care to the underserved, including people who are homeless, individuals with addictions, intellectual disabilities, dementia, and dual diagnoses. Most of the patients in this unit are on Medicare or Medicaid, but the hospital does not turn away individuals who cannot pay for their care. The hospital receives some state funding and grants to help cover the care of individuals who do not have insurance. A typical length of stay for patients in this unit is 3-4 days, but some patients stay for months because the site tries not to discharge clients until they are guaranteed a safe place to go home to, such as a boarding house, shelter, or an apartment or house. This unit is critical in providing necessary care because more than 50% of all people in the United States will be diagnosed with a mental illness or disorder at some point in their life, and people who experience early adverse life experiences such as trauma or abuse are at a higher risk of developing mental health conditions (CDC, 2018). This statistic is particularly relevant for an underserved population who may be at higher risk of experiencing trauma or abuse. My DCE project focuses on developing a standardized model of practice for occupational therapy services in this unit. However, I also focus on gaining advanced practice skills related to OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 5 advocacy while working in this setting because I will be working with an underserved population addressing highly stigmatized conditions. Throughout the development of my project, I will gain experience in advocating for these clients as well as in advocating for the best occupational therapy services in the development of my model of practice. The remainder of this report will emphasize relevant information about this population, the needs assessment I completed, research I conducted, the theories used to guide this project, details about project design and implementation, the outcomes of the project, and wrapping up with overall conclusions. Background When speaking to my site mentor at the Midtown Mental Health Recovery Center, she made it clear that one of the biggest issues that she would like to address in their unit is the lack of a standardized approach to providing occupational therapy services to patients in this setting (J. Button, personal communication, 2020). I plan to conduct research on outcome measures, functional assessments, and specific OT models to develop and present a specific model of evidence-based practice that can help improve the efficacy and efficiency of occupational therapy services in this unit. The primary goal in creating this set of practice guidelines for this unit is to increase the efficiency of occupational therapy providers on the unit, which is particularly important due to the fact that this site does not bill in the same way as some more traditional settings, and thus does not track productivity in any official capacity. Some of the occupational therapy services that practitioners frequently use in mental health settings include interventions addressing community reintegration, work and employment, and life skills or activities of daily living (ADLs) (Gibson et al., 2011; Gutman & Brown, 2018; Kirsh et al., 2019). These interventions focus on three of the most commonly impacted areas of occupation for individuals with mental health conditions and can help guide the creation of an OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 6 intervention guideline for my DCE project. Another approach to intervention that requires further research into its efficacy is the use of activity-based group work (Bullock & Bannigan, 2011). Activity-based group work can also include activities such as playing board games. In a study by Edel et al. (2017), researchers used this example of board games as an alternative to receiving occupational therapy services. They found that although both groups experienced a reduction in depressive symptoms, the group receiving occupational therapy services effectively reduced anxiety and other symptoms (Edel et al., 2017). These articles provide evidence to support the practice of occupational therapy interventions in mental health units such as the Midtown Mental Health Recovery Center and can guide my creation of an intervention guideline. Some of the assessments used in mental health occupational therapy services include the Mental Health Recovery Measure (MHRM), activity based assessment (BIA), the Brief Assessment of Cognition in Schizophrenia (BACS), the Schizophrenia Cognition Rating Scale, and the Social Functioning Scale (Chang et al., 2013; Eklund et al., 2008; Shimada et al., 2018). These assessments are all supported as valid and reliable assessment tools for occupational therapy providers to assess cognitive, emotional, and occupational performance skills in clients with mental health conditions. Understanding the research behind specific assessment tools will allow me to compile a list of acceptable and evidence-based assessments that can help improve the efficiency of occupational therapy services in this unit. Other research supporting occupational therapy in mental health settings include studies about the level of function at discharge as a predictor of readmission rates, predicting quality of life-based on engagement in meaningful activity, and the use of shared decision-making in inpatient mental health settings (OFlynn et al., 2018; Odes et al., 2011; Stacey et al., 2016). OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 7 Each of these studies promotes occupational therapy practices by emphasizing an individualized occupational therapy approach and supporting engagement in meaningful occupations to improve outcomes for individuals with mental health conditions. These are considerations that I will need to make when compiling intervention guidelines for occupational therapy practitioners at this site. Throughout my research of assessments and interventions commonly used or supported for use in mental health or psychiatric settings, I did not come across any form of resource that compiles these assessments or interventions into an easily understandable and quick reference for practitioners to use to validate their assessment and intervention choices. My goal in conducting this research was to find evidence that supports the use of different assessments and interventions and compile it into one resource that can be easily accessed and utilized by OT practitioners at the Midtown Mental Health Recovery Center. Theory The model/theory I chose to guide my DCE project is the model of human occupation (MOHO). I chose this because it is a holistic approach that addresses both external and internal barriers to engagement in occupation, which is particularly important for the mental health population that I will be working with (Cole & Tufano, 2008). Many of these individuals experience a great deal of environmental effects on their condition, as well as having to cope with the internal considerations that may be affected by their condition. It will be important for me to realize that each individual in this setting may have many different barriers or supports for engagement in occupations and that not every group session will be equally effective for all clients. My visual diagram demonstrates that an individuals volition, habituation, and OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 8 performance skills shape environmental inputs and interactions with others, affecting their output of performance, skills, and participation (Cole & Tufano, 2008). The frame of reference that I chose to guide my DCE is the Psychodynamic Frame of Reference. This frame of reference uses Freuds Psychodynamic theory as a guide and includes five primary areas as highlighted in my visual diagram: social participation and relationships; emotional expression and motivation for engagement in occupations; self-awareness through reality testing and feedback from others; defense mechanisms such as denial and sublimation through the symbolism of activities and occupations; and projective activities such as communication and clarification of occupational goals and priorities (Cole & Tufano, 2008). This frame of reference is very applicable to the mental health population that I will be working with because it addresses some of the most common concerns associated with mental health conditions. The Psychodynamic Frame of Reference has several similarities, including its foundation in Freuds theories, with the Psychosocial Rehabilitation theoretical perspective that has been critical in the development of mental health occupational therapy services (Morato & de Oliveira Lussi, 2018). Keeping this frame of reference in mind during my DCE will allow me to consider each client as an individual and appreciate how their conditions may impact their occupations, such as social participation and emotional engagement. Project Design For my project, I developed a portfolio of assessment tools and interventions for patients in an inpatient mental health setting and organized them based on the specific aspects of mental health or occupation that they address. I developed this portfolio by conducting research on some of the most popular and frequently used assessments and interventions in this population, as well as newer assessments or interventions that are evidence-based. After determining if an OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING assessment or intervention had enough research to support its use, I would assess what areas of occupation and mental health are addressed within it and create a category for my portfolio. For the assessment binder, I separated assessments into categories based on the Occupational Therapy Practice Framework (AOTA, 2020). The categories include the following: outcome measures, occupational profile, occupational performance- ADLs/IADLs, occupational performance- leisure, performance skills- sensory, performance skills- cognition, performance skills- social interaction skills, performance patterns, and client factors. After assigning each assessment to one of the previously listed categories, I would then write a brief overview of the assessment, its uses, its cost, and where it can be purchased in order to give OT practitioners a quick method of determining whether or not that assessment will fit their patients needs at the time. The intervention portion of the binder was categorized by common areas of goals for patients in the unit. The intervention categories were as follows: communication, coping, future orientation, grief & loss, group activities, planning & scheduling, self-esteem, and wellness & mindfulness. In order to determine the success of my project, I decided to implement a pre- and post-test survey of the OT staff on the unit focused on their satisfaction with the evaluation and intervention process on the unit. Project Implementation Implementation of my project consisted of completing the portfolio and both printing a hard copy for the OT office as well as giving the OTR on staff a digital copy of the portfolio via email. After printing off hard copies and assembling them into physical assessment and intervention binders, I had to educate the OT staff on how to use the information within the binders. Some of the challenges I faced in implementing the project included finding research supporting assessment tools that had higher prices attached to the official test and not having 9 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 10 access to them. Some of the successes during my research came from speaking to other students in the cohort who have experienced working in an inpatient mental health setting and could share some of the assessment tools and interventions that were successful at their site. Project Outcomes Results were calculated by implementing a pre- and post-intervention satisfaction survey among the Occupational Therapy staff on the unit. Areas that were addressed in the survey include the following: satisfaction with current evaluation process, whether or not patients needs are appropriately identified with current evaluation process, comfort with performing standardized assessments and evaluations, appropriateness of current assessments and evaluations for the population, whether current assessments and evaluations appropriately identify patients needs, patients benefit from current intake process, whether there is room for improvement in current intake process, if current intake process is evidence-based, satisfaction with current interventions, whether or not current interventions address patients needs, comfort with planning interventions to address patient goals, patients benefit from current interventions, room for improvement in interventions, and whether or not interventions are evidence-based. Overall, all areas of the survey were ranked as either the same or improved since implementation of the intervention and assessment binders on the unit. Areas in which improvement in the operations of the occupational therapy department was documented on the pre- and post-test surveys were the following questions: I am satisfied with the current OT evaluation process for our patients. I feel that the standardized assessments and evaluations used on this unit give OT providers appropriate knowledge of patients needs. I feel that the patients benefit from the current OT intake process. OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 11 I feel that the current OT intake process could be improved. The current OT intake process is up to date with evidence-based practice and supported by research. I am satisfied with current OT interventions being implemented on the unit. The current OT interventions being implemented on the unit address individual patients needs appropriately. I am comfortable planning OT interventions to address the individual goals and needs of our patients. I feel that the patients benefit from the current OT interventions being implemented on the unit. I feel that the OT interventions currently being implemented on the unit could be improved. The OT interventions currently being implemented on the unit are up to date with evidencebased practice and supported by research. Summary The major need that I identified at my site was a need for a more standardized approach to the method that OT practitioners on the unit use to address assessing new patients to determine goals as well as the methods that they use to address those goals through interventions. My project was to create a more standardized approach to providing OT services on the unit by creating intervention and assessment binders that include evidence-based research to support interventions and assessments that are commonly used in inpatient psychiatric settings. The goal was to increase efficiency of OT services and improve the quality of care that patients are receiving on the unit. In order to address this goal, I researched assessments and interventions and compiled organized binders. After implementing the binders on the unit and educating OT OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 12 staff about how to effectively utilize these binders, I conducted the post-survey to assess subjective satisfaction and compared results to the pre-survey. Overall, OT staff reported increased satisfaction with the methods of providing OT services on the unit. Conclusions Throughout this projection, I successfully created a resource of evidence-based interventions and assessments that are appropriate for an inpatient psychiatric setting and organized them in a way that will be easy to understand and utilize for OT staff on the unit. Occupational therapy practitioners at the Mental Health Recovery Center reported overall increased satisfaction with OT services provided on the unit after implementation of the OT intervention and assessment binders. The assessment and intervention binders address the goals of increasing efficiency of OT services on the unit and improving quality of care for patients by providing OT staff with resources of evidence-based practice that can be quickly applied to specific patient goals and utilized more quickly than prior interventions. Limitations of this project include limited opportunity to implement new standardized assessments due to high case load and limited time for OT practitioners to review new assessments. Another limitation is the cost of new standardized assessments, there may not be room in the units budget for purchasing new assessment tools. In order to continue to promote evidence-based practices in the OT department, the OT binders should be regularly updated with new information on assessments or interventions that are relevant to this population. This project can remain an ongoing focus for any OT setting in order to increase efficiency and quality of care that OT practitioners provide to their patients. OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 13 References American Occupational Therapy Association. (2020). Occupational therapy practice framework (4th ed.). American Journal of Occupational Therapy, 74(2). https://doi.org/10.5014/ajot.2020.74S2001 Bullock, A., & Bannigan, K. (2011). Effectiveness of activity-based group work in community mental health: A systematic review. American Journal of Occupational Therapy, 65, 257266. https://doi.org/10.5014/ajot.2011.001305 Centers for Disease Control and Prevention. (2018). Mental health basics. Retrieved from https://www.cdc.gov/mentalhealth/learn/index.htm Chang, Y. C., Ailey, S. H., Heller, T., & Chen, M. D. (2013). Rasch analysis of the mental health recovery measure. American Journal of Occupational Therapy, 67, 469-477. https://doi.org/10.5014/ajot.2013.007492 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Edel, M-A., Blackwell, B., Schaub, M., Emons, B., Fox, T., Tornau, F., Vieten, B., Roser, P., Haussleiter, I. S., & Juckel, G. (2017). Antidepressive response of inpatients with major depression to adjuvant occupational therapy: A case-control study. Annals of General Psychiatry, 16(1). https://doi.org/10.1186/s12991-016-0124-0 Eklund, M., rnsberg, L., Ekstrm, C., Jansson, B., & Kjellin, L. (2008). Outcomes of activitybased assessment (BIA) compared with standard assessment in occupational therapy. Scandinavian Journal of Occupational Therapy, 15, 196-203. https://doi.org/10.1080/11038120802022110 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 14 Eskenazi Health. (2016). Kathi & Bob Postlethwait Mental Health Recovery Center. Retrieved from https://www.eskenazihealth.edu/mental-health/acute/recovery-center Gibson, R. W., DAmico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65, 247-256. https://doi.org/10.5014/ajot.2011.001297 Gutman, S. A., & Brown, T. (2018). A bibliometric analysis of the quantitative mental health literature in occupational therapy. Occupational Therapy in Mental Health, 34(4), 305346. https://doi.org/10.1080/0164212X.2017.1413479 Kirsh, B., Martin, L., Hultqvist, J., & Eklhund, M. (2019). Occupational therapy interventions in mental health: A literature review in search of evidence. Occupational Therapy in Mental Health, 35(2), 109-156. https://doi.org/10.1080/0164212X.2019.1588832 Morato, G. G., & de Oliveira Lussi, I. A. (2018). Contributions from the perspective of psychosocial rehabilitation for occupational therapy in the field of mental health. Brazilian Journal of Occupational Therapy, 26(4), 943-951. https://doi.org/10.4322/2526-8910.ctoARF1608 OFlynn, P., ORegan, R., OReilly, K., & Kennedy, H. G. (2018). Predictors of life among inpatients in forensic mental health: implications for occupational therapists. BioMed Central Psychiatry, 18(16). https://doi.org/10.1186/s12888-018-1605-2 Odes, H. Katz, N., Noter, E., Shamir, Y., Weizman, A., & Valevski, A. (2011). Level of function at discharge as a predictor of readmission among inpatients with schizophrenia. American Journal of Occupational Therapy, 65, 314-319. https://doi.org/10.5014/ajot.2011.001362 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 15 Shimada, T., Ohori, M., Inagaki, Y., Shimooka, Y., Sugimura, N., Ishihara, I., Yoshida, T., & Kobayashi, M. (2018). A multicenter, randomized controlled trial of individualized occupational therapy for patients with schizophrenia in Japan. PLoS ONE, 13(4). https://doi.org/10.1371/journal.pone.0193869 Stacey, G., Felton, A., Morgan, A., Stickley, T. Willis, M., Diamond, B., Houghton, P., Johnson, B., & Dumenya, J. (2016). A critical narrative analysis of shared decision-making in acute inpatient mental health care. Journal of Interprofessional Care, 30(1), 35-41. http://dx.doi.org/10.3109/13561820.2015.1064878 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 16 Appendix Wee k 1 DCE Stage (orientation, screening/evaluat ion, implementation, discontinuation, dissemination) Orientation Weekly Goal Objectives Tasks Date complet e 1.) Complete orientation by the end of the week Complete staff introductions and tour of the unit/facility Complete any orientation training/paperwork 1/14/20 22 Gain access to EPIC and get badge/keys Observe the role of OT on the unit Update/finalize MOU Review any documentation/resou rces the facility has on current practices for OT Observe current process for intake/evaluati ons of new patients 2 Screening/Evalua tion 1.) Complete needs assessment 2.) Complete literature search of inpatient mental health OT interventions by end of week Finalize questions for needs assessment Review needs with site mentor & faculty mentor Complete SWOT analysis Research interventions 1/21/22 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 3 Screening/Evalua tion 1.) Observe administration of intakes/evaluati ons 2.) Create pre/post-test outcome measure for patients 4 Screening/Evalua tion 3.) Complete literature search on OT mental health assessments by end of week 1.) Complete literature search on OT mental health evaluations by end of week 2.) Begin data collection starting midweek 5 Screening/Evalua tion 6 Screening/Evalua tion 7 Implementation 1.) Compile rough draft of evaluation guidelines 1.) Complete final draft of evaluation guidelines 1.) Educate staff on new evaluation guidelines Establish outcome assessment Determine appropriate OT assessments for the unit 17 Review outcome assessments with site and faculty mentors Conduct intake Review data interviews collected with site with site mentor mentor 1/28/22 2/4/22 Conduct discharge interviews with site mentor Create evaluation guidelines for unit Send final draft to site and faculty mentor Meet with OT and COTA to review evaluation guidelines Review evaluation guidelines with site mentor 2/11/22 Revise draft as needed 2/18/22 Finalize posttest measure 2/25/22 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 8 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 9 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 10 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 11 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 12 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 13 Discontinuation 1.) Analyze survey results by end of week 14 Dissemination 1.) Present Disseminate Present project to project results DCE and site to site by end project of week Doctoral Capstone Experience and Project Weekly Planning Guide 18 3/4/22 3/11/22 3/18/22 3/25/22 4/1/22 4/8/22 4/15/22 ...
- Creator:
- Mary Grace Willis
- Date:
- 2022-05
- Type:
- Capstone Project
-
- Keyword matches:
- ... 1 Creating a Cultural Competence Toolkit for Indiana First Steps Providers Fatima Tapia May 05, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jenna Trost, OTD, OTR 2 Abstract The purpose of this capstone was to evaluate the effects of a cultural competence toolkit on early intervention (EI) providers self-reported levels of comfort in providing culturally competent services to minority families on their caseload. This quantitative, quasi-experimental design study used a pretest posttest method to assess change in comfort level scores relating to cultural awareness, knowledge, skills, and practice using an adapted version of the Cultural Competence Assessment Inventory (CCAI). Adaptation of the CCAI was completed to tailor the questions to the needs of the site and of the project. This capstone was conducted at a pediatric autism center with its affiliated EI service providers. Participants included 10 occupational, physical, speech, and developmental EI therapists (N= 10). Participants completed a pre-outcome measure and were then presented with the cultural competence toolkit that they completed and integrated for five weeks. Following the completion of the toolkit, EI therapists participated in an opendialogue, virtual reflection session. Immediately following, participants completed the postoutcome measure. Pre and post data were collected in Likert scale form and were later assessed using SPSS and the Wilcoxons signed-rank test. EI providers demonstrated a statistically significant improvement in comfort levels when addressing minority families after the intervention. Aggregate scores improved 3.9 points from 27.8 on the pretest to 31.7. Cultural competence education in an EI setting where providers must interact and step in-home with culturally diverse families significantly enhances attitudes, knowledge, communication, and advocacy in therapeutic services. Keywords: early intervention; cultural competence; multicultural diversity; ethnic minorities; pediatrics 3 Creating a Cultural Competence Toolkit for Indiana First Steps Providers All children have the right to equitable learning opportunities that help them achieve their full potential as engaged learners and valuable members of society (NAEYC, 2019). Within early intervention (EI) services and throughout the United States, minority populations continue to grow (Durand, 2010). This growth urges EI professionals to develop skills that support proficient, multicultural services. To develop skills that meet the needs of society, therapists need organizational support and readily available resources within the workplace. Unfortunately, therapists often report feeling unsupported by their organizations (Grandpierre et al., 2018; Martinez & Leland, 2015). Possibilities Northeast (PNE) is a pediatric therapy clinic in Fort Wayne, Indiana whose vision is to develop programs that meet the needs and unique differences of all children and families served (Possibilities Northeast, n.d.). The clinic offers EI services that address the needs of children aged zero to three from Burmese, Hispanic/Latino, African American/Black, Amish, and Mennonite backgrounds (C. Elder, personal communication, February 22, 2021). Population data is presented in Figure 1. First Steps, Indianas EI program, provides occupational, physical, speech, and developmental therapies to children from birth to three years of age who face developmental delays or disabilities. First Steps goal is to ensure that children receive help early to support them in their future. Reporting more than 20,000 families and children served, EI therapists see a multitude of cultures and ethnicities daily (Family and Social Services Administration, 2020). First Steps is guided on providing client-centered, culturally competent, and individualized services (Family and Social Services Administration, 2020). Without cultural competence development, EI professionals are unable to carry out the foundations that drive the program. 4 Figure 1 Populations Served by Indiana First Steps Providers at Possibilities Northeast Asian 11% Other: 4% Black/African American 32% Mennonite 4% Amish 14% Burmese 3% Hispanic/Latino 32% Note. Data collected was from 10 First Steps therapists (N=10). Response in Other category was Indian. Approximately 92% of EI staff at PNE is White (C. Elder, personal communication, February 22, 2021). With many diverse families seeking EI care, a predominantly White staff struggles to provide culturally competent services (C. Elder, personal communication, February 22, 2021). PNE fails to provide therapists with trainings that address diverse population care, resulting in decreased levels of comfort when caring for minority families (C. Elder, personal communication, February 22, 2021). A lack of confidence in multicultural care puts minority families at risk of not obtaining high quality services. The purpose of this capstone was to develop a cultural competence toolkit that enabled EI therapists to develop the necessary skills to address multicultural needs when providing in-home services. The toolkit included four modules (see Appendix A). This capstone aimed to increase organizational support and EI therapist comfort levels when providing services to minority families. 5 Background In 2015, the United States Census Bureau projected that by the year 2020, more than half of the nations children would belong to a minority race or ethnic group (U.S. Census Bureau, 2015). As U.S. minority populations grow, a cultural competency toolkit is necessary to prepare EI professionals to work with cultures different than their own (Agner, 2020). Govender et al. (2017) defines cultural competence as: A process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, and ethnic backgrounds in a way that recognizes, affirms, and values the worth of the individual and protects and preserves the dignity of each. (pp. 2) The continued advancement of the occupational therapy profession relies on the preparation of therapists to practice across multicultural settings (Sonn & Vermeulan, 2018). With a majorityminority nation ahead (U.S Census Bureau, 2015), culturally competent healthcare is vital to increasing patient satisfaction (Govere & Govere, 2016). Cultural competence programs have been created in variety of forms, but with similar aims to improve attitudes, knowledge, and skills of healthcare professionals (Jernigan et al., 2016). One study suggests that approximately 40% of programs have based their trainings on the foundations of Betancourt et al. (2003) that identifies attitudes, knowledge, and skills as necessary to build cultural competence. Attitudes and self-awareness measure healthcare professionals recognition of biases, curiosity, and empathy (Association of American Medical Colleges, 2022). As cultural competence cannot begin until one understands how personal cultural values affect their health care beliefs (Govender et al., 2017), understanding how ones own views affect work cross-culturally is imperative. Programs addressing attitudinal barriers 6 increased confidence among professionals (Kaul & Guiton, 2010; Lie et al., 2010; Campbell et al., 2011; Parisi et al., 2012). Improving culturally diverse knowledge is targeted among cultural competence programs. Some existing programs view culturally diverse knowledge as properly addressing families and identifying cultural customs (Dabney et al., 2016), while others view it as understanding how to enable understanding of cultural competence, racial awareness, and appropriate clinical behaviors (Webb & Sergison, 2002; Crandall et al., 2003). Many cultural competence programs lack providing healthcare professionals with the norms, values, and beliefs of the very minority populations they serve. Easy access to this information may allow therapists to be more open to learning about their clients cultures, leading to greater knowledge of their background, and increasing cultural competence. One factor consistent in determining patient satisfaction in minority populations is communication (Govender, 2017; Martinez & Leland, 2015; Mirza & Harrison, 2018). Occupational therapy relies on communication to deliver effective intervention (Govender, 2017). Without communication, exchanging vital information pertaining to intervention, recommendations, and parent/caregiver education will lack. As a result, language discordance can have a detrimental impact on cultural competence and therapeutic services (Govender et al., 2017). Several cultural competency training programs address cross-cultural communication through effective education on communication strategies and interpreter usage (Aeder et al., 2007; Crandall, 2003; Webb & Sergison, 2002; Cha-Chi et al., 2010). By incorporating crosscultural communication education, therapists may feel more comfortable and equipped to provide higher levels of care to minority populations (Brown et al., 2016). 7 An online cultural competency toolkit will not be effective on its own. Mirza and Harrison (2018) highlight the importance of combining online trainings with reflective assessments to produce long-term effects. To sustain long-term cultural competence, maintaining higher-level moral thinking through cultural awareness is necessary (Henderson et al., 2018). Involving healthcare professionals in open dialogue supports the advancement of culturally competent care (Manis, 2012). Different than other training programs, this toolkit included open dialogues with EI professionals to promote development of culturally competent skills. Sonn and Vermeulen (2018) found that therapists need to be supported in participating in culturally diverse situations. This toolkit pushed therapists beyond education and supported them in taking advantage of their position as EI professionals to apply their knowledge within in-home services. The repetition of self-reflection provides reinforcement of behaviors that lead to more culturally competent services (Mirza & Harrison, 2018). A needs assessment with therapists, directors, and First Steps coordinators of PNE determined that therapists require increased support and resources when addressing families with diverse cultures. Creating a cultural competency toolkit that addressed attitudes, knowledge and skills enabled PNE and their EI therapists to meet the unique needs and differences of all children and families served, as their vision statement delineates (Possibilities Northeast, n.d.). This unique toolkit enabled therapists to not only feel better prepared to conduct face-to-face interventions with multicultural families, but took a distinctive approach to cultural competence, more aligned with cultural humility. An encyclopedic knowledge of cultures was not expected from therapists; instead, the toolkit challenged therapists to undertake a lifelong commitment of self-evaluation, self-analyzation, and self-progression to create permanent changes in their crosscultural service delivery (Stubbe, 2020; Rajaram & Backrath, 2015). 8 Theory to Guide Practice Occupational Adaptation The Occupational Adaptation (OA) model focuses on the interactive processes between a person, their environment, and the internal adaptive process that occurs when the individual is engaged in occupations (Cole & Tufano, 2008). When an environment demands more than what the individual can competently meet, decreased occupational performance results (Cole & Tufano, 2008). PNE creates a high demand for culturally competent therapists but does not provide resources that prepare therapists to provide culturally competent services. The OA model delineates the importance of guiding change through intrinsic motivation (Cole & Tufano, 2008). Incorporating a cultural competence toolkit allowed therapists to self-reflect and recognize the need to change, modify, or adapt their services. This behavioral change allowed therapists to go through an adaptation response mechanism, or a plan for action (Cole & Tufano, 2008). Integrating a cultural competence toolkit enabled PNE to provide resources for therapists to meet their environmental expectations. Ecology of Human Performance The Ecology of Human Performance (EHP) guided satisfactory occupational, physical, speech, and developmental therapy services received by multicultural populations. The EHP focuses on the impact that context has on task performance (Cole & Tufano, 2008). The EHP looks at four constructs: the person, context, tasks, and how well the person can perform tasks in their environment (Cole & Tufano, 2008). For this DCE, a childs personal variables disrupt the way they can independently engage in occupations and roles. The toolkit addressed the contextual factors that minority families were in, having trickling effects that supported their childs personal variables. The cultural competence toolkit addressed how therapists can better 9 understand the families environment, culture, and expectations to equip them on how to modify, adapt, or establish tasks and roles (Cole & Tufano, 2008). The EHP guided the DCE project as it helped navigate how cultural competency trainings allow therapists to better adapt to the contextual needs of minority families. Project Design To measure EI therapist comfort levels when providing services to multicultural families, a quasi-experimental design with a pretest posttest method was used. Through convenience sampling, 10 EI therapists participated in completing the cultural competence toolkit. Prior to the completion of the toolkit, therapist comfort levels were assessed using the Cultural Competence Assessment Instrument (CCAI). The CCAI, a 36-item tool created by Suarez-Balcazar et al. (2011), measures cultural competence among rehabilitation practitioners who serve individuals with disabilities from diverse backgrounds. Demonstrating strong psychometric properties, the CCAI looks at four cultural factors: awareness, knowledge, skills, and practice. Due to our focus on comfort levels in these four areas, the CCAI was modified to consist of 13 items that are rated on a three-point Likert scale with a rating of 3 indicating very comfortable, a rating of 2 indicating somewhat comfortable, and a rating of 1 indicating not comfortable, to fit the needs of the site and of the therapists of being quick to use (Preston & Coleman, 2000). The pre and post outcome measures were developed on Qualtrics, an online survey software, and sent to EI therapists. The adapted version of the CCAI was administered during the second and 10th week of the DCE to obtain changes in comfort levels when serving minority families. Due to limitations in technology and usage by PNE EI providers, modules were created using Microsoft PowerPoint, a familiar system to all therapists, to increase effectiveness (Hode et al., 2018). An overview module was sent out, along with the pre-outcome measure, to provide 10 therapists with a background of the project. The other modules, created using evidence-based findings, included: Attitudinal Barriers, Learning About Cultures, Communication, and Resources. The capstone was divided into three phases: initial implementation, reflection, and dissemination. EI therapists who completed the pre-outcome measure, were sent an email containing a timeline of the project and attachments to all modules. Successful implementation of the capstone required delegating roles to different site stakeholders. The primary role of the executive director of PNE included sending out email communications, pre and post outcomes measures, and project files. Due to staff shortages, the director faced difficulties in sending out email communications on time, setting back the project timeline. This timeline setback forced an adjustment of dates for phase two which included open dialogue reflections. 10 EI therapists participated in a five-week implementation period where they completed the toolkit and actively implemented suggested strategies into their First Steps sessions. Due to COVID-19 concerns, communication with therapists occurred through email and Zoom, a video conferencing platform. After the implementation period, a reflection session was conducted via Zoom. By eliciting thought and innovation through open-ended questions, participants actively considered their and others thoughts and actions and used reflective thinking as a tool for continuous improvement (Helyer, 2015). Open-ended questions were guided by Gibbs reflective cycle to allow for reflection about their learned experiences (Markkanen et al., 2020; see Appendix B). To evaluate the efficacy of the toolkit, therapists were sent a post-outcome measure immediately following the reflection session. At the final dissemination, all participating therapists, and the director of PNE were presented with the project outcomes and discussed future directions and implications of the project. 11 Project Outcomes A total of 10 EI therapists participated in the completion of the cultural competence toolkit. Participants included occupational, physical, speech, and developmental therapists. All participating therapists were White females. Pre and post-test scores were compared for each of the 13 items on the modified CCAI. Data from the modified CCAI was imported into a Microsoft Excel spreadsheet and then analyzed in SPSS utilizing the Wilcoxon Signed Ranks Test. The Wilcoxon Signed Ranks Test produces a more sensitive statistical test when using it with paired data that are measured on at least an ordinal scale and is especially effective when the sample size is small (Doane & Seward, 2007; see Table 1). When examining the 13 items, statistically significant improvements, or positive ranks, were notable on 11 of the 13 items (see Figure 2). Additionally, therapists comfort level total scores (aggregate score for all 13 items) showed significant improvement after completion of the cultural competence toolkit (see Appendix C). Aggregate scores improved 3.9 points from 27.8 on the pretest to 31.7 on the posttest. A Wilcoxon signed rank test revealed that therapist comfort levels significantly increased after completion of the cultural competence toolkit (Md=2.4, n=13) compared to before (Md=2.1, n=13), z = -2.92, p=.004, with a large effect size, r = .57. These statistical results show that the presentation of a cultural competence toolkit significantly increased therapist levels of comfort when providing services to minority families. Figure 2 Modified CCAI Pre Outcome Measure Scores vs. Post Outcome Measure Scores 12 3 2.5 Score 2 1.5 Pre Score Post Score 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Item Number on Modified CCAI Note. Information displayed demonstrates scores obtained from Modified CCAI (Cultural Competence Assessment Instrument). Table 1 Wilcoxon Signed Ranks Test Ranks N Negative Ranks Mean Rank Sum of Ranks 2.00 2.00 6.91 76.00 1a Posttest - Positive Ranks 11b Ties 1c Total 13 Pretest Note. Superscript a = posttest < prettest, superscript b = posttest > pretest, superscript c = posttest = prettest. 13 Therapists demonstrated increased scores in three areas: obtaining resources, having readily available resources, and advocating for the inclusion and healthcare of minority families. During the reflection session, therapists expressed that the cultural competence toolkit was the only resource given to them by their organization that addressed cultural competence needs. Many therapists stated that they found most use in the fourth module as they explored not only the resources made available to them, but the resources available through the state to give to their families. Therapists stated feeling like their role in advocacy needed to increase and felt supported through the toolkit to do so. Item six of the modified CCAI demonstrated a score decrease, meaning that therapists reported decreased comfort in providing quality services to non-English proficient minority families. Summary For therapists, it is important to understand their role in advancing equitable care. The demographics reported in this project are indicative of the rapidly growing minority populations needing EI services, increasing the urgency of developing culturally competent therapists. Organizations must rapidly follow suit to increase the support they give therapists to alleviate levels of comfort. Through the exploration of already existing cultural competence trainings, the importance of creating programs that meet the current needs of therapists and society was noted. Integrating innovative practices within the toolkit, such as open-dialogue reflection, further addressed the desired permanency of learned practices, skills, and used resources within therapists daily services. Examining the effects of implementation of a cultural competence toolkit within EI is important within OT intervention and all other EI services. This toolkit provided EI therapists with cultural competence resources for self-reflection, cultural knowledge, communication, education, and advocacy. The toolkit sought to identify changes in levels of 14 comfort when providing services to minority families using a pretest posttest measure and addressed gaps within already developed programs to target lifelong learning. Project outcomes demonstrated a statistical significance in the modified CCAI scores assessed, indicating increased levels of comfort with providing services to multicultural families after completing the cultural competence toolkit. Increased comfort levels in 11 items supported findings in the literature of the predicative relationship between higher organizational support and higher integration of equitable practice (Grandpierre et al., 2018; Martinez & Leland, 2015). The item with a negative rank demonstrated decreased levels of comfort in providing quality services. Based on this project's goal of helping therapists understand their own biases in culturally competent care, the negative rank may be indicative of therapists renewed understanding that their previous care did not meet the quality standards that they and their organizations once assumed. The decreased score can be reflected to be a positive change in guiding needed modifications within therapeutic practice to meet the needs of the eclectic cultures EI therapists serve. It is important to support therapists bridge their cultural knowledge gap when caring for families that share differing cultures. Addressing this gap may ultimately help create and maintain rapport with minority families. This capstone may help promote increased therapeutic outcomes in minority homes and help all children work towards a more purposeful and meaningful life. Conclusion The outcomes of the project were disseminated to therapists and directors of PNE through an in-person presentation that included tables, figures, and easy to understand data followed by a collaborative discussion. Given the significance of the results, the director spoke about the importance of implementing the toolkit within their onboarding programming. 15 Additionally, a physical therapist at the site is currently developing a project for EI therapists that delineates important contact information for different doctors and specialists in the Fort Wayne area. Due to the nature and topic of this DCE project, many therapists expressed the importance of including contact information of providers who focus on specific minority cultures as a resource for these families. Obtaining only a small sample size within a suburban city raises several opportunities for future research. This project was designed specifically with PNE at the forefront, but First Steps expands throughout the entire state of Indiana. To further elaborate on this projects findings, future research can venture out to other agencies to acquire data on a wider, more generalizable, scale. Additionally, demographics taken of EI therapists provided us with some knowledge of therapist background. Further investigating how comfort levels may be impacted by income, age, geographical location, socioeconomic status, and graduating year may provide a more accurate baseline depiction of pre outcome measure scores. Culture is complex and as a result, developing cultural competence will not occur overnight. As occupational therapists, cultural competence is a skill that is necessary to increase the effectiveness of client-centered care. The continued growth of the occupational therapy profession relies on therapists to effectively interact with diverse populations. Therapists are constantly expected to evolve their practices to meet the everchanging needs of the communities they serve but obtaining resources that are pertinent to those needs is not an easy task. Workplaces must be ready to support their staff in developing skills to meet their clients goals. Allowing EI therapists to complete a cultural competence toolkit provided them with the opportunity to seek and implement suggested strategies and learnings within their day-to-day care of minority families. This capstone readily addressed the needs of the site and of the 16 therapists and provided a foundation for which to improve the quality of care to the minorities they serve. 17 References Aeder, L., Altshuler, L., Kachur, E., Barrett, S., Hilfer, A., Koepfer, S., Schaeffer, H., & Shelov, S. P. (2007). The "culture osce"--introducing a formative assessment into a postgraduate program. Education For Health, 20(1), 11. Agner, J. (2020). Moving from cultural competence to cultural humility in occupational therapy: A paradigm shift. American Journal of Occupational Therapy, 74(4), 1-7. Association of American Medical Colleges. (2022). Tool for assessing cultural competence training (TACCT). https://www.aamc.org/what-we-do/equity-diversity-inclusion/tool-forassessing-cultural-competence-training Basu, G., Costa, P. V., & Jain, P. (2017). Clinics obligations to use qualified medical interpreters caring for patients with limited english proficiency. AMA Journal of Ethics, 19(3), 245-252. Beckford, M. (2020). Naturalising whiteness: Cultural competency and the perpetuation of white supremacy. Social Work & Policy Studies: Social Justice, Practice and Theory, 3(1), 115. Betancourt, R. J., Green, R. A., Carrillo, E. J., & Ananeh-Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Report, 118(4), 293-302. Brown, E. A., Bekker, H. L., Davison, S. N., Koffman, J., & Schell, J. O. (2016). Supportive care: Communication strategies to improve cultural competence in shared decision making. Clinical Journal of the American Society of Nephrology, 11(10), 19021908. https://doi.org/10.2215/CJN.1366121 18 Campbell, A., Sullivan, M., Sherman, R., & Magee, W. P. (2011). The medical mission and modern cultural competency training. Journal of the American College of Surgeons, 212(1), 124-129. Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35(1), 13105. Cha-Chi, F., Lagha, R. R., Henderson, P., & Gomez, A. G. (2010). Working with interpreters: How student behavior affects quality of patient interaction when using interpreters. Medical Education Online, 15(1), 17. Chabon, S., Brown, J. E., & Gildersleeve-Neumann, C. (2010). Ethics, equity, and englishlanguage learners: A decision-making framework. The ASHA Leader, 15(9), 2-7. Clair, M., & Denis, J. F. (2015). Sociology of racism. International Encyclopedia of the Social & Behavioral Sciences, 19, 857 863. Cole, M., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Community Relations Service. (n.d.). Understanding bias: A resource guide. U.S. Department of Justice. https://www.justice.gov/file/1437326/download Crandall, S. J., George, G., & Marion, G. S. (2003). Applying theory to the design of cultural competency training for medical students: A case study. Academic Medicine, 78(6), 588594. Dabney, K., Lavisha, M., Romano, E., Fitzgerald, D., Bayne, L., Oceanic, P., Nettles, L. A., & Holmes Jr., L. (2016). Cultural competence in pediatrics: Healthcare provider knowledge, awareness, and skills. International Journal of Environmental Research and Public Health, 13(1), 14. 19 Dewees, M. (2001). Building cultural competence for work with diverse families: Strategies from the privileged side. Journal of Ethnic & Cultural Diversity in Social Work, 9(3), 3351. Disability Rights Pennsylvania. (2017). Early intervention supports and services: Facts for families. Office of Child Development and Early Learning. https://www.delcohsa.org/earlyintervention/EI_FactsforFamilies081213.pdf Doane, D., & Seward, L. (2007). Applied statistics in business and economics. New York: McGraw-Hill Irwin Publishing Co. Durand, T. M. (2010). Celebrating diversity in early care and education settings: Moving beyond the margins. Early Child Development and Care, 180(7), 835- 848. https://doi.org/10.1080/03004430802466226 Family and Social Services Administration. (2020). First steps home. https://www.in.gov/fssa/4655.htm Family and Social Services Administration. (2022). Services Offered. https://www.in.gov/fssa/firststeps/parents/services-offered/ Govender, P., Mpanza, D. M., Carey, T., Jiyane, K., Andrews, B., & Mashele, S. (2017). Exploring cultural competence amongst ot students. Occupational Therapy International, 1-8. https://doi.org/10.1155/2017/2179781 Govere, L., & Govere, E. M. (2016). How effective is cultural competence training of healthcare providers on improving patient satisfaction of minority groups? A systematic review of literature. Worldviews on Evidence-Based Nursing, 13(6), 402410. https://doi.org/10.1111/wvn.12176 20 Grandpierre, V., Milloy, V., Sikora, L., Fitzpatrick, E., Thomas, R., & Potter, B. (2018). Barriers and facilitators to cultural competence in rehabilitation services: A scoping review. BMC Health Services Research, 18(1), 18-23. Helyer, R. (2015). Learning through reflection: The critical role of reflection in work-based learning. Journal of Work-Applied Management, 7(1), 15-27. Henderson, S., Horne, M., Hills, R., & Kendall, E. (2018). Cultural competence in healthcare in the community: A concept analysis. Health & Social Care in the Community, 26(4), 590 603. https://doi.org/10.1111/hsc.12556 Hode, G. M., Behm-Morawitz, E., & Hays, A. (2018). Testing the effectiveness of an online diversity course for faculty and staff. Journal of Diversity in Higher Education, 11(3), 347365. https://doi.org/10.1037/dhe0000063 Hyun, E. (2007). Cultural complexity in early childhood: Images of contemporary young children from a critical perspective. Childhood Education, 83(5), 261-266. Indiana University School of Medicine. (2021, September 09). Information about our afghan community. https://medicine.iu.edu/blogs/uncategorized/information-about-our-afghancommunity Jernigan, V. B., Hearod, J. B., Tran, K., Norris, K. C., & Buchwald, D. (2016). An examination of cultural competence training in US medical education guided by the tool for assessing cultural competence training. Journal of Health Disparities Research and Practice, 9(3), 150167. Johnson-Weiner, M. K. (2007). Train up a child: Old order amish & mennonite schools. The Johns Hopkins University Press. 21 Jones, W., & Lorenzo-Hubert, I. (2008). The relationship between language and culture. Zero to Three, 29(1), 11-16. Kaul, P., & Guiton, G. (2010). Responding to the challenges of teaching cultural competency. Medical Education, 44(5), 506. Lie, D., Shapiro, J., Cohn, F., & Najm, W. (2010). Reflective practice enriches clerkship students cross-cultural experiences. Journal of General Internal Medicine, 25(2), 119 125. Livingston, W. R. (2002). The role of perceived negativity in the moderation of african americans implicit and explicit racial attitudes. Journal of Experimental Social Psychology 38(4), 405413. Locatis, C., Williamson, D., Gould-Kabler, C., Zone-Smith, L., Detzler, I., Roberson, J., Maisiak, R., & Ackerman, M. (2010). Comparing in-person, video, and telephonic medical interpretation. Journal of General Internal Medicine, 25(4), 345350. Manis, A. A. (2012). A review of the literature on promoting cultural competence and social justice agency among students and counselor trainees: Piecing the evidence together to advance pedagogy and research. The Professional Counselor, 2(1), 48-57. Markkanen, P., Valimaki, M., Anttila, M., & Kuuskorpi, M. (2020). A reflective cycle: Understanding challenging situations in a school setting. Educational Research, 62(1), 46.62. Martinez, J., & Leland, N. (2015). Language discordance and patient-centered care in occupational therapy: A case study. OTJR: Occupation, Participation & Health, 35(2), 120128. https://doi.org/10.1177/1539449215575265 22 Melndez, L. (2005). Parental beliefs and practices around early self-regulation: The impact of culture and immigration. Infants and Young Children, 18(2), 136-146. Mirza, M., & Harrison, E. A. (2018). An online training to prepare occupational therapy students to work with clients with limited english proficiency and interpreters. Journal of Occupational Therapy Education, 2(3). National Association for the Education of Young Children. (2019). Advancing equity in early childhood. https://www.naeyc.org/resources/position-statements/equity. Negarandeh, R., Mahmoodi, H., Noktehdan, H., Heshmat, R., & Shakibazadeh, E. (2013). Teachback and pictorial image educational strategies on knowledge about diabetes and medication/dietary adherence among low health literate patients with type 2 diabetes. Primary Care Diabetes, 7(2), 111-118. Occa, A., & Suggs, L. S. (2015). Communicating breast cancer screening with young women: An experimental test of didactic and narrative messages using video and infographics. Journal of Health Communication, 21(1), 1-11. Panayiotou, A., Gardner, A., Williams, S., Zucchi, E., Mascitti-Meuter, M., Goh, A. M., You, E., Chong, T. W., Logiudice, D., Lin, X., Haralambous, B., & Batchelor, F. (2019). Language translation apps in health care settings: Expert opinion. JMIR mHealth and uHealth, 7(4), e11316. Parisi, V., Ahmed, Z., Lardner, D., & Cho, E. (2012). Global health simulations yield culturally competent medical providers. Medical Education, 46(11), 1126-1127. Parlakian, R., & Snchez, Y. S. (2006). Cultural influences on early language and literacy teaching practices. Zero to Three, 27(1), 52-57. Perception Institute. (n.d.). Implicit bias. https://perception.org/research/implicit-bias/ 23 Phinney, S. J., & Ong, D. A. (2007). Conceptualization and measurement of ethnic identity: Current status and future directions. Journal of Counseling Psychology, 54(3), 271-281. Possibilities Northeast. (n.d.). Possibilities northeast pediatric therapy and autism services. https://possibilitiesnortheast.com Preston, C. C., & Colman, A. M. (2000). Optimal number of response categories in rating scales: Reliability, validity, discriminating power, and respondent preferences. Acta Psychologica, 104(2000), 1- 15. Puig, V. I. (2010). Are early intervention services placing home languages and cultures at risk? Early Childhood Research & Practice, 12(1). 1-18. Rajaram, S. S., & Bockrath, S. (2015). Cultural competence: New conceptual insights into its limits and potential for addressing health disparities. Journal of Health Disparities Research and Practice, 7(5), 82-89. Sieren, S., Grow, M., GoodSmith, M., Spicer, G., Deline, J., Zhao, Q., Lindstrom, M., Harris, A., Rohan, A., & Seroogy, C. (2016). Cross-sectional survey on newborn screening in wisconsin amish and mennonite communities. Journal of Community Health, 41(2), 282 288. Sonn, I., & Vermeulen, N. (2018). Occupational therapy students experiences and perceptions of culture during fieldwork education. South African Journal of Occupational Therapy, 48(1), 34-39. Stevenson, C. H., & Arrington, G. E. (2009). Racial/ethnic socialization mediates perceived racism and the racial identity of african american adolescents. Cultural Diversity Ethnic Minority Psychology, 15(2), 125136. 24 Stubbe, E. D. (2020). Practicing cultural competence and cultural humility in the care of diverse patients. Focus, 18(1), 49-51. Suarez-Balcazar, Y., Balcazar, F., Taylor-Ritzler, T., Portillo, N., Rodakowski, J., GarciaRamirez, M., & Willis, C. (2011). Development and validation of the cultural competence assessment instrument: A factorial analysis. Journal of Rehabilitation, 77, 413. Suh, E. E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2), 93- 102. Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PloS One, 15(4), e0231350. United States Census Bureau. (2015, March 3). New Census Bureau Report Analyzes U.S. Population Projections [Press Release]. https://www.census.gov/newsroom/pressreleases/2015/cb15-tps16.html Webb, E., & Sergison, M. (2002). Evaluation of cultural competence and antiracism training in child health services. Archives of Disease in Childhood, 88(4), 291-294. Woo, B., Fan, W., Tran, V. T., & Takeuchi, T. D. (2019). The role of racial/ethnic identity in the association between racial discrimination and psychiatric disorders: A buffer or exacerbator? SSM Population Health, 7, 1-10. Young, M. I. (2011). Justice and the politics of difference. Princeton University Press. Zippia. (2021, December 14). Developmental therapist demographics and statistics in the us. https://www.zippia.com/developmental-therapist-jobs/demographics/ Zippia. (2021, December 14). Occupational therapist demographics and statistics in the us. https://www.zippia.com/occupational-therapist-jobs/demographics/ 25 Zippia. (2021, December 14). Physical therapist demographics and statistics in the us. https://www.zippia.com/physical-therapist-jobs/demographics/ Zippia. (2021, December 14). Speech language pathologist demographics and statistics in the us. https://www.zippia.com/speech-language-pathologist-jobs/demographics/ 26 Appendix A Transcripts of Cultural Competence Toolkit Modules Cultural Competency Tool Kit Module 1: Attitudinal Barriers First Steps YOU ARE HERE! Lets Review What is Cultural Competence? Understanding Biases Who are YOU? o Understanding ones own values derived from family, background and position in society is critical for developing culturally responsive practice (Dewees, 2001). Lets Reflect o How do these things position you in society? Understanding Your Racial and Ethnic Identity Why are Identities Important? o Ones racial and ethnic identity is a foundation for self-identity as it is how we identify with a given groups culture, values, and beliefs. o These identities may influence individuals' perspectives of race/ethnic stressors and how they enable culturally competent practice. Information retrieved from: (Woo et al., 2019; Phinney & Ong, 2007; Carter, 2007; Stevenson & Arrington, 2009). Critical Self Reflection Self-Awareness is Key to Cultural Competence: An Example o We are shaped by the world around us, like our geographic location, culture, social groups, etc. o Example: Eye contact How we look at people is a basic and clear representation of our cultural values. One individual may be raised in a family on beliefs of look me in the eyes when I am talking to you! While the other individual may be raised in a family on beliefs of dont you dare look me in the eyes! The White Majority o Demographics: OTs: 78.8% White, 8.4% Asian, 6.2% Hispanic/Latino PTs: 73.9% White, 13.7% Asian, 6.0% Hispanic/Latino SLPs: 82.8% White, 8.2% Hispanic/Latino, 4.2% Black/African American Developmental Therapists: 68.1% White, 14.6% Hispanic/Latino, 8.4% Black/African American Information retrieved from: (Zippia, 2021). 27 Identity Development for White Practitioners However, Cultural Competence is NOT for White Practitioners Only o Research finds that workplaces often assume practitioners can competently interact with anyone who shares their skin color. o The problem? Some racialized individuals carry negative feelings about members of their own race. o Negative stereotypes and attitudes toward their own group are often adopted Information retrieved from: (Beckford, 2020; Clair and Denis, 2015; Livingston, 2002; Young, 2011). Bottom Line o All practitioners MUST be cautious not to project their own experiences and biases onto their clients. Cultural Bias: Explicit Bias o Cultural bias begins when we are no longer neutral, but rather we have a preference or aversion to a person or a group of people (Perception Institute, n.d.). o Explicit Bias: When individuals are aware of their prejudices and attitudes towards certain groups (Community Relations Service, n.d.). The positive or negative preferences are conscious. Examples: racism and racist comments Cultural Bias: Implicit Bias o How do Biases Impact Therapy o Examples of Biases Demonstrated by Therapists Assessing Your Bias Cultural Competence Self-Assessment Checklist Use this checklist to identify your strengths and weakness and to develop opportunities for continuous personal and professional development: https://www.avma.org/sites/default/files/2020-08/DiversityCulturalCompetenceChecklist.pd We will revisit this checklist at midterm and at the end of the project. The more points you have, the more culturally competent you are becoming. Up Next: Module 2: Learning Resources Cultural Competency Tool Kit Module 2: Learning About Cultures Lets Review Cultural competence is a continuous process with the goal of gaining the skills to work effectively with diverse groups and communities with a detailed awareness, specific knowledge, refined skills, and personal and professional respect for cultural attributes, both similarities and differences (Suh, 2004). 28 YOU ARE HERE! Why is Learning About Cultures Important? Knowledge is Key Where Early Intervention Falls Short o American Culture is Used as the Norm Understanding Cultures Gives Us Insight o Every interaction we have with a child is a cultural exchange (Parlakian & Sanchez, 2006). o Caregiver routines and traditions are a direct reflection of the values, beliefs, and cultures of families and communities around them (Hyun, 2007). Cultural Competence Expectations Early intervention professionals cannot be expected to develop encyclopedic knowledge of all values, beliefs, and practices in every culture. Instead, early intervention professionals should find ways to learn about and understand others cultures to more accurately deliver services that reflect practices and values of the families they serve. By increasing basic knowledge of cultures, early intervention professionals can more effectively integrate family caregiving practices, beliefs, and goals into their therapeutic services. Information retrieved from: (Jones & Lorenzo-Hubert, 2008; Melendez, 2005). In this Module o We will focus on providing quick fact sheets for 6 minority populations: Black/African American Hispanic/Latinos Burmese Amish Mennonite Afghan Why these Populations? Lets Get Started! Black/African American Cultural Norms Hispanic/Latino Cultural Norms Burmese/Myanmar Cultural Norms o Burmese and Myanmar Culture 'Burmese Cultural Norms Traditional Customs of Burmese Families The Karen The Chin o Amish and Mennonite Cultural Norms Understanding Amish and Mennonite Communities Many cultural norms are based on the families churchcommunity. Changes in the norms of social interaction between members of a church-community or between the church-community and the 29 outside world generally indicate changes in the religious beliefs that constitute the communitys sense of itself (Johnson-Weiner, 2007). o Understanding Amish and Mennonite Communities Amish and Mennonite individuals live in closed, well-defined communities. They follow a lifestyle that separates them from mainstream society. Marriages outside of their community is frowned upon and prohibited. Individuals very rarely convert to their faith. As a result of all these conditions, there is a high degree of genetic relatedness between parents. Increased prevalence of specific genetic disorders present within their communities. Information retrieved from: (Sieren et al., 2016). o Common Genetic Disorders in Amish and Mennonite Communities Amish and Mennonite Cultural Norms o Afghan Cultural Norms Understanding Ethnic Groups in Afghanistan Ones ethnicity is an instant cultural identifier in Afghanistan and usually defines peoples social organization (IU School of Medicine, 2021). Understand that experiences of persecution differ between ethnic groups. As a result, members of minority ethnicities may prefer to indentify by their ethnic affiliation (IU School of Medicine, 2021). Know that most Afghans are Asian, not Middle Eastern. The most common ethnic groups are the Pashtuns, Tajiks and Hazaras (IU School of Medicine, 2021). o Afghan Minority Populations o Research o Afghan Cultural Norms o Traditional Customs of Afghan Families Disclaimer! Cultural norms discussed are based on evidence-based research and are NOT based on direct in-home observations of individual families. Black/African American, Hispanic, Burmese, Amish, Mennonite and Afghan minority groups DO NOT all share the same culture. The cultural norms discussed may apply to only some of your families! Up Next: Module 3: Communication Resources Cultural Competency Tool Kit Module 3: Communication 30 Whats Next? We have discussed attitudinal barriers and the importance of cultural self-awareness. We have also dived deep into different minority populations and their cultural norms. How do we put these pieces together? YOU ARE HERE! Why is Communication Important? Culture Plays a Role in Communication o Cultural differences can lead to conflict between patients, families, and clinicians. o Culture defines how individuals make sense of the world around them. o Culture influences how people view the healthcare experience and how they make decisions. Information retrieved from: (Brown et al., 2016). Communication Alleviates Unequal Treatment of Minority Families Communication Allows EI Professionals to Adhere to Regulations o Non-English proficient minority families are aided by federal regulations that protect their rights by requiring that assessments and evaluations be completed in the language that is most dominant to the child, unless it is not feasible to do so (Puig, 2010). o EI professionals are expected to identify and assess linguistic resources that may be needed (Puig, 2010). o Many states EI programs acknowledge the need to assess the child in their native language but are often not equipped or required to provide their services in the dominant language of the child (Puig, 2010). o No requirements exist to support EI that builds upon families cultural and linguistic resources through direct work with children and families in their home languages (Puig, 2010). Communication Allows for Client-Centered Services Communication Increases Outcomes The Foundations for Effective Communication Step 1 o Like previously discussed in Module 1: Attitudinal Barriers & Module 2: Learning About Cultures Reflect. Understand the inherent beliefs, values, and biases you hold as a healthcare provider. Become aware of the influence your organization/workplace has on your services. Once providers become conscious of these factors, they are more receptive to the beliefs and values of their patients, especially when differences are present. Understand how minority families beliefs and values impact their views on the healthcare system and your roles as healthcare professionals. Step 2 o Use effective communication strategies that are: 31 Evocative Nonjudgmental Respectful o Cross-cultural communication includes: Strategies that address and acknowledge individual cultural traditions Consider ones own beliefs, values, and experiences Avoid generalizing patients beliefs or values (norms were provided in the previous module, but providers should be careful in addressing all patients on an individual basis Information retrieved from: (Brown et al., 2016). Communication Strategies for Initial Sessions Ask-Tell-Ask Strategy o Why is this strategy beneficial? Collaborative communication method Encourages a two-way conversation Asks open ended questions Assesses patients knowledge prior to disclosing more information Does not ask EI professionals to tell patients what to do, but rather ask patients what they are willing to do and moving forward in a collaborative manner after. Information retrieved from: (Brown et al., 2016). Examples of Open-Ended Questions When Trying to Better Understand Patients How to Properly Convey Information Integrating Culturally Competent Communication Strategies Linguistic Mismatch Ethical Considerations o Chabon et al. (2010) point out legal and ethical considerations within their decision-making framework in determining if the SLP should provide services at all. o However, it is not permissible to refuse services based on a cultural mismatch. o If a language matching SLP is not available, the only ethical consideration is to locate and work with an interpreter to provide culturally competent services. o We know how difficult this can be as an EI provider. Information retrieved from: (Chabon et al., 2010). SLP Difficulties in Early Intervention Communication During Treatment Sessions The use of appropriate language services and the right of families and children with limited-English proficiency to access healthcare are inextricably linked (Basu et al., 2017). o For families and children with limited-English proficiency, meaningfully communicating with an EI professional would indicate that EI professional is only using the child and families preferred language of care (Basu et al., 2017). Giving Access to Appropriate Language Services 32 o As early intervention services, we can begin this process by hiring staff who is bilingual (Basu et al., 2017). o However, hiring bilingual staff in all patients preferred language is not always possible (Basu et al., 2017). o So, we must have systems in place for accessing professional language assistance services rather than relying on ad hoc interpreters (Basu et al., 2017). Ad Hoc Interpreters Qualified Interpreters o The Department of Health and Human Services establishes competences required to be a qualified interpreter: Knowledge of specialized terminology Knowledge of interpreter ethics Skills to interpret accurately, effectively, and impartially o The use of qualified medical interpreters with LEP patients, improves comprehension, service utilization, clinical outcomes, and patient satisfaction with services. Information retrieved from: (Basu et al., 2017) Types of Interpreters o Research suggests that patients rate in-person translators higher than remote interpreter services. o However, when rating remote methods, patients demonstrated a high preference for video services. Information retrieved from: (Locatis et al., 2010) How to Appropriately Use a Medical Interpreter But What If Interpreters Arent Available? o CALD Assist Free application on Apple Store & Google Play. Once downloaded, no internet or is Wi-Fi required. Enables conversation with limited preset phrases led by healthcare professionals in 11 different languages. Specifically designed for healthcare settings. Preset phrases only cover topics or situations considered within the scope of everyday clinical conversation. Does NOT include topics/situations that require medical professional interpreters. Information retrieved from: (Panayiotou et al., 2019) How CALD Assist Works Why CALD Assists Limited Phrases is Actually a Good Thing Communication Methods at the End of a Treatment Sessions Teach-Back Method o Always check to ensure that communication with your LEP patients has been understood. o Asl parents/caregivers/families to explain and/or show you what you have completed with their child during your session that day. 33 o Asking them to recall strategies allows for increased carry over into the home. Information retrieved: (Talevski et al., 2020) Teach-Back + Video Support o Videos have a greater influence, when compared to infographics, to communicate healthcare information (Occa & Suggs, 2015) o Didactic messages delivered in video format have the most positive effect on awareness and knowledge (Occa & Suggs, 2015) o Use teach-back strategies first. o Example: Have the caregiver show you how to position their child during feeding. Once caregiver shows you, if they appear to struggle with the provided information, provide them with a video that demonstrates how to position a child. Send it to them via email after session to provide a reference for when they are helping child with feeding during the week. If family is willing, have them take video of you positioning their child in their natural environment. Teach-Back Strategy + Pictorial Support o Using pictorial support is shown to be effective for patients with low health literacy (Negarandeh et al., 2013). o Pictorial support is recommended to be used according to patients conditions (Negarandeh et al., 2013). o Example: Have caregiver show you how to apply different sensory techniques presented during the session. If they struggle showing you different methods, provide picture reminders of different techniques. BONUS: if the pictorial support is in their native language Remember Always Go Back to Teach-Back Up Next: Module 4: Obtaining Resources Resources Cultural Competency Tool Kit Module 4: Obtaining Resources Supporting Our Therapists YOU ARE HERE! Roles of Early Intervention Professionals Early intervention professionals have a role in helping families resolve difficulties that hinder the child from fully participating in EI services. o Because social workers are often scarce on caseloads, our role can extend to link families with resources or other services in their community. 34 Information retrieved from: (Family and Social Services Administration, 2022) Providing Resources for Families o TANF Cash Assistance o CHIP - Health Coverage o WIC Food & Nutrition o CCDF Child Care Financial Assistance o SNAP Food Assistance Familiarize Yourself First! In the Last Module We discussed how we could use the teach- back method with videos and pictorial supports to facilitate communication with families who have limited English proficiency (LEP). In the Next Slides Video Support Resources Obtaining Video Consent When Necessary o In Module 3, we discussed using the teach-back method with video support to further solidify carry over into the home with LEP families. o One method discussed was recording yourself and then recording the family completing intervention strategies provided during the session. o We understand that if you have not done this before, it may be uncomfortable to initiate this conversation. o This video may help in getting the ball rolling: https://www.youtube.com/watch?v=5--GzEeUops Intervention Resource: TEIS o This YouTube channel has great resources for therapists and parents alike. o Examples: Working with Picky Eaters, Symmetrical Movement, Tummy Time Activities, Leg, Arm, and Digestion Massage, Facial Strokes for Babies, Assisted Rolling, Movement/Sensory Play and Techniques, Variety of Play Activities, Crawling, Walking, and Many More! https://www.youtube.com/c/TeisincEarlyIntervention/videos Information Sheets: Pathways o Allows you and parents to quickly and easily look up milestones by age. o Provides quick explanations and videos to supplement what milestones should look like. o https://pathways.org/?fbclid=IwAR1UnM3zu8HqZKz6TuIITRFOFDZoRaxgmcyVv7YeOR5QLaQwDAqWx9bdr4 Pictorial Support Resources Information Sheet Resources o The Royal Childrens Hospital 35 This website provides occupational therapy information sheets with pictures Pathways Downloadable Brochures in English, Spanish, Hindi, Oriya, Turkish, and Greek Depicts developmental milestones by age and skills Provides explanations for parents to understand what is being addressed. In this picture, sensory integration is being explained. A checklist of signs is additionally provided for parents. Resources in Spanish A great resource to use with Spanish speaking families that explains early intervention, what OT does as a profession to help their child and outlines developmental milestones. Intervention Resources Therapy Street for Kids This website breaks activities down by skill areas and then provides a list of activities that will address those areas. Additionally, the website provides homemade play ideas. Mama OT This website provides play ideas using household items. Several of the links provided in the website will redirect you to Pinterest. Multidisciplinary Support Resources Tools to Grow OT Sections out skills by OT, PT, and SLP. However, has a neat section for handouts that can be used multidisciplinary. This may facilitate workload for families and help maintain in-home work to address all 3 therapies with one activity. This is how communication between therapists can be extremely useful! This website does require a subscription for some of their handouts, but many can be accessed free by simply signing up. o o o o Resources to Explain Therapy in Other Languages Explaining Therapy in Spanish o Occupational Therapy: https://www.youtube.com/watch?v=o2qhpRIMg2Q o Physical Therapy (0-1:36) https://www.youtube.com/watch?v=jS9YojHvxvI o Speech Therapy: https://www.youtube.com/watch?v=oi3LzsMzqy0 Explaining Occupational Therapy in Other Languages Addressing the Gaps Our Role in Advocacy Building Bridges 36 Other Potential Physician Roles Advocating for First Steps Services o Family Voices provides a concise fact sheet with a description of First Steps, eligibility criteria, services provided, cost, and how to get started. o Make sure to get updated links for families, as changes may occur with time. Clusters o First Steps is administered at a local level in regions. These regions are groups of counties known as "clusters. o IN.gov provides an interactive map where families can access offices near them. First Steps Resource for Spanish Speakers o The CDC provides a great Spanish description of First Steps and provides hyperlinks to resources and who to contact by their state. Fulfilling Your Role o By providing these resources to families, you are fulfilling your role. o The purpose of early intervention is to provide families/caregivers and early education practitioners with proper supports and resources to further enable their childs learning and development. Information retrieved from: (Disability Rights Pennsylvania, 2017) You Have Now Completed: o Your role now is to take information from all 4 modules and reflect, learn, and implement different strategies into your sessions with minority families on your caseload. Whats Next? Reflection! Resources Appendix B Reflective Session Discussion Questions Description Share an experience where cultural competence was necessary. Feelings 37 After completing the toolkit, how has your understanding of the term cultural competence changed? Evaluation After completing the toolkit, what did you determine as your strengths relating to cultural competency? Analysis Discuss your comfort levels then versus now in dealing with clients of varied cultures and language backgrounds? In what areas did you feel challenged or notice a need for growth? Conclusion How does your therapy change the most when working with clients/families who have a different culture and speak a different language than your own? Action Plan Did this program provide you with useful materials available in the languages and formats that you can readily use? What module would you see yourself referring back to the most? What other materials would you have liked to be included in this toolkit? Any changes you would like to see within the toolkit for its use in the future? Appendix C Modified CCAI Pretest and Posttest Score Comparisons Modified CCAI Items Question 1: How comfortable are you with integrating a client's culture into the therapy process? Pretest Mean Score 2.20 Posttest Mean Score 2.40 38 Question 2: How comfortable are you in asking your clients questions regarding their cultural beliefs and values ? 2.10 2.40 Question 3: How comfortable are you in obtaining resources to provide to minority families on your caseload? 1.90 2.80 Question 4: How comfortable are you in advocating for the inclusion and healthcare of minority children and families on your caseload? 2.30 2.70 Question 5: How comfortable are you in going into minority homes with readily available resources that reflect the cultures and backgrounds of minority families and children on your caseload? 1.80 2.30 Question 6: How comfortable are you in providing quality therapy services to nonEnglish proficient families and children? 2.0 1.90 Question 7: How comfortable are you working with culturally diverse backgrounds? 2.20 2.60 Question 8: How comfortable are you in identifying cultural beliefs that are not expressed by a caregiver but might interfere with therapy service delivery? 2.00 2.40 Question 9: How comfortable are you adjusting your therapeutic strategies when 2.30 2.30 39 providing therapy services to minority families and children? Question 10: How comfortable are you in using non-verbal communication when providing therapy services to non-English speaking families and children (ex: teach-back strategies, videos)? 2.10 2.20 Question 11: How comfortable are you in examining personal biases related to race and culture that may influence your behavior as a therapy service provider? 2.40 2.80 Question 12: How comfortable are you in considering the cultural values and beliefs of minority families and children when food is involved? 2.60 2.70 Question 13: How comfortable are you going into minority homes with adequate organization/workplace provided resources that help you promote cultural competence within my sessions? 1.90 2.20 TOTAL SCORE 27.8 31.7 Note. CCAI = Cultural Competence Assessment Instrument; scale 1 (not comfortable) to 3 (very comfortable). 40 Appendix D Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Weekly Goal Objectives Tasks Date complete 41 1 2 3 4 Orientation Evaluation/Program Development Evaluation/Program Development Evaluation/Program Development 1) Complete orientation by end of the week 2) Complete and get survey out to Nancy 3) Complete Overview Module 4) Complete Module 1 1) Continue literature to build efficacy of tool kit 2) Complete Module 2 1) Complete Module 3 2) Talk to different staff/therapists to confirm best delivery method of tool kit 1) Complete Module 4 2) Finalize Tool Kit Meet with site mentor Create timeline for project Create survey for evaluation of current need for toolkit Send out preFinalize MOU survey by end of with any updates week and turn in Creation of 1st Complete module pre/post survey used for outcome measurement Send out Outcome assessment with one week deadline Send needs evaluation survey to participating therapists Meet with Chelsea to determine formatting of toolkit Continue to search literature to develop effective tool kit Create 2nd module Meet with critical stakeholders of the company to determine how this may be implemented after you leave Create 4th module Create 3rd module Complete draft of Introduction Complete draft of Background 42 5 6 Implementation Implementation 1) Tool kit to be received by at least 5 therapists 2) Meet with different therapists in clinic to determine caseload demographics 1) Develop written observations that are articulate and clear for later dissemination Meet with stakeholders to discuss the importance of the toolkit and present draft Open lines of communication to participating therapists and be available to respond to any questions or troubleshooting issues. Therapists will begin navigating though tool kit Create a documentation system for inhome observations Continue inhome observations of implementation of tool kit. Develop organization and distribution method to make handouts more readily available to therapists and families Continue work on clinic handouts. Begin going inhome with therapists serving minority families to Find individuals observe changes from community in services of prevalent cultures that can Work on help with increasing health increasing health literacy of clinic literacy of hand handouts outs Project Design Due 43 7 8 Implementation Implementation 1) Meet with participating therapists and develop good interviewing skills 1) Develop a continuous understanding of health literacy and how best to show that with clinic handouts Set up meetings with therapists via zoom individually or with group to discuss how things are going with navigating the tool kit Complete midterm reflections to increase efficacy of tool kit Ask questions about what they have learned, what they have changed, and how they will continue to grow with their cultural competence Continue inhome observations of implementation of tool kit Talk to some of the families (if able and they give permission) to determine some of the things they would like to see change within their care and how we can be better suited to serve them as minority families with minority children Continue inhome observations of implementation of toolkit Check in with participating therapists Continue work on clinic handouts 44 9 Implementation 1) Develop method for collection of data with post survey 2) Compile data of post survey Develop best Send out postway to distribute survey with post survey deadline for the end of the week Compile all data in an organized Continue inmanner home observations of Meet with implementation Chelsea to of toolkit review the findings together Continue work and discuss on clinic meanings handouts Determine what findings mean for the company and its future in cultural competency 10 Discontinuation 1) Create visual for data Meet with critical stakeholders such as Nancy and Jake to discuss the importance of the findings Gather all observations Meet with therapists/email therapists to have them give you final thoughts Compile all data Outcomes draft due 11 Dissemination 1) Develop most effective dissemination plan Gather final results Finalize results from survey Analyze results and their meaning Make visual of pre/post outcomes to 45 12 13 Dissemination Dissemination 1) Develop aesthetic and effective dissemination 1) Finalize all work Make clear written documentation for presentation in dissemination Discuss with Chelsea best avenue to present project to First Steps therapists Reach out to First Steps therapists and ask what they would prefer in presentation Continue to work on dissemination show changes (if any) Complete work on Summary Complete work on handouts Begin work on clinic Dissemination Continue work on Dissemination Work on presentation 14 Dissemination 1) Present final project Finalize schoolwork and any work for clinic Prepare to present Disseminate findings -location TBD ...
- Creator:
- Fatima Tapia
- Date:
- 2022-05-05
- Type:
- Capstone Project
-
- Keyword matches:
- ... 1 Evaluating Perceived Competence After Taking a Cancer Survivorship Elective with an Embedded Service Learning Component Taryn Springgate, Megan Yingling, Sierra Kern, Ashton Williams, Shelby Cash, & Kate Kelley 12/16/2022 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Katie M. Polo DHS, OTR, CLT-LANA 2 A Research Project Entitled Evaluating Perceived Competence After Taking a Cancer Survivorship Elective with an Embedded Service Learning Component Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Taryn Springgate, Megan Yingling, Sierra Kern, Ashton Williams, Shelby Cash, & Kate Kelley Doctor of Occupational Therapy Students Approved by: Katie M. Polo, DHS, OTR, CLT-LANA Research Advisor Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date 3 Abstract Community engagement models (CEMs) encompass teaching pedagogies used to provide students an opportunity for hands-on application of classroom learning while servicing local populations (Bandy, 2019). Incorporating service learning into a curriculum aligns with the Experiential Learning Theory, which is a dynamic, holistic process of learning from experience (Kolb & Kolb, 2017). The purpose of this study was to examine if students CEM experience shaped their perceived competence. Researchers used a sequential explanatory mixed methods design consisting of an online survey, several virtual focus groups, and interviews to assess perceived competence and impressions of the CEMs effects. Participants were alumni of an entry-level doctorate of occupational therapy (OTD) programs cancer survivorship elective. In total, ten alumni completed the survey and eight of those alumni participated in virtual focus groups and interviews. Results from qualitative data suggest that after participating in cancer survivorship education and taking part in a service-learning component, entry-level OT alumni felt competent and confident in their ability to treat cancer survivors. Alumni reported increased interest in treating cancer survivors and a better understanding of the role of OT in the community. No significant correlations between quantitative and qualitative research in terms of perceived competence were found. Given the literature and call for further curricular development in cancer survivorship content, programs should consider developing course content that includes a service learning component to support their graduates competence and confidence in working with cancer survivors. Keywords: cancer survivorship, curriculum design, service learning, education 4 Introduction Community engagement models (CEMs) encompass teaching pedagogies that provide students an opportunity for hands-on application of classroom learning and foster student skill development while simultaneously addressing community needs (Bandy, 2019). CEMs are a crucial part of an occupational therapy (OT) curriculum because they provide practitioners with hands-on experience, which can improve self-confidence, increase cultural awareness, and improve professional development (Jacobs, 2020; Keane & Provident, 2017; Mu et al., 2016; Peterson et al., 2014). Service learning can increase students' knowledge of their field, enhance clinical skills, and improve overall competency (Alt et al., 2011; Kaf & Strong, 2011; Peterson et al., 2014; Ten Tusscher et al., 2020). Service learning pedagogies are categorized as CEMs and incorporate learning goals and meaningful community involvement to encourage student and community growth (Bandy, 2019). Competence encompasses performance, application, and integration of knowledge and skills, including applying standards of care and appropriate policies and procedures in an educational or clinical setting (Moyers, 2002). Competence also includes the ability to use knowledge, skills, attitudes, and values that allow an individual to perform successfully in a profession or occupation (Moyers, 2002). The ideology of incorporating service learning into a curriculum aligns with the Experiential Learning Theory (ELT) (Healey & Jenkins, 2000; Kolb & Kolb, 2017). Kolb & Kolb (2017) defined the ELT as a dynamic, holistic theory of learning from experience that contains four cyclical components: a concrete experience, reflective observation, abstract conceptualization, and active experimentation (see Figure 1). In ELT, two 5 elements encompass the student experience, including learning the basic concepts and reflecting on what students learned. Additionally, two components transform the students' experience, including conceptualizing and actively carrying out what was learned (Kolb & Kolb, 2017). Service learning pedagogies implement these principles by having students learn knowledge from classroom instruction and then apply skills in a hands-on, community experience. Figure 1 Kolbs Experiential Learning Theory (2017) Kaf and Strong (2011) discussed that only some students have the opportunity to be involved in CEMs, which could influence the students outcomes, establishing a need for a CEM provided to all students. Within Kaf and Strong's (2011) study, 48 students participated in a service learning pediatric audiology course, while a control group of ten other students did not participate in the course. The researchers found that 87% of the students that engaged with service learning reported an increase in their overall knowledge and clinical skill development, and 42% reported an increased interest in working with pediatric audiology as a career (Kaf & Strong, 2011). Overall, the students 6 who participated in a service learning component had better outcomes than those who did not (Kaf & Strong, 2011). Mu et al. (2016), Kohlbry (2016), and Keane & Provident (2017) also established a need for integration of CEMs to within classes rather than taking place following the completion of the course, a concept supported by ELT (Kolb & Kolb, 2017). CEMs with service learning pedagogies are utilized across disciplines within academia, especially within healthcare fields. For example, students in baccalaureate and post-baccalaureate healthcare programs engage in the community, service-based learning opportunities within the curriculum to gain hands-on, real-life experience (Alt et al., 2011; Kaf & Strong, 2011; Peterson et al., 2014; Ten Tusscher et al., 2020). Literature supports the use of service learning pedagogy in healthcare education, such as OT. However, limited research exists for OT academia regarding service learning. Ashby et al. (2016) established a need for further research into the curricula and other processes that help students form a professional identity, including service learning. Many published articles also demonstrate a need for a smooth transition from learning knowledge and skills to applying those in CEMs (Mollica & Hyman, 2016; Merritt & Murphy, 2019; Martinez-Mier et al., 2011), and service learning would bridge this gap. Within many emerging fields of OT practice, such as cancer care, the benefits of a service-learning approach have not been explored despite a call for specific education and training, including CEMs (Ten Tusscher, 2020; Baxter et al., 2017; Childress & Gorder, 2012). Further research is needed to evaluate the benefits felt by students after completing a course with a service learning component CEM. Purpose & Aims 7 The purpose of this study was to examine if the service learning experience in an entry-level OTD cancer survivorship elective shaped alumnis competence. This study aimed to evaluate the perceived competence of OTD alumni after taking the elective with an embedded community service learning component. Research Questions The research questions that guided this study were: 1. What is the experience of perceived competence that alumni in the OTD 620 elective describe? 2. What is the relationship between years of experience and the perceived competence scale? 3. What is the difference among practice settings on the perceived competence scale? 4. How do the themes generated from the focus groups support, modify, or contradict the perceived competence scale findings? Methods Research Design Researchers used a sequential explanatory mixed methods design (Feldhacker & Greiner, 2022) to examine perceived competence among OT alumni that took the cancer survivorship elective. We chose this method to promote data triangulation and provide sufficient data for interpretation (Guy et al., 2020). Quantitative data was gathered first and included a non-experimental, descriptive design with a five-point Likert scale survey to assess alumni's perceived competence. The qualitative portion followed a case study design and consisted of semi-structured, virtual focus groups and 8 interviews to further explain quantitative findings. Using this design, researchers examined trends from reported data and built upon the existing quantitative data (Guy et al., 2020). Course Description Since 2016, a cancer survivorship elective with a service learning component has been offered yearly to OTD students. The university offers a cancer survivorship elective with a service learning component to OTD students that are interested. The elective's structure reflected ELT (Kolb & Kolb, 2017), which includes four cyclical steps: concrete experience, reflective observation, abstract conceptualization, and active experimentation. The elective began with concrete experience, including several weeks of lecture content related to the basics of cancer, including OT's role within the cancer population, typical side effects of cancer treatment, and the impact of cancer on occupational performance. Students engaged in abstract conceptualization by reviewing evidence-based interventions to improve an individual's occupational performance and well-being. The instructor scheduled a meeting with the cancer support site to conduct a needs assessment each year of the elective, so the delivery of interventions varied year-to-year depending on the site's needs. For the final three to four weeks, the students engaged in active experimentation and reflective observation as they went to a cancer-specific community setting and performed various interventions under the instructor's supervision. Examples of these interventions included one-on-one evaluations, individualized interventions, group education, and delivery of a scripted, evidence-based intervention designed by the instructor, followed by small group problem-solving and follow-up each week. 9 Participants and Sampling Alumni were recruited by University of Indianapolis staff using class rosters from the elective in academic years 2016-2019 using non-probability convenience sampling. An uninvolved university staff member emailed a recruitment flyer describing the study to those eligible using email addresses retrieved from course alumni contact lists in order to maintain the alumnis anonymity. University staff also provided researchers with phone numbers from the contact lists used to perform cold calls to recruit alumni to participate. Alumni then filled out a quantitative survey, indicated their interest, and were contacted by a single researcher for focus group scheduling. Researchers collected names and email addresses of alumni from a survey question but de-identified data before the primary researcher analyzed data to reduce potential bias. The criteria for inclusion in the study were as follows: enrollment and participation in the OTD 620 Cancer Survivorship Elective ability to comprehend English ability to participate in virtual surveying and video calls Exclusion criteria included any alumni who did not take the elective. Data Collection Instruments/Measures Quantitative. Researchers developed a virtual survey consisting of demographic questions and a 15-item perceived competence scale using a five-point Likert scale in which 1 indicated no competence to 5 indicated expert competence. Questions were based on a questionnaire designed to evaluate the perceived competence of occupational therapists in mental health (Cottrell, 1990) and adjusted to be specific to 10 the cancer survivorship elective. The itemized survey included questions regarding evaluation, intervention, and foundational concepts/core knowledge in occupational therapy cancer care (see Table 1). The content validity of the survey was established by collecting feedback from oncology experts within the occupational therapy field (Taylor, 2017, p. 285-286). We collected names and email addresses of alumni from a survey question, but de-identified data before the primary researcher analyzed data to reduce potential bias. An uninvolved staff member sent the quantitative surveys via email to maintain the alumni's anonymity. Table 1 Quantitative Survey Questions on Perceived Competence of Alumni # 1 2 3 4 5 6 7 8 9 10 11 12 13 Question Describing OTs role in oncology and cancer survivorship to multidisciplinary and/or interdisciplinary healthcare teams. Describing OTs role in oncology and cancer survivorship to individuals with cancer and/or living beyond cancer. Engaging with cancer survivors in a community treatment setting. Understanding the impact of cancer culture on cancer survivors. Providing culturally competent care to cancer survivors from diverse backgrounds. Knowing the typical side effects of cancer and cancer treatments. Understanding the unique needs of cancer survivors. Evaluating cancer survivors symptoms and side effects of cancer treatment and their impact on occupational performance. Designing and leading educational and self-management groups or individual interventions with cancer survivors. Designing interventions for cancer survivors. Providing interventions to cancer survivors given the common side effects of cancer treatment to improve occupational performance. Facilitating self-management behaviors for symptoms of cancer and cancer treatment. (i.e. fatigue, cancer-related cognitive impairments etc.) Using evidence-based practice and providing proper educational, community, and technology resources (i.e. apps) for intervention support 11 14 15 for those with and living beyond cancer. Providing shared decision making (working together with the client to make decisions) on modifications and adaptations in daily activities to improve occupational performance of cancer survivors. Using current research findings relevant to the nature of oncology and cancer survivorship in interventions with cancer survivors. Qualitative. Focus groups and interviews allowed alumni to reflect on their experiences within the course and their current practice. We scheduled focus groups and interviews based on convenience. Individuals that could not attend the focus groups had an interview. Ideally, researchers aimed for five to eight participants in each focus group (Krueger & Casey, 2014). Researchers utilized a semi-structured interview guide (See Table 2), developed from the quantitative survey to ensure elaboration of answers in the focus groups (Schoonenboom & Johnson, 2017). Table 2 Semi-Structured Focus Group Questions 1. The cancer survivorship course was structured differently from year-to-year and some of you most likely took it during different years. Can you describe the structure of the cancer survivorship elective when you took it? 2. What does your current practice with cancer survivors look like? a. For those who have not answered yet, can we assume you have not worked with cancer survivors? 3. What aspects of what you learned in the elective carry through to your daily practice? 4. Can you briefly describe your learning experiences at the community site? 5. Can you explain if the hands-on experience in the community affected your practice? a. Did you learn any transferable skills? 6. Can you explain if you feel more competent in treating cancer survivors after taking the elective? a. Can you please expand on that feeling? 12 7. Reflecting on your current practice, what additional information would have been helpful for you to receive during the elective? 8. Can you explain if you feel more aware of the social norms within the cancer community after taking the elective? a. If so, how do you feel that awareness affects your practice? 9. Can you explain if you feel comfortable connecting cancer survivors with resources and education after taking the elective? 10. Has your experience with the cancer survivorship elective increased your interest in working with the cancer survivor population? Procedures After approval by the Institutional Review Board at the University of Indianapolis, researchers attempted to contact alumni multiple times via email and phone and gauge interest in participation. After agreeing to informed consent, alumni completed a Qualtrics survey which gathered descriptive data that were later de-identified to maintain anonymity. Researchers chose Google Meets as the virtual platform to conduct focus groups and interviews over the following weeks and months due to the programs audio and video recording features and transcription capabilities. Data was de-identified and transcribed verbatim using a Google Chrome extension and placed in a secure Google Drive. The primary investigator, the course instructor, was not present during focus groups or interviews to limit bias in responses. Additionally, the primary investigator only had access to de-identified transcripts and data to decrease potential bias in data analysis. Data Analysis A researcher, who was not the primary investigator, exported de-identified data into a password-protected Microsoft Excel spreadsheet. Quantitative data were analyzed using descriptive statistics, including independent t-tests, to compare 13 demographic and perceived competence variables (Chen & Price, 2020; Norman, 2010). Then, researchers categorized total calculated competence scores into four levels of competence, and an ANOVA was used to compare perceived competence data with specific descriptive data (see Table 3). Data from individuals who did not complete the full quantitative survey were not analyzed to maintain consistency across the results. Researchers analyzed qualitative data using thematic analysis framework from Roberts et al. (2019) to support rigor, credibility, and replicability. The framework consists of a multiphasic thematic analysis, including generating initial codes, searching for codes within the transcripts, reviewing codes, refining codes and subcodes, and developing a report (Roberts et al., 2019). Researchers analyzed qualitative data line by line using direct quotes from alumni and utilized constant comparative analysis throughout the coding process (Boeije, 2002). Researchers followed qualitative data analysis guidelines from Roberts et al. (2019), unanimously agreed on themes and sub-themes to ensure reliability and consistency, and re-read transcripts until no new themes were found indicating data saturation (Roberts et al., 2019). Researchers used a connection model of mixing both quantitative and qualitative data; the point of integration occurs in the results using a joint display (Schoonenboom & Johnson, 2017). For integrative analysis, quantitative data was transposed into qualitative data, coded, and then integrated into the existing qualitative data. Researchers coded Likert-scale questions and compared the quantitative data results to the qualitative results. Results 14 Quantitative Data Ten alumni completed the study's quantitative portion (n=10), and eight participated in the qualitative focus group/interview (n=8). All were white, between 25 and 48 years old, two were male, and eight were female. The alumnis current practice settings included inpatient acute care (n=4), inpatient rehabilitation (n=2), inpatient pediatrics (n=1), long-term acute care (n=1), burn unit (n=1), combined inpatient/outpatient care (n=1), and no longer practicing (n=1). Fifty percent of alumni had 1-2 years of experience (n=5), 40% (n=4) had 3-4 years of experience, and one alumnus had less than one year of experience. Alumni reported how frequently they worked with cancer survivors in current practice and the number of cancer survivors on their annual caseload. Sixty percent of the alumni often worked with cancer survivors (n=6), seeing one survivor each week, and 50% of alumni had more than 20 cancer survivors on their annual caseload (n=5). See Table 3 for Participant Demographics. Table 3 Participant Demographics Descriptive Data Number of Participants (n=) Gender Male 2 Female 8 Current Practice Settings Inpatient acute care 4 Inpatient rehabilitation 2 Inpatient pediatrics 1 15 Long term acute care 1 Burn unit 1 Inpatient/outpatient care 1 No longer practicing 1 Years of Experience Less than 1 year 1 1-2 years 5 3-4 years 4 Number of Cancer Survivors on Annual Caseload Less than 5 2 6-10 1 16-20 3 More than 20 5 Frequency Working with Cancer Survivors Rarely (1 survivor annually) 1 Occasionally (1 survivor monthly) 3 Often (1 survivor weekly) 6 Always (1 survivor daily) 1 In the 15-question survey, alumni rated their perceived competence in various knowledge and skills built into the elective from 1 (no competence) to 5 (expert competence). Total perceived competence scores were calculated for each alumnus by adding their rating of each question from 15 to 75 (see Table 4). Table 4 Alumnis Total Perceived Competence Scores Score Range Level of Competence Alumni Responses 16 15-28 Below Basic Competence 0% (n=0) 29-42 Basic Competence 10% (n=1) 43-59 Advanced Competence 80% (n=8) 60-75 Expert Competence 10% (n=1) Total perceived competence scores ranged from 41 to 63, indicating that overall, alumni of the elective feel that they have basic competence or above when working with the cancer population. Ninety percent of the alumni (n=9) perceived having an advanced or expert competence level. The mean scores for perceived competence for each question indicated that all alumni perceived having at least a basic level of competence in each aspect of working with cancer survivors. Table 5 shows the frequency of perceived competence scores by each question. Among alumni, the years of experience as an OT and total perceived competence exhibited a positive, yet weak, correlation of r(8) = 0.102, p = .778. Researchers performed a one-way ANOVA to compare the effect of the current practice setting on perceived competence scores. Some practice settings only had one participant response, so researchers recategorized data to run the one-way ANOVA. Both adult and pediatric acute care settings were combined into an inpatient acute care setting. Researchers merged settings such as burn unit, LTAC, and outpatient and inpatient into an other category. The one-way ANOVA revealed no statistically significant difference between at least two groups in the current practice setting (F(2, 6) = 0.519, p = .619). Researchers found that the mean value of perceived competence score was not significantly different between any of the three categories of practice settings when compared side-by-side after a post hoc Bonferroni test for multiple comparisons. 17 Table 5 Frequency of Perceived Competence Scores by Scale Item (n = 10) Frequency # Question No competence (n=) 1 Describing OTs role in oncology and cancer survivorship to multidisciplinary and/or interdisciplinary healthcare teams. 2 Describing OTs role in oncology and cancer survivorship to individuals with cancer and/or living beyond cancer. 3 Engaging with cancer survivors in a community treatment setting. 4 Understanding the impact of cancer culture on cancer survivors. 5 Providing culturally competent care to cancer survivors from diverse backgrounds. 6 Knowing the typical side effects of cancer and cancer treatments. Less than basic competence (n=) Basic competence Advanced competence Expert competence Mean Score (1-5) M (n=) (n=) (n=) 2 8 3.8 3 7 3.7 3 7 3.7 6 4 3.4 1 2 7 3.6 1 3 6 3.5 18 7 Understanding the unique needs of cancer survivors. 8 Evaluating cancer survivors symptoms and side effects of cancer treatment and their impact on occupational performance. 9 Designing and leading educational and self-management groups or individual interventions with cancer survivors. 10 Designing interventions for cancer survivors. 11 Providing interventions to cancer survivors given the common side effects of cancer treatment to improve occupational performance. 12 Facilitating self-management behaviors for symptoms of cancer and cancer treatment. (i.e. fatigue, cancer-related cognitive impairments etc.) 13 Using evidence-based practice and providing proper educational, community, and technology resources (i.e. apps) for intervention support for those with and living beyond cancer. 1 1 1 2 6 1 3.7 2 8 3.8 3 6 3.5 4 6 3.6 3 6 3.5 4 6 3.6 2 8 3.8 19 14 Providing shared decision making (working together with the client to make decisions) on modifications and adaptations in daily activities to improve occupational performance of cancer survivors. 15 Using current research findings relevant to the nature of oncology and cancer survivorship in interventions with cancer survivors. 4 4 2 3.8 7 2 1 3.4 20 Qualitative Data Eight alumni participated in focus groups or individual interviews after completing the quantitative perceived competence survey. Researchers ran three virtual focus groups and conducted two interviews based on the availability of the alumni. Analysis of the focus groups revealed six main themes: 1. Hands-on experience 2. Perceived gain of knowledge and skills 3. Deeper understanding of the community setting and cancer culture 4. Gained confidence in working with cancer survivors 5. Ability to apply the course to current practice 6. Interest in the cancer survivorship field. See Table 6 for quotes from alumni supporting each theme. Theme 1: Hands-On Experience Alumni in the focus groups felt that hands-on experience through the CEM portion of the elective was crucial to their learning following the lecture portion. One alumnus talked about how the hands-on experience solidified aspects of treatment in their mind due to the trial by fire nature of direct client care, and another shared it helped them gain perspective on what they had learned in the classroom. A subtheme of the hands-on experience was the context of the cancer-specific community site, as alumni felt that it enhanced their understanding of survivors stories and experiences. Alumni thought the hands-on experience was crucial to developing skills such as problem-solving, intervention planning, and advocacy. They also felt that interacting with actual clients in the community allowed them to understand the clients' interpersonal, 21 emotional, and social experiences. Witnessing empathetic peer support that is key to the cancer survivorship community was a growth opportunity for alumni. See section 1.0 of Table 6 for quotes supporting hands-on experience. Theme 2: Perceived Gain of Knowledge and Skills Through the cancer survivorship elective, alumni reported a gain of knowledge and skills relating to OT practice and treating cancer survivors. Subthemes included increased knowledge, client-centered care, adaptability, shared decision-making, empathy, self-guided learning, evidence-based practice, and therapeutic use of self. During focus group sessions, alumni discussed feeling more competent in treating cancer survivors. They noted that interacting with different clients in this setting helped further their skills in providing client-centered care. Alumni felt that their knowledge of cancer survivors' differing needs increased throughout the elective, improving their skill of adaptability. One alumnus mentioned carrying over the skills of self-guided learning and evidence-based practice from the cancer survivorship setting into their current practice setting, including finding and providing client resources. See section 2.0 of Table 6 for quotes supporting this theme. Theme 3: Deeper Understanding of the Community Setting and Cancer Culture A deeper understanding of the community practice setting following the elective was expressed in the focus groups. This theme included the importance and uniqueness of peer support amongst cancer survivors and social norms surrounding the cancer community. Alumni also had a deeper understanding of the stigma surrounding cancer and how to deal with other aspects of cancer culture after taking the elective. They particularly noted healthcare practitioners' discomfort around cancer and how they 22 often felt the need to take the lead in interprofessional education about cancer. Finally, alumni discussed a better understanding of cancer's short- and long-term side effects after having seen them first-hand at the community site. See section 3.0 of Table 6 for quotes supporting the alumnus' understanding of the community setting and cancer culture. Theme 4: Gain Confidence in Working with Cancer Survivors Along with new knowledge and skills, alumni in the focus groups reported that they felt their confidence increased after working with cancer survivors. Sub-themes related to gained confidence included advocacy, increased comfort working with survivors, and a better understanding of OTs scope of practice, including when to make referrals. Overall, alumni described feeling more comfortable providing OT care to cancer survivors following the CEM portion of the elective. They felt better prepared to address the topic of cancer with future clients after engaging with cancer survivors, noting that there are some instances in their current practice where they are the most knowledgeable about cancer care and survivorship in a given care team. Reflecting on the hands-on experience, alumni reported that they overcame the nerves of discussing a cancer diagnosis in an individual session with a client. One alumnus mentioned that they felt they would need a specialty in that area despite what was learned in the elective if they were to work solely with the cancer population. See section 4.0 of Table 6 for supporting quotes for this theme. Theme 5: Ability to Apply Course to Current Practice Alumni expressed that they have been able to apply what they learned and experienced during the elective course to their current practice as occupational 23 therapists in varied practice settings. For example, an alumnus felt that strategies learned in the elective helped build up their practice across many populations. At the same time, another mentioned the solid foundation the elective gave them, supporting the subtheme of transferability of skills across settings and populations. Other alumni discussed using energy conservation strategies learned during the elective with current clients. Alumni discussed the subtheme of using resources and the importance of providing community resources to clients to facilitate community support. However, two alumni reported that it has been difficult for them to provide community resources in their current practice due to limited time and referral options in acute care, as well as practicing in states with fewer community resources than where they were educated. In addition to using resources to support cancer survivors, alumni discussed the importance of educating the client, caregivers, and other healthcare professionals. Alumni acknowledged the importance of addressing cancer, even as a secondary diagnosis, and recognizing how it can impact the clients life. Alumni also mentioned educating other healthcare professionals on the needs of cancer survivors, such as giving them rest breaks during activity, as an actual application to current practice. See section 5.0 of Table 6 for quotes supporting this theme. Theme 6: Interest in the Cancer Survivorship Field Finally, multiple alumni reported increased interest in working with cancer survivors after graduation. Most stated that their interest in working with this population increased after taking the elective. In contrast, several indicated that they had a personal connection to cancer, which fueled their interest in the elective in the first place. However, others stated that working exclusively with the cancer population would 24 be too emotionally draining, so they would prefer more variety in their caseload. See section 6.0 of Table 6 for quotes about alumnis interest in the cancer survivorship field. Course Recommendations Researchers asked alumni to provide recommendations to improve the course and suggest changes or additions that would have increased the benefits gained from participation. These recommendations were: expanding the lecture content to include information about the most common diagnoses and symptoms in cancer care, the cancer treatment and cancer care continuums, planning and utilizing assessment tools and interventions that are appropriate for different stages of severity and treatment (e.g., at time of the first diagnosis versus when entering remission), and how to connect both practitioners and patients with appropriate support and resources. 25 Table 6 Supporting Quotes of Alumni for Themes from Focus Groups Theme Quotes from Focus Group to Support 1.0 Hands-on Experience 1. So being able to kind of play with that [community] environment and . . . motivate others into like Hey you're not alone. But I'd say that was the coolest aspect was seeing patients kind of interact with one another, and you know they kind of feed off each other where I've been there before or are easily able to be empathetic toward one another. 2. It's better if you just kind of trial by fire that and just experience it [direct client care] because then you're not gonna forget it. 3. So I got to apply those problem solving skills that the graduate program teaches us. But also I got to get first-hand experience on how we can modify and adapt some of the cancer survivors activities of daily living in order to promote their independence . . . And I think just having that experience there it kind of helped me kind of initiate and start the process of thinking about those activity analyses we were taught in graduate school and how we can just take little tweaks and changes into an activity of daily living or a simple strategy in order to maximize their independence. I also learned a lot about the power of advocating and giving the patient or the cancer survivors their power to advocate for themselves. 4. I think the benefit of going to the cancer support community for our class and me personally, was just to see the impact, emotionally and socially that cancer can have on someone's life. 5. So I know having that hands-on experience and interacting with them in particular was an incredible learning opportunity that shaped my overall perspective of this process. 6. It was an actual person with an active condition and they were coming to us as like a free resource, but it really felt like I had the opportunity just to use my skills and see what I could do to help the person. And that's something that I've taken with me from that. It might have been a short experience, but yeah, it was definitely valuable. 2.0 Perceived Gain of Knowledge and Skills 1. But this [the cancer survivorship elective] was the first class where I was able to kind of get creative on my own and try things and see what would happen and I think that was really valuable. 2. I definitely feel more competent in dealing or treating cancer survivors. 3. Just getting to know them and talk to them on a personal level helped me further in my practice. 4. I think it [the cancer survivorship elective] allowed us to like do a lot of self-guided learning and learn the importance of evidence-based practice and carry that over to like the education with the different people that attended and just carry that into like practice just getting that foundation and learning different things 26 and resources that you could provide people. 5. I think since I was given the opportunity through this elective course since I was able to get hands-on experience like advice, education, I feel like it has made me more competent. It's also made me more accountable, where all cancer survivors are completely different. 3.0 Deeper Understand ing of the Community Setting 1. If one of them [the CSC clients] is having a hard day they can relate and they can kind of you know go at a different pace and kind of bring them up and motivate them. I know we all can kind of relate like if you're having a bad day and someone's, you know, trying to help cheer you up a little bit and make your day better. And, you know, it can be little things like that. and you know, a lot of the patients verbalized that they felt that way. 2. The community setting is a great place to learn that because these most of these patients are past their acute treatment and are in remission and they're still having some sort of side effect or problem that's affecting them. So, getting to see that's something that does last as long, if not longer than treatment and you know, can be years later was definitely something that's more of a norm that I wasn't aware of. 3. I think a lot of times it [cancer] might . . . be brushed over almost with some patients. Like it's just in their [patients] list of things that they have going on, cancers one of them. And sometimes I feel like people even have a difficult time like bringing it up, like they dont want to talk about it. Even healthcare practitioners, just kind of like avoid it. 4.0 Gained Confidence in Working with Cancer Survivors 1. So I feel like that [classroom knowledge] helps me be more confident in approaching the subject, especially for the patients who initially find out [about their diagnosis]. . . . They [the CSC clients] had cancer and you know I can be better prepared and more confident and competent in kind of going into that and meeting my patients, where they're at today? 2. So, it [the cancer survivorship class] helped me personally get over my nerves. Those first few sessions I was very nervous. You know making sure like you know Do I have everything I need? Am I gonna mess this up? But kind of just you know, building that confidence in myself as an OT at that time as a student . . . And I definitely think it's helped with my confidence with survivors in general like working with them when they come in for the one-on-ones. Like getting to say, you know, . . . I've had more experience than just that working with cancer survivors and I've got to see, you know, a range of the effects that it can have on survivors. So I think it's definitely helped a lot with my practice in general. 3. Yes. It definitely led to my interest and just my comfort too with working with that population. 4. Sometimes you might be the one who knows the most about just that diagnosis and how it's impacting that person 5. I think in the elective that having that time to actually be with real people, real cancer survivors, and kind of work with them really provided a good opportunity that way when I went into practice, it was something that I was already very comfortable with even like as a student in my fieldwork. 27 5.0 Course Application 1. So, it [strategies learned from the course] really helps kind of build up your practice with whatever population you're working with. 2. I still use a lot of the energy conservation strategies that the instructor taught us. I actually still actually use the handout that we created as a group in her elective that I give out to survivors, kind of just using the therapeutic use of self that the instructor pushed a lot. 3. I don't think until this elective I understood the power of community resources and the power community support can have on a patient, especially a cancer survivor. Just being able to help those survivors or even patients in any way when they go home . . . I feel the more resources the better and this gives them the the power to delegate and the power to take back their lives where they felt cancer took it [control] away from them. 4. It [the cancer survivorship elective] provided a really good foundational component to be able to go out and then learn further into whatever setting you practice in after that. 5. But even if that [cancer] is not their primary diagnosis or why we're seeing them, I try to address that [cancer] and how it's impacting their occupations, whether it's the fatigue, lymphedema, decreased sleep habits. . .Trying to incorporate that in relating it back to like, You might be here for something else, but this still is part of your life. And how can we best address that to meet your daily needs? 6. I do try to educate family or staff members about how to best like meet a person's needs and giving them [cancer survivors] breaks instead of trying to rush them through whatever they're doing which can be hard in healthcare these days. 6.0 Interest in Field 1. I think I, it kind of started my competency in the area. Before I took her elective, I had no interest really in survivorship. . . . . It definitely fueled my interest in it, so that I continued with it in my capstone and now in my career and doing more research, and I wouldn't say, like, everything I know now is because of that, but it definitely jump started it, and gave me the foundation that I felt competent and confident enough that I wanted to continue with it. 2. I have had cancer survivors on both sides of my family so I already had that interest and passion. It was one of the reasons why I wanted to become an OT but taking this cancer survivorship elective definitely heightened my interest for the population. I did my capstone on it. Anytime we get an oncology patient, I'm the one who sees them therapy wise at my place just because I know a lot and they have that special population place in my heart. I just love working with them and trying to help them through their battle. 28 Integration of Mixed Methods and Visual Diagram There were common intersections between qualitative themes seen throughout the data. Hands-on experience gave alumni a better understanding of the community setting, better awareness of cancer culture, and more comfort working with cancer survivors. The elective also gave alumni the confidence to discuss cancer with other healthcare providers, clients, and families who might be uncomfortable with it. Alumni learned skills in the elective, such as group-based education, that can be applied beyond the cancer population to all populations in alumnis current practice settings. Additionally, knowledge, skills, and a better understanding of the cancer culture through hands-on experience in the course fostered alumnis confidence with application into their current practice. Finally, alumni felt their gained knowledge, skills, and cultural awareness was transferable to current practice. Upon qualitative and quantitative data integration, researchers found multiple areas of agreement between all components (Table 7). Alumni reported increased competence in qualitative themes of a gain of transferable knowledge and skills along with a better understanding of community setting and cancer culture, where they said basic to above basic competency. Alumni also reported above or advanced competency in confidence in working with cancer survivors and applying course content to practice. The Integrative Logic Diagram (Figure 2) is a visual representation of connections between areas of agreement in our data. During and after participation in the CEM, alumni gained transferable knowledge, skills, and a deeper understanding of the community setting and the cancer culture. These contributed to greater confidence in working with cancer survivors, which empowered them to apply course material and 29 experience in their current practice. Throughout all of this, the alumni experienced an increased perceived competence in treating cancer survivors. Overall, the Integrative Logic Diagram in Figure 2 demonstrates qualitative and quantitative data integration as they correspond with increased perceived competence after participating in the cancer survivorship elective. Table 7 Integration Coding of Mixed Methods Analysis Theme (Qualitative) Survey Question (Quantitative) 1. Gain of Transferable Knowledge and Skills - Alumni gained knowledge and client-centered skills required for clinical practice from the elective. - Take-aways from the elective include adaptability, empathy, shared decision making, therapeutic use of self. Corresponding Survey Questions: 1, 2, 10, 11, 12, 14 - Above basic competency was found for the skills of describing OTs role, designing interventions, and providing interventions. - Alumni reported high levels of perceived competence for shared decision making. 2. Better Understanding of the Community Setting and Cancer Culture - Alumni gained a better understanding of treatment in the community setting, whether it be in a group or individual sessions, and overall knowledge of cancer culture from the elective. Corresponding Survey Questions: 3, 4, 5, 6, 7 - Majority of alumni reported above basic competence for providing culturally competent care and understanding cancer culture and cancer-specific side-effects. - More alumni reported basic competence for understanding the impacts of cancer culture on cancer survivors than above basic competence. 3. Gain of Confidence in Working with Cancer Survivors - Alumni showed an increase in confidence and competence of skills while working with cancer survivors after completion of the Corresponding Survey Questions: 8, 9 - Most alumni reported advanced competence for evaluating clients with cancer and cancer survivors. - Majority of alumni reported above average competence in designings 30 elective. and implementing groups for cancer survivors. 4. Ability to Apply Course to Current Practice - Alumni stated application of knowledge gained from course content such as learned conditions or common symptoms to guide current treatment sessions. - Resources or handouts created during the elective are utilized in current practice. Corresponding Survey Questions: 13, 15 - Almost all alumni reported advanced competence for using evidence-based practice and providing resources as a means of intervention support for cancer survivors. - Each alumnus reported at least basic competence in using current research within interventions for cancer survivors. 5. Increased Interest in the Cancer Survivorship Field - Alumni showed an increased interest and comfort in working with cancer survivors following the completion of the elective. No corresponding survey question. Corresponding Interview Question: 10 Figure 2 Integrative Logic Diagram 31 Discussion This study adds to the current literature on cancer care and curriculum development within OT programs, supporting and expanding on the previously-studied benefits of CEMs. Previous researchers found that CEMs improve self-confidence, increase cultural awareness, and improve professional development (Jacobs, 2020; Keane & Provident, 2017; Mu et al., 2016; Peterson et al., 2014). Yet from this study, we found that CEMs are associated with an increased skill set and knowledge transferred into course alumni's current practice. Alumni reported feeling that the elective improved competence in working with cancer survivors. Its design reflected the ELT (Kolb & Kolb, 2017), suggesting that using ELT for curriculum design benefits learning. Both quantitative and qualitative findings reflected that the service-learning course component is associated with alumni's feelings of competency, preparedness, and confidence in practice. Ninety percent of the alumni who took the cancer survivorship elective reported having advanced or expert competence in working with cancer survivors upon entering into practice, suggesting that the elective could have helped prepare them. The findings of Kaf and Strong (2011) further support this elective design, who stated that embedding a service learning component into a pediatric audiology course increased student interest, readiness to evaluate clients, comfort level with patient care, and general knowledge of that specific field. Finally, researchers found a weak, positive correlation between alumnis years of experience in practice and competence scores, implying that with more years of experience, alumni feel more confident working with cancer survivors. 32 Due to the low number of participants in the study, there was not a statistically significant difference in competence scores across alumnis current practice settings. Despite the statistical insignificance of the data, qualitative results suggest improved skills such as adaptability, shared decision-making, empathy, self-guided learning, evidence-based practice, and therapeutic use of self. Even alumni who were not working directly with the cancer population at the time of data collection noted that they treat patients who have cancer as a secondary diagnosis and feel more prepared to work with cancer survivors because of the hands-on experience within the elective course. A theme that emerged from focus groups and interviews is alumni having a better understanding of the community setting and cancer culture. Alumni in the elective expressed increased awareness of social norms that exist in community cancer culture, and an increased confidence in navigating these norms in current practice situations. These results are similar to those in existing literature highlighting CEMs impact on cultural competence. Results from Keane & Provident (2017), Merrit & Murphy (2019), and Mu et al. (2016) also indicate that service-learning courses can increase confidence in working with diverse populations and improve overall cultural competence. These studies integrated international service learning opportunities and showed that students had increased cultural awareness following cultural immersion, supporting hands-on experience in CEMs. While alumni of the elective didnt have an international experience, they did have the chance to be immersed into community cancer culture and expressed how this impacted their cultural competence in working with individuals 33 with cancer. Increased cultural competence following CEMs contributes to practitioners having a more holistic approach to patient care. Other skills gained from the cancer survivorship course that carried over to alumnis current practice include increased confidence, empathy, and therapeutic use of self. In addition to self-awareness and self-efficacy, these skills aligned with personal outcomes uncovered in a literature review investigating student development in service learning (Myers, 2020). Therefore, including CEMs in curricula also supports students self-development and professional identity. Limitations Researchers encountered several limitations while completing this study. After an extensive review of the literature, researchers did not find an appropriate survey to measure the perceived competence of alumni. Therefore, researchers developed a new scale to measure perceived competence, modeling the structure and scoring after an existing scale (Cottrell, 1990). However, due to time constraints, the survey needed to be thoroughly tested for reliability and validity before administration which could impact the dependability of our quantitative results. Researchers had a small number of individuals who qualified to participate in this study, which limited our results' generalizability, significance, and strength. The ideal number of participants required for a focus group was not achieved due to scheduling conflicts, running the study during a global pandemic, and a limited number of potential participants. Interviews did not provide the opportunity for alumni collaboration, potentially impacting data saturation (Krueger & Casey, 2014). Finally, the professor 34 who taught the elective was involved in the coding and analysis process, creating a potential for confirmation bias. Impact on Occupational Therapy Education This study shows that, after participating in a cancer survivorship elective with a CEM service-learning component, entry-level occupational therapists felt competent and confident in their ability to treat cancer survivors, applying the knowledge and skills gained through the CEM. The findings of this study suggest that educators should consider building CEMs, such as service learning, into OT courses to support competence and confidence in the future practice of OT students. Alumni reported that being in this course increased their interest in practicing with cancer survivors and provided them with a better understanding of the scope of OT. The elective also helped them better understand how interprofessional teamwork benefits the patient. These skills learned through hands-on experience are crucial for the future support of OT in cancer care. Therefore, future educators are encouraged to consider embedding CEM components into cancer survivorship courses to foster perceived knowledge, skills, cultural awareness, confidence, and student interests. Future Recommendations Baxter et al. (2017) recommend using CEMs to enhance students learning and suggest integrating cancer care education and courses into OT curricula. Therefore, the creation and implementation of further cancer survivorship courses in OT education should utilize a service learning approach to increase knowledge and confidence in an emerging practice field. 35 Future research about the effect of CEMs in OT education should utilize pre- and post-test measures of perceived competence to grasp these courses' impact better. It would also be beneficial to compare the results of these measures between alumni who have taken the course and those who have not. For courses of this type created in the future, we recommend implementing the course improvement recommendations provided by alumni as described in the Results section of this paper. Additionally, this course took place over only half of a semester. We recommend instead including more course content and patient interaction over an entire semester. Conclusion The results of this study suggest that implementation of CEMs in OT education according to the ELT (Kolb & Kolb, 2017) provides a deeper understanding of the community setting, increased interest in emerging fields of practice, and improved confidence in treatment as an entry-level practitioner. Alumni reported increased confidence, interest, and understanding of treating within an emerging field of practice and reported the benefits of the hands-on model. Graduate-level OT programs should implement CEMs in their curricula to gain knowledge and skills as entry-level practitioners and for transferability into future practice. More research using various forms of CEM in OT curricula is needed. 36 References Alt, K. L., Nguyen, A. L., & Meurer, L. N. (2011). The effectiveness of educational programs to improve recognition and reporting of elder abuse and neglect: A systematic review of the literature. J Elder Abuse Negl, 23(3), https://doi:10.1080/08946566.2011.584046 Ashby, S. E., Adler, J., & Herbert, L. (2016). An exploratory international study into occupational therapy students perceptions of professional identity. Australian Occupational Therapy Journal, 63(4), 233243. https://doi.org/10.1111/1440-1630.12271 Bandy, J. (2019, November 6). What is service learning or community engagement? Vanderbilt University, https://cft.vanderbilt.edu/guides-sub-pages/teaching-through-community-engage ment/ Baxter, M.F., Newman, R., Longpre, S.M., & Polo, K.M. (2017). Health Policy Perspectives--Occupational therapys role in cancer survivorship as a chronic condition. American Journal of Occupational Therapy, 71, 7103090010. https://doi.org/10.5014/ajot.2017.713001 Belpoliti, F., & Prez, M. E. (2019). Service learning in Spanish for the health professions: Heritage language learners competence in action. Foreign Language Annals, 52(3), 529550. Boeije, H. (2002). A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality and quantity, 36(4), 391-409. https://doi.org/10.1023/A:1020909529486 37 Braun, V., & Clarke, V. (2012). Chapter 4: Thematic analysis. In H. Cooper (Eds.), APA handbook of research methods in psychology: Vol. 2 research designs. (pp. 57-71). American Psychological Association. DOI: 10.1037/13620-004. Chen, M.J., & Price, A.M. (2020). Comparing undergraduate student nurses' understanding of sustainability in two countries: A mixed method study. Nurse Education Today, 88. https://doi.org/10.1016/j.nedt.2020.104363 Childress, S. B., & Gorder, D. (2012). Oncology nurse internships: A foundation and future for oncology nursing practice? Oncology Nursing Forum, 39(4), 341-4. https://doi.org/10.1188/12.ONF.341-344 Cottrell, R. F. (1990). Perceived competence among occupational therapists in mental health. American Journal of Occupational Therapy, 44(2), 118124. https://doi.org/10.5014/ajot.44.2.118 Creswell, J. W., & Poth, C. N. (2018). Data Collection. In Qualitative inquiry and research design: choosing among five approaches (4th ed., pp. 164164). Essay, Sage. European Centre for Disease Prevention and Control. (2017). Public health emergency preparedness: Core competencies for EU member states. Retrieved from https://www.ecdc.europa.eu Feldhacker, D. R., & Greiner, B. S. (2022). Evaluating Course Design for Significant Learning Among a Blended Cohort of Occupational Therapy Students. Journal of Occupational Therapy Education, 6(1), 1. https://doi.org/10.26681/jote.2022.060101 38 Forest, C. P., & Lie, D. A. (2018). Impact of a required service-learning curriculum on preclinical students. Journal of Physician Assistant Education (Lippincott Williams & Wilkins), 29(2), 7076. https://doi.org/10.1097/JPA.0000000000000193 Guy, L., Cranwell, K., Hitch, D., & McKinstry, C. (2020). Reflective practice facilitation within occupational therapy supervision processes: A mixed method study. Australian Occupational Therapy Journal, 67(4), 320-329. https://doi.org/10.1111/1440-1630.12660 Hansen, A. M. W. (2013). Bridging theory and practice: Occupational justice and service learning. Work, 45(1), 4158. https://doi.org/10.3233/WOR-131597 Healey, M., & Jenkins, A. (2000). Kolb's experiential learning theory and its application in geography in higher education. Journal of Geography, 99(5), 185-195, DOI: 10.1080/00221340008978967 Jacobs, A. C. (2020). The benefits of experiential learning during a service-learning engagement in child psychiatric nursing education. African Journal of Health Professions Education, 12(2), 8185. https://doi.org/10.7196/AJHPE.2020.v12i2.1214 Kaf, W. A., & Strong, E. C. (2011). The promise of service learning in a pediatric audiology course on clinical training with the pediatric population. American journal of audiology, 20(2), S220S232. https://doi.org/10.1044/1059-0889(2011/10-0022) 39 Keane, E., & Provident, I. (2017). Combining online education with international service learning to increase cultural competence. Internet Journal of Allied Health Sciences and Practice, 15(3), 1-7. https://nsuworks.nova.edu/ijahsp Kohlbry, P. W. (2016). The impact of international service-learning on nursing students cultural competency. Journal of Nursing Scholarship, 48(3), 303311. https://doi.org/10.1111/jnu.12209 Kolb, A. Y., & Kolb, D. A. (2017). Experiential Learning Theory as a Guide for Experiential Educators in Higher Education. Experiential Learning & Teaching in Higher Education (ELTHE): A Journal for Engaged Educators, 1(1), 744. Krueger, R. A., & Casey, M. A. (2014) Focus groups: A practical guide for applied research. Fifth edition. SAGE Publications. Martinez-Mier, E. A., Soto-Rojas, A. E., Stelzner, S. M., Lorant, D. E., Riner, M. E., & Yoder, K. M. (2011). An international, multidisciplinary, service-learning program: an option in the dental school curriculum. Education for Health (Abingdon, England), 24(1), 259. Merritt, L. S., & Murphy, N. L. (2019). International service-learning for nurse practitioner students: Enhancing clinical practice skills and cultural competence. Journal of Nursing Education, 58(9), 548-551. doi:10.3928/01484834-20190819-107 Mollica, M., & Hyman, Z. (2016). Professional development utilizing an oncology summer nursing internship. Nurse Education in Practice, 16(1), 188192. https://doi.org/10.1016/j.nepr.2015.07.001 Moyers, P. (2002). Continuing competence & competency: What we need to know. OT Practice, 7(17), 18-22. 40 Mu, K., Peck, K., Jensen, L., Bracciano, A., Carrico, C., & Feldhacker, D. (2016). CHIP: Facilitating interprofessional and culturally competent patient care through experiential learning in China. Occupational Therapy International, 23(4), 328337. https://doi.org/10.1002/oti.1434 National Comprehensive Cancer Network, NCCN Guidelines for Survivorship (Version 2.2017). http://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf Norman, G. (2010). Likert scales, levels of measurement and the laws of statistics. Adv. in Health Sci. Educ, 15, 625-632. https://doi.org/10.1007/s10459-010-9222-y Peterson, J. J., Wardwell, C., Will, K., & Campana, K. L. (2014). Pursuing a purpose: The role of career exploration courses and service-learning internships in recognizing and developing knowledge, skills, and abilities. Teaching of Psychology, 41(4), 354-359. https://doi.org/10.1177/0098628314549712 Roberts, K., Dowell, A., & Nie, J. (2019). Attempting rigour and replicability in thematic analysis of qualitative research data; a case study of codebook development. BMC Medical Research Methodology, 19(1), 1-8. https://doi.org/10.1186/s12874-019-0707-y Schoonenboom, J. & Johnson, R.B., (2017). How to construct a mixed methods research design. Kln Z Soziol, 69(107-131). https://doi.org/10.1007/s11577-017-0454-1 Tang, K. C., Davis, A. (1995). Critical factors in the determination of focus group size, Family Practice, 12(4), 474475, https://doi.org/10.1093/fampra/12.4.474 41 Taylor, R. (2017). Kielhofners research in occupational therapy: Methods of inquiry for enhancing practice (2nd edition). F.A. Davis Company. Ten Tusscher, M. R., Groen, W. G., Geleijn, E., Berkelaar, D., Aaronson, N. K., & Stuiver, M. M. (2020). Education Needs of Dutch Physical Therapists for the Treatment of Patients With Advanced Cancer: A Mixed Methods Study. Physical Therapy, 100(3), 477486. https://doi.org/10.1093/ptj/pzz172 Zach. (2021, July 21). The Complete Guide: How To Report ANOVA Results. Statology. Retrieved May 7, 2022, from https://www.statology.org/how-to-report-anova-results/ ...
- Creator:
- Taryn Springgate, Megan Yingling, Sierra Kern, Ashton Williams, Shelby Cash, and Kate Kelley
- Date:
- 2022-12-16
- Type:
- Capstone Project
-
- Keyword matches:
- ... 1 Canine-Assisted Interpersonal Development in an Independent Living Setting for Adults with Developmental Disabilities Anna Slusser May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Beth Ann Walker, PhD, MS, OTR, FAOTA 2 Abstract Many individuals with ID/DD have challenging behaviors (CB) which may cause household conflict (Bowring et al., 2019; McGill et al., 2018). Scorzato et al. conducted a pilot study and found animal-assisted therapy (AAT) had a significant effect on basic social skills, communication, cooperation, and participation, specifically in group settings, for individuals with intellectual and/or developmental disabilities (Scorzato et al., 2017). A six-session CanineAssisted Team Building Program was designed and implemented to increase Core Members team skills to reduce household conflict by focusing on problem-solving, decision-making, communication, participation, and collaboration. Program outcomes were determined through Core Member reports on the pre/post-test assessment, the Team-Effectiveness Scale, and the Animal-Based Program Feedback Survey. Using narrative analysis, outcomes indicated an improvement in team-building skills and knowledge in all areas and participants reported positive feedback regarding therapy dog incorporation. These outcomes show that canineassisted group sessions focused on team-building can improve individuals' knowledge of conflict resolution skills. According to the CASS Housing staff and Core Members, the therapy dog intraining motivated individuals to attend and participate in classes as well as work together as a team. Keywords: canine-assisted, team-building, adults with intellectual/developmental disabilities 3 Canine-Assisted Interpersonal Development in an Independent Living Setting for Adults with Developmental Disabilities CASS Housing is a non-profit organization in Fort Wayne, Indiana, that assists adults with developmental disabilities (DD) and intellectual disabilities (ID) by providing different levels of community living, programs to attend to improve their cooking skills, money management, wellness, and knowledge on healthy relationships, and support they need throughout their transition and new living experience. The acronym, CASS, represents the mission and purpose of this organization: to create and maintain Customizable, Affordable, Sustainable, and Safe living arrangements for individuals with developmental and/or intellectual disabilities that promote independent living skills (CASS Housing, 2021, para. 3). CASS Housing offers Independent Living housing models for individuals who require minimal to no assistance and complete daily tasks independently. CASS has five Independent Living houses built so far, which house 13 individuals, also known as Core Members (CASS Housing, 2021). According to the Director of Residential Services, there is frequent conflict among the 13 Core Members (C. Stackhouse, personal communication, December 7, 2021). To reduce household conflict, I proposed and implemented a program focused on team building that will provide core members with conflict resolution skills to lessen conflict within their home and community. A unique quality of this program is that it is animal-assisted. Cooper, a therapy dog in-training, will attend and participate in all sessions of the program in hopes to encourage participation, open communication, and collaboration, all critical qualities of a successful team. This paper will determine gaps in the literature, provide a program layout, and determine if CASS core members and staff find this program helps reduce conflict between core members by providing them with conflict resolution skills. 4 Background Schalock, Luckasson, and Tass (2019) define an intellectual disability as significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills (p.224). Developmental disability is defined as a set of abilities and characteristics that vary from the norm in the limitations they impose on independent participation and acceptance in society (Odom, Horner, and Snell, 2009, p.4). Common intellectual and/or developmental disabilities experienced by CASS residents include ADHD, Autism, Cerebral Palsy, Down Syndrome, and Developmental Delay. Needs Assessment During the needs assessment, CASS staff identified concerns for resident behavioral issues which may contribute to conflict between residents. I proposed creating a Canine-Assisted Team Building Program to work on communication, problem-solving, decision-making, and collaboration to provide the Core Members with skills to reduce the occurrence of behavioral issues and conflict between Core Members. A Doctoral Capstone Experience (DCE) Weekly Planning Guide was developed and utilized throughout the 14-week capstone to ensure every task was completed in a timely manner (see Appendix A). Challenging Behaviors and Conflict Challenging behaviors (CB) are a recurring problem in supported community living settings for individuals with ID (McGill et al., 2018). According to Bowring et al. (2019), CB may lead to reduced quality of life and negative personal outcomes for adults with ID. Poor quality of life and personal outcomes can result in limited friendships and inclusion, interfere with the individuals development and ability to learn, and are also associated with higher rates of self-injury and injury to caretakers (Bowring et al., 2019; McGill et al., 2018). Individuals 5 with ID/DD who present with CB increase potential conflict within households as their behaviors affect those around them. Bowring et al. (2017) categorized CB of individuals with ID into three categories: aggressive destructive behaviors, self-injurious behaviors, and stereotyped behaviors. Aggressive destructive behaviors consist of biting others, being verbally abusive, and bullying and had a prevalence rate of 8.3%. Self-injurious behaviors include self-scratching, hair pulling, head hitting, and teeth grinding. These behaviors were prevalent in 7.5% of the individuals within this study. Lastly, stereotyped behaviors included repetitive finger and hand motions, rocking/repetitive rocking movements, pacing, jumping, bouncing, running, yelling and screaming, and waving or shaking arms. Stereotyped behavior is most common and has a 10.9% prevalence rate (Bowring et al., 2017). All of these behaviors can result in increased tension and stress in community living settings for the individual, their housemates, and the staff of the organization. Therefore, residents who experience challenging behaviors may benefit from instruction-based interventions such as communication training and discussions regarding selfmanagement skills (Montgomery et al., 2014). Team Building and Collaboration A good team consists of individuals with developed interpersonal skills such as problemsolving, decision-making, communication, as well as participation among each team member (Montgomery et al., 2014). A crucial role of a team is conflict management and resolution through the use of their interpersonal skills and trust in one another (Behfar, Peterson, Mannix, & Trochim, 2008). High trust leads to greater commitment, greater effort, and greater cooperation (Driskell, Goodwin, Salas, and OShea, 2006, p. 262). Therefore, if team members have mutual trust, they will be more likely to give and receive feedback, engage in activities 6 related to conflict resolution, and stimulate healthy, open communication (Driskell, Goodwin, Salas, and OShea, 2006). Addressing the above skills will support conflict resolution in their independent living models and within the CASS community. Individuals with ID/DD often have difficulty with communication skills which may hinder their ability to work well as a team. Communication skills are needed to develop and maintain relationships, have a meaningful job, live independently, and be more likely to face challenges and obstacles in academic settings (Pennington, Bross, Mazzotti, Spooner, and Harris, 2021). Providing support and communication strategies to individuals with ID/DD can promote positive outcomes regarding their communication skills, therefore, leading to a more successful team. Animal-Assisted Therapy and Intellectual Disabilities According to Giuliani and Jacquemettaz (2017), animal-assisted therapy (AAT) is defined as the positive interaction between an animal and a patient within a therapeutic framework (p. 13). Numerous studies found AAT beneficial to individuals with anxiety, a common comorbidity of ID (Cajares et al., 2016; Giuliani & Jacquemettaz et al., 2017; Holman, et al., 2020; Maber-Aleksandrowicz et al., 2016; Phung et al., 2017). However, research limitations exist on the effectiveness of AAT and intellectual disabilities. Giuliani and Jacquemettaz (2017) conducted an observational study where participants with ID completed the State-Trait Anxiety Inventory (STAI) before and after a therapeutic session, either with the therapist and dog or only the therapist. The researchers found that participants had significantly lower scores on the STAI after sessions with the dog than without the dog, demonstrating decreased anxiety levels. 7 Scorzato et al. (2017), conducted the first study addressing the effects of AAT on behavior, basic social skills, and communication in adults with ID, which are all major components of a functional team. Researchers found significant results in incorporating AAT with specific interventions such as fine motor, visuomotor coordination, and basic social skills. Researchers also found that the sole presence of a dog demonstrated positive improvements in individuals basic cognitive abilities, including attention, memory, and communication. Basic cognitive abilities assist with understanding our environment as well as how we respond to our surroundings. Therefore, improved attention, memory, and communication are crucial for performing activities of daily living (ADLs), overall motor development, and social interaction (Scorzato et al., 2017). The impact AAT has on basic cognitive functioning for individuals with ID has the potential to encourage the development of communication skills and positive social interactions and behaviors (Scorzato et al., 2017). Scorzato et al. also found significant results with AAT regarding participation and collaboration in group activities (2017). Based on this study and the above evidence, the Core Members may benefit from canine-based experiences to promote communication skills, social behaviors, and team-building techniques in hopes to reduce household conflict. My program differs from other studies as it focuses on individuals with ID/DD in independent living and will measure the effectiveness of canine-assisted activities regarding team skills. According to Scorzato et al. (2017), there is a lack of research regarding AAT and individuals with ID/DD. I am hoping to provide findings that support canine-assisted activities with this population to begin bridging this literature gap. Theoretical Foundations of Project 8 The Canadian Model of Occupational Performance (CMOP) focuses on the harmonious relationship between the person, environment, and occupation. According to the CMOP, disability is a disruption in one or more areas of occupation that causes difficulty in having those relationships (Cole & Tufano, 2008). Household conflicts between residents are a primary concern of this organization, therefore, demonstrating the residents are in a state of disability. To promote a healthy relationship between the person, environment, and occupation, Core Members should have opportunities to learn and develop team-building skills, conflict resolution skills, and techniques to manage intense behaviors to maintain positive occupational performance. The Canine-Assisted Team Building Program may provide these opportunites as a dogs presence provides a safe environment for many individuals and the dog may act as a motivator to attend and participate in class (Scorzato et al., 2017). Additionally, the Lifespan Development Frame of Reference (FOR) focuses on assisting individuals with transitional tasks and providing developmentally appropriate interventions (Cole & Tufano, 2008). The Core Members recently moved into an independent living home with minimal to no support, therefore, transitioning into adulthood and learning to live independently. Issues encountered during transitions may arise as the individuals are going through new experiences with new individuals. The aim of the Canine-Assisted Team Building Program would be to provide developmentally appropriate interventions for individuals with ID/DD that target problem-solving and decision-making strategies to assist them through this new part of their life. As previously discussed, individuals with ID/DD often experience challenging behaviors (McGill et al., 2018). To provide effective interventions, I am also using the CognitiveBehavioral FOR to encourage successful outcomes as this approach is crucial for developing 9 social skills (Cole & Tufano, 2008). Throughout the program, I will ensure I am providing each individual with an environment in which they can succeed and encourage the individuals to use cognitive processes to reason and create accurate self-perceptions. Tasks will be upgraded and downgraded as needed to motivate the Core Members and to provide them with a safe space to practice their social skills. The Canine-Assisted Team Building Program offers a unique opportunity to practice social skills with one another and with a therapy dog in training. Program Design and Implementation Program Design A program for individuals with intellectual disabilities should be holistic, align with goals related to their lifespan and interest, and have long-term effects (Kishore et al., 2019). Based on the needs assessment and collaboration with the site mentor, the focus for this program centered on reducing conflict by focusing on team-building skills. The goal of the Canine-Assisted Team Building Program was that the Core Members will review and learn two new conflict resolution techniques to lessen conflict within CASS homes and community through improved interpersonal and team-building skills as measured by the pre/post assessment. To gather data on such a specific topic with a particular population, two outcome measures were developed to inform my assessment. The open-ended Team Effectiveness Scale (TES) was used as a pre/post-test to measure how participants viewed themselves as a team member and how they viewed their team as a whole before the program compared to after the program (see Appendix B). The Team Performance Scale guided the development of the Team Effectiveness Scale (Thompson et al., 2009). The TES measures problem-solving, decisionmaking, communication, and interpersonal skills, as well as participation through situationalbased questions and straightforward general questions geared toward the topics of the program. 10 To measure the use of the therapy dog and gather the Core Members' views on the therapy dog, I developed the Animal-Based Program Feedback Survey (see Appendix C). I used the AnimalAssisted Therapy Patient Feedback Survey as a reference when developing this outcome measure (Markovich, 2011). The Animal-Based Program Feedback Survey consists of eight open-ended questions related to the program and was administered during the last session to gather the Core Members' thoughts on the therapy dogs involvement in the program. Both outcome measures were completed in a group setting where the instructor would read each question and have the individuals go in a circle to provide feedback. Program Implementation The Canine-Assisted Team Building Program consisted of six, 60-minute sessions. The overarching theme of the program was team-building and interpersonal skills. Session topics included a general team-building introduction, problem-solving, decision-making, communication, participation, and collaboration. Each session consisted of an activity related to the corresponding topic and reflection following the activity focusing on processing and generalizing the information then applying what they discussed. Sessions had two learning objectives each, one focusing on during the session and the other focusing on takeaways from the session (see Appendix D). The therapy dog in-training was directly involved in every session by assisting with the demonstration of the activity or being incorporated in the activity. Two weeks before the start of the program, flyers and schedules were passed out to core members and were provided to each house. The flyer had a very large picture of the therapy dog on it. On average, seven core members attended each session, eight completed the pre/post-TES, and nine completed the Animal-Based Program Feedback Survey. Program Outcomes 11 The open-ended pre/post-TES measured what the Core Members learned throughout the program regarding their team-building skills. The Animal-Based Program Feedback Survey gave the instructor insight into how the Core Members viewed the therapy dogs involvement in the program as well as what couldve been done differently if replicated. Both tools were developed using pre-existing, similar tools allowing for increased understanding by the Core Members. Due to familiarity with group discussions, the tools were open-ended and completed in a group setting. The TES determined the Core Members growth in knowledge regarding problemsolving, decision-making, communication, participation, and collaboration. The Core Members identified three problem-solving strategies for the pre-TES, and six strategies for the post-TES as a group. For the situational question about decision-making, the participants identified four techniques in the pre-TES and seven in the post-TES. When asked to define good communication skills, the participants pinpointed five factors in the pre-TES and seven in the post-TES. When administering the pre-TES, many of the participants struggled to define a team and the importance of working together. However, during the post-TES, every participant was able to define a team, the skills necessary for a successful team, and the importance of everyones participation and contribution to the team. Individuals reported that their participation changed positively throughout the program as many expressed how critical it is to collaborate and work together. Based on this analysis, the participants, as a whole, demonstrated increased knowledge with team-building skills and activities. According to the Animal-Based Program Feedback Survey, all participants enjoyed having the therapy dog in class as well as being involved in the activities. The Core Members reported that they were more motivated to come to class knowing Cooper would be in 12 attendance. In the opinion of one of the Core Members, Cooper helps us work as a team. None of the participants were able to identify a challenge when working with Cooper and only reported positive feedback. However, one challenge observed by the leader was that Cooper can be a distraction to the Core Members and they can become fixated on him throughout the session. Though, based on the feedback from this survey, Cooper was an asset to the program and provided the Core Members with unique memories and experiences that will help them remember the skills learned in future situations. Cooper attended the majority of the classes and programs offered during the 14-week rotation, not only the Canine-Assisted Team Building Program. Core Members and the Program Director provided positive feedback regarding attendance and participation in other programs when Cooper was present. For instance, some of the feedback included, I am sad when Cooper isnt in class, I go to class to see Cooper, Cooper increases participation and moods during classes, and Cooper motivates me to come to class and learn. Any time Cooper entered the classroom, the room would be filled with joy, laughter, and excitement. When Cooper was in class he would act as an icebreaker and increase conversations between participants who are typically very shy and anxious when engaging in social situations. Another participant reached out to me multiple times reporting that Cooper calms her down and reduces her panic attacks. Cooper was able to make an impact on so many of the individuals in different ways than I had initially anticipated. To encourage the continued development of team-building skills and conflict resolution skills, I developed a CASS Housing Team Building Activity and Resource Binder (see Appendix E). The binder consists of activities completed within the program and 25+ new activities that focus on aspects of team-building discussed throughout the program. Each activity has 13 instructions, supplies needed, and occupations/skills addressed. This binder aims to promote program sustainability as the Core Members can complete these activities together without the help of CASS staff. Summary CASS Housing offers living models for individuals with ID/DD. Prior to housing individuals, staff may have neglected to think about recurring problems and conflicts that arise within the houses and between Core Members. According to McGill et al., CB are a recurring problem in supported community living settings for individuals with ID (2018). Individuals with ID/DD who present with CB increase potential conflict within households as their behaviors affect those around them. Therefore, the needs assessment guided the students capstone project as there was a need for conflict resolution techniques among the Core Members. Though many populations have found AAT beneficial, there is little research on AAT with adults with ID/DD. A pilot study concluded that AAT had a significant effect on basic social skills, communication, cooperation, and participation, specifically in group settings, for individuals with intellectual and/or developmental disabilities (Scorzato et al., 2017). All of the previously listed skills and qualities are components of a successful team (Montgomery et al., 2014). A crucial role of a team is conflict management and resolution through the use of their interpersonal skills and trust in one another (Behfar, Peterson, Mannix, & Trochim, 2008). From the literature review and background research, the topics of the program were developed: problem-solving, decision-making, communication, collaboration, and participation. The program consisted of six, 60-minute sessions. Each session consisted of an activity related to the corresponding topic and reflection following the activity to discuss what went well, what went poorly, alternative methods to the activity, etc. The therapy dog in training was 14 directly involved in every session by assisting with the demonstration of the activity or being incorporated in the activity. Results were determined through Core Member reports on the preTES, post-TES, and Animal-Based Program Feedback Survey. Using narrative analysis, outcomes indicated an improvement in team-building skills and knowledge in all areas (problemsolving and decision-making strategies, communication skills, ways to participate, and the importance of collaborating), and participants reported positive feedback regarding therapy dog incorporation. These findings show that canine-assisted group sessions focused on team-building can improve individuals' knowledge of conflict resolution skills. However, improvements in conflict resolution performance and translation into real-life situations take an extended period of time to achieve. Conclusions This DCE project provided me with ample opportunities to further my personal growth and knowledge as an occupational therapy practitioner. I interacted with the CASS staff, Core Members, and other local organizations on a frequent basis through written, oral, and nonverbal communication. Despite being at a site without an occupational therapist, I still expanded my proficiency in ways that benefit my future practice. For instance, I gained knowledge related to the following topics: adults with ID/DD, animal-assisted therapy, CASS Housing organization, grant writing, leadership, and advocacy. Furthermore, this site and experience allowed me to develop and implement a program that improved my creativity and ability to grade tasks on the spot. Prior to this experience, I had little background in program development and implementation. I was unaware of how in-depth this process was. I advanced my research, creativity, and leadership skills throughout this process. I discovered the importance of flexibility 15 throughout my program sessions as not everything goes as planned. I learned to advocate for the occupational therapy profession and animal-assisted therapy as many individuals have heard of the term occupational therapy, but few knew what it meant. I also became aware that most people thought a therapy dog was the same thing as an emotional support animal. Therefore, I found myself defining a therapy dog and describing its role in therapy often. CASS Housing benefitted from the Canine-Assisted Team Building Program as Core Members are now able to identify conflict resolution strategies and the importance of working together. For program sustainability, an activity binder was given to each CASS Housing home as well as shared electronically with the Directors of CASS. The binder consists of activities that were completed within the program and 25+ new activities that focus on aspects of teambuilding. Each activity has instructions, supplies needed, and occupations/skills addressed. The CASS Housing staff and Core Members were extremely thankful for this resource. The staff is looking forward to the Core Members taking initiative and participating in the activities on their own time and for them to use the binder to further their knowledge and skills regarding teamwork and conflict resolution. The DCE project and activity binder encourage continued development of teamwork and conflict resolution skills among the Core Members. After an extended period of time, I hope the CASS Housing staff observe a positive change regarding household conflict and cooperation. This project also demonstrates the benefits of AAT. The Animal-Based Program Feedback Survey, observations, interviews, and general feedback received from the Core Members, daily service providers, and the directors demonstrated the positive impact the therapy dog had on the participants. The findings of this project assist in bridging the gap between AAT and individuals with ID/DD. 16 References Behfar, K., Peterson, R., Mannix, E., & Trochim, W. (2008). The critical role of conflict resolution in teams: A close look at the links between conflict type, conflict management strategies, and team outcomes. The Journal of Applied Psychology, 93, 170188. https://doi.org/10.1037/0021-9010.93.1.170 Bowring, D. L., Painter, J., & Hastings, R. P. (2019). Prevalence of challenging behaviour in adults with intellectual disabilities, correlates, and association with mental health. Current Developmental Disorders Reports, 6(4), 173181. https://doi.org/10.1007/s40474-019-00175-9 Bowring, D. L., Totsika, V., Hastings, R. P., Toogood, S., & Griffith, G. M. (2017). Challenging behaviours in adults with an intellectual disability: A total population study and exploration of risk indices. British Journal of Clinical Psychology, 56(1), 1632. https://doi.org/10.1111/bjc.12118 Cajares, C., Rutledge, C., & Haney, T. (2016). Animal assisted therapy in a special needs dental practice: An interprofessional model for anxiety reduction. Journal of Intellectual Disability - Diagnosis and Treatment, 4(1), 2528. https://doi.org/10.6000/22922598.2016.04.01.3 CASS Housing. (2021). https://www.casshousing.org/. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Driskell, J. E., Goodwin, G. F., Salas, E., & OShea, P. G. (2006). What makes a good team player? Personality and team effectiveness. Group Dynamics: Theory, Research, and Practice, 10(4), 249271. https://doi.org/10.1037/1089-2699.10.4.249 17 Giuliani, F., & Jacquemettaz, M. (2017). Animal-assisted therapy used for anxiety disorders in patients with learning disabilities: An observational study. European Journal of Integrative Medicine, 14, 1319. https://doi.org/10.1016/j.eujim.2017.08.004 Holman, L. F., Wilkerson, S., Ellmo, F., & Skirius, M. (2020). Impact of animal assisted therapy on anxiety levels among mentally ill female inmates. Journal of Creativity in Mental Health, 15(4), 428-442. Kishore, M. T., Udipi, G. A., & Seshadri, S. P. (2019). Clinical practice guidelines for assessment and management of intellectual disability. Indian journal of psychiatry, 61(Suppl 2), 194210. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_507_18 Maber-Aleksandrowicz, S., Avent, C., & Hassiotis, A. (2016). A systematic review of animalassisted therapy on psychosocial outcomes in people with intellectual disability. Research in Developmental Disabilities, 4950, 322338. https://doi.org/10.1016/j.ridd.2015.12.005 Markovich, K.M. (2011) An evaluation of an animal-assisted therapy program in an adult inpatient hospital rehabilitation unit. (Publication No. 3484535) [Doctoral dissertation, Adler University]. ProQuest Dissertations Publishing. McGill, P., Vanono, L., Clover, W., Smyth, E., Cooper, V., Hopkins, L., Barratt, N., Joyce, C., Henderson, K., Sekasi, S., Davis, S., & Deveau, R. (2018). Reducing challenging behaviour of adults with intellectual disabilities in supported accommodation: A cluster randomized controlled trial of setting-wide positive behaviour support. Research in Developmental Disabilities, 81, 143154. https://doi.org/10.1016/j.ridd.2018.04.020 Montgomery, J., Martin, T., Shooshtari, S., Stoesz, B. M., Heinrichs, D. J., North, S., Dodson, L., Senkow, Q., & Douglas, J. (2014). Interventions for challenging behaviours of 18 students with autism spectrum disorders and developmental disabilities: A synthesis paper. Exceptionality Education International, 23(1). https://doi.org/10.5206/eei.v23i1.7701 Odom, S. L., Horner, R. H., & Snell, M. E. (Eds.). (2009). Handbook of developmental disabilities. Guilford Press. Pennington, R. C., Bross, L. A., Mazzotti, V. L., Spooner, F., & Harris, R. (2021). A review of developing communication skills for students with intellectual and developmental disabilities on college campuses. Behavior Modification, 45(2), 272296. https://doi.org/10.1177/0145445520976650 Phung, A., Joyce, C., Ambutas, S., Browning, M., Fogg, L., Christopher, B. A., & Flood, S. (2017). Animal-assisted therapy for inpatient adults. Nursing2020, 47(1), 63-66. Schalock, R. L., Luckasson, R., & Tass, M. J. (2019). The contemporary view of intellectual and developmental disabilities: Implications for psychologists. Psicothema, 31.3, 223 228. https://doi.org/10.7334/psicothema2019.119 Scorzato, I., Zaninotto, L., Romano, M., Menardi, C., Cavedon, L., Pegoraro, A., Socche, L., Zanetti, P., & Coppiello, D. (2017). Effects of dog-assisted therapy on communication and basic social skills of adults with intellectual disabilities: A pilot study. Intellectual and Developmental Disabilities, 55(3), 125139. https://doi.org/10.1352/1934-955655.3.125 Thompson, B. M., Levine, R. E., Kennedy, F., Naik, A. D., Foldes, C. A., Coverdale, J. H., Kelly, P. A., Parmelee, D., Richards, B. F., & Haidet, P. (2009). Evaluating the quality of learning-team processes in medical education: Development and validation of a new 19 measure. Academic Medicine, 84(Supplement), S124S127. https://doi.org/10.1097/ACM.0b013e3181b38b7a 20 Appendix A DCE Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Weekly Goal Orientation - - 2 Orientation - - Learn about the history of CASS Complete orientation of site/employee s/core members Review project with site mentor and begin brainstorming topics for sessions Continue building a relationship with core members Meet all 15 core members Finalize timeline for my program Objectives - - - Tasks Meet with site mentor, core members, and directors to introduce myself and educate on OT. Update MOU, if needed Shadow directors to see different roles Meet core members and begin to develop a rapport. - Confirm session topics with site mentor Shadow program director and attend vocational classes CASS offers to core members - - - - - Finalize and submit MOU Begin working on methodology of project Determine main theme of project Begin creating templates/outli nes for each session Begin looking for grants for CASS Confirm CASS submitted the background check Set up a recurring meeting with faculty mentor Find 2 grants for CASS to apply for Create PowerPoint about my 21 - Continue literature search - Help core members ramp down the gardens - 3 Screening/Evaluati on & Program Development - - Continue literature search Complete any necessary pretesting/screeni ng Continue working on session plan Have a rough draft of methodology Begin writing introduction - Present program to CASS directors Finalize outcome measures Finalize session 14 plan Determine core members interest - - - 4 Program Development - Continued program planning Finish lit review Score any pretests and review screenings - Finalize session 5 and 6 Schedule rooms for sessions Set up session times Make a physical calendar for core - - project to present in week 3 to directors Attend a quarterly meeting Observe a house tour Observe administration of independent living scale Confirm outcome measures with site mentor Edit literature review Edit/write methodology Continued attendance in established programs at CASS Continue grant work Rough draft of introduction Meet with faculty mentor Meet/communi cate with core members and staff to determine time of sessions Make calendar for core 22 - Continue working on methodology - members with sessions on it Determine and gather necessary supplies - - 5 Implementation - - Introduce therapy dog to core members/site/ staff Implement session 1 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback members and staff Schedule space in turnstone for location of program Gather supplies Continue grant work Attend classes and events with therapy dog - Plan Valentines Dance - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog Meet with faculty mentor - - Finalize Valentines Dance 23 6 Implementation - Implement session 2 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - - - - 7 Implementation - Implement session 3 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - - - Confirm meeting time/space for program Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog 24 8 Implementation - Implement session 4 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - Plan another social event for Core Members - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog Meet with faculty mentor - - 9 Implementation - Implement session 5 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - - - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and match 25 making events with therapy dog 10 Implementation - Implement session 6 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - Administer ILS to Core Members - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog - - 11 Discontinuation - Have core members complete post program test - Score and review all screens and tests Gather feedback from core members and staff about the program - Administer ILS to Core Members - Plan themed movie night for Core Members - Attend classes and events with therapy dog Meet with core members individually to complete post program test - 26 - 12 Discontinuation - - - 13 Dissemination - Create physical binder for each house Create an electronic binder and share with site mentor for future houses to have Meet with core members who have pets to show them animal assisted strategies they can use when stressed/anxio us - Present findings to staff via PPT - - - Discuss findings of program with core members and staff Ask core members their preference on binder layout Have staff review binder prior to giving to the homes Create PPT of results Discuss how program can be continued Begin discussing therapy dog leaving to prepare core members Meet with faculty mentor Gather feedback from staff and core members - Administer ILS to Core Members - Gather supplies for binder Find additional resources for binder that werent used in the program Provide additional activities for the core members to further their skills - - - Administer ILS to Core Members - Meet with directors, staff to discuss my findings Pass out binder to Core Members - 27 14 Dissemination - Create poster and VT for UIndy dissemination - Create first draft of poster for UIndy Record VT - Reduce therapy dogs time at CASS - Have site mentor and faculty mentor review poster Write conclusion/sum mary/ and abstract - 28 Appendix B Open-ended TES PRE 1. What is a team? a. What are some qualities and skills of a good team? 2. What are some strategies you know to solve problems? Example: 3. Say you are going to a friends house and someone suggests playing games. What are some ways the group can decide which game to play? 4. What are good communication skills? 5. Say you are in class and your teacher wants everyone to participate in an activity. What are some ways you can participate? 29 POST 1. How did your participation change throughout the program? 2. What strategies did you learn for problem-solving? 3. What is something you learned during the team-building program? 4. Say you are going to a friends house and someone suggests playing games. What are some ways the group can decide which game to play? 5. What are good communication skills? 6. Say you are in class and your teacher wants everyone to participate in an activity. What are some ways you can participate? 30 Appendix C Animal-Based Program Feedback Survey Name: ___________________________________________ Date: ___________________ 1. Did you enjoy the Animal-Based Program? Why or why not? 2. What did you enjoy most? 3. What did you least enjoy? 4. How will Cooper help you remember conflict resolution skills in the future? 5. How did Cooper help you become a better team member? 6. How did Cooper make the CASS team stronger? 7. What was challenging about involving Cooper in group activities? 8. Is there anything else you would like me to know about using Cooper in group activities? 31 Appendix D Learning Objectives of Program Sessions Session 1: Participants will collaborate with one another to complete a timed, team-building activity under 2 minutes. After completing session 1, the participants will be able to identify three skills or qualities necessary for a good team. Session 2: Participants will discover the importance of communication and name two components of good communication. After completing session 2, participants will specify three factors of good communication. Session 3: Participants will list three reasons why collaborating and participating is important when working as a team. After successful completion of session 3, participants will identify three problem-solving strategies. Session 4: Participants will make a decision as a team eight times throughout the session. After session 4, participants will identify three decision-making strategies they can use in a group setting. Session 5: 32 Participants will demonstrate team-building knowledge by planning an event with minimal assistance and cueing from program leader. After session 5, participants will list at least five tasks that goes into planning an event. Session 6: Participants will recall three problem-solving and decision-making strategies they can use when resolving conflict. After session 6, participants will evaluate the event and determine any mistakes or forgotten tasks of planning an event. 33 Appendix E CASS Housing Team Building Activity and Resource Binder CASS Housing Team-Building Activity Binder 2022 Developed by Anna Slusser, University of Indianapolis Occupational Therapy Student 34 Impromptu Skits Areas of Occupation Addressed: - Social skills Social interaction Communication Participation Teamwork Supplies Needed - Paper, pen Scenarios to act out Directions: 1. Come up with multiple scenarios that you want to act out. 2. You can pick to act the skits out in small groups or one large group. 3. Have each group pick a scenario. 4. Take 10-15 minutes to figure out every persons role and practice the skit. 5. When everyone is ready, take turns presenting the skits. Have fun with it! Space Needed Indoor 35 Telephone Areas of Occupation Addressed: - Social skills Social interaction Communication Recall memory Participation Active Listening Supplies Needed - Nothing - just a group of people! Directions: 1. Have everyone sit in a circle or a line. 2. Pick what side of the line will start. 3. The first person thinks of a sentence, word, saying, anything! Once you know what you will say, whisper it into the next persons ear. 4. Once the word has been told to the next person, they will whisper it to the person next to them. 5. When it gets to the end of the line, the last person will say what they heard and see if you got it right. 6. Take turns going first so everyone has a chance to think of a new phrase. Space Needed Indoor or outdoor 36 Get to Know You Bingo Areas of Occupation Addressed: - Social skills Social interaction Communication Recall memory Participation Supplies Needed - People Bingo sheet Marker, pen, or pencil Directions: 7. Print off enough People Bingo sheets for everyone playing. 8. Give everyone a sheet. 9. Ask anyone you see the prompts in the boxes. If you find someone who has done whatever is in the box, have them sign that box. 10. The first person to get 5 boxes in a row (up and down, side to side, or diagonally) calls out BINGO! 11. Once someone calls bingo tell everyone what boxes you got signed. Space Needed Indoor 37 38 Social Jenga Areas of Occupation Addressed: - Social skills Social interaction Quick thinking Decision-making skills Hand-eye coordination Fine motor skills Turn-taking Communication Supplies Needed - Jenga Table to play on Directions: 1. Set-up Jenga 2. Decide who is starting and pick one Jenga block out of the tower. 3. After getting the block out, place it on top of the tower. 4. Then ask either the group a question or tell a fun fact about yourself. 5. Continue this with each player until the tower falls. 6. Repeat until everyone is done playing. Space Needed Indoor or outdoor, weather permitting 39 Talent Show Areas of Occupation Addressed: - Social skills Social interaction Public speaking or performance Event Planning Collaboration/Participation Communication Decision-Making Problem-Solving Supplies Needed - Speaker Chairs Paper Coloring and decorating supplies Items for each individual performance Directions: 1. Everyone thinks of what they want to perform. If you want to have a host, choose one. Otherwise, you can decide the order of acts. 2. Make and decorate signs for each act. 3. Set up chairs for the audience and other performers. Turn on the speaker and have the songs ready to play for the performers. 4. Take turns performing, cheer each other on and have fun! Space Needed Indoor or outdoor, weather permitting 40 Fishbowl Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Teamwork Problem-Solving Supplies Needed - Paper slips Pen/pencil Bowl/basket Timer Notepad Directions: 1. Divide into 2 even teams 2. Each person writes down 5 things that they like on individual paper slips 3. Fold up each slip and place them in the basket 4. (Round 1) Each team will take turns alternating who will select a slip from the basket and explain selected words without using any word written on the slip of paper to get their team to guess as many words as possible in 30 seconds. 5. Once the words in the basket are exhausted, count up the number of words each team guessed (each word guessed is 1 point) then record the score on a notepad. 6. (Round 2) Each team will take turns alternating who will select a slip from the basket and use one word to convey a clue regarding their selected word without using any word written on the slip of paper to get their team to guess as many words as possible in 30 seconds. 7. Repeat step 5. 8. (Round 3) Each team will take turns alternating who will select a slip from the basket and act out their selected word without speaking to get their team to guess as many words as possible in 30 seconds. 9. Repeat step 5. 10. Add up the points from all three 41 rounds for each teams final score. Whichever team received the highest score is the winner. Space Needed Inside or outside 42 Kemps Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Teamwork Decision-making Problem-Solving Supplies Needed - Deck of cards Table Chairs Directions: 1. Divide into even teams of 2 players each 2. Have each pair meet to determine a secret, subtle signal. This signal needs to be non-verbal and nothing too obvious. 3. Once all pairs have decided on a good signal, have everyone sit in a circle facing each other. Partners should be seated across each other. 4. Say, Ready, set, go! and begin the round. Each player can discard a card from their hand and then grab any card from the center of the table. It is an ongoing process without structured turns; players simply exchange single cards from their hands with cards that show up on the table. Again, a player cannot have more than four cards in their hand at the same time. 5. The goal is for you (or your partner) to get four of the same rank (e.g., four 8s, or four Queens, etc.). If no players want any of the four cards that are in the center, the dealer can remove the four cards and deal out four new cards and the process continues. Once you successfully have four-of-a-kind, use your secret signal to try to get your teammate to yell Kemps! If Kemps! is called on a person, that person must reveal their hand to show whether or not they have four-of-a-kind. 6. If your partner yells Kemps! and you 43 have four-of-a-kind (or vice versa), then your team gets a point and wins the round. If your teammate yells Kemps! but you dont have four of a kind (or vice versa), then your team loses a point. You can also yell Kemps! and point to an opponent if you think they have four-of-akind. If successful, you also win a point, but if you are wrong, you lose a point. 7. The team that earns four points (or whatever point value you wish) first, wins. Space Needed Inside or outside 44 Short Outdoor Walk Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Health management Supplies Needed - Good walking shoes Directions: 1. Go as a pair or as a group 2. Tell other team members in charge where you are going before you go. 3. Stay on the sidewalk and watch for oncoming traffic when crossing the street Space Needed Outside 45 Outdoor Scavenger Hunt Areas of Occupation Addressed: - Communication management Team-Building Collaboration Play participation Leisure participation Social participation Health participation Supplies Needed - Scavenger hunt list (can find several others on Pinterest or Google) Pen/pencil Directions: Space Needed 1. Work together as a group to find all of the items on the list 2. Mark off each item as you find them 3. Stay together as a group Outside 46 47 Music/Karaoke Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Collaboration Supplies Needed - Phone with music or musical instrument Speaker (optional) Your voice! :) Directions: Space Needed 1. Pick different songs and sing either individually, with a partner, or as a group 2. (Optional) Have someone play a musical instrument for each song or play a song on someones phone/speaker/etc. 3. Sing! Inside or outside 48 Hot Potato/Musical Ball Areas of Occupation Addressed: - Physical activity Play participation Teamwork Problem-Solving Decision-Making Supplies Needed - Small or large ball Music/Speaker Directions: 1. Have players sit in a circle 2. One person starts holding the ball 3. Turn on the music and have one person in charge of stopping/starting music 4. Pass the ball around the circle as quickly as possible 5. Have one person stop/start music randomly 6. If the ball stops on you when the music stops, you are out! 7. Play until only one person is left in the center of the circle Space Needed Outside 49 Movement Chain Areas of Occupation Addressed: - Physical activity Play participation Cognition Social participation Teamwork Decision-Making Supplies Needed - None Directions: 1. Everyone stands in a circle where you can view each player 2. Nominate someone to start the chain 3. This nominated person does a movement/pose (ex. Thumbs up, kick, jumping jack, yoga pose) 4. Go around the circle, the next player does the first players movement and then a movement of their own in sequence 5. Continue around the circle repeating prior movements in order and adding your own/new movement to the end of sequence 6. Continue until everyone adds a movement to the sequence Space Needed Inside or outside 50 Group Storytelling Areas of Occupation Addressed: - Social participation Creativity Cognition Communication Participation/Collaboration Supplies Needed - None Directions: 1. One individual or group decides the topic of a story they will tell 2. The first person tells one sentence to start the story 3. Each person then adds a sentence to the story one at a time, taking turns 4. Continue to add sentences to the story until each player has added one sentence or the story is ready to end Space Needed Inside 51 Medusa Areas of Occupation Addressed: - Play participation Teamwork Collaboration Supplies Needed - None Directions: 1. Players stand in a circle with arms around each other OR can stand at a distance from each other 2. All players bow heads/look at the ground 3. At the count of 3 everyone looks up at another player 4. If 2 people are looking at each other, they are frozen and out of the game 5. The game continues until there are only 2 players left Space Needed Inside or outside 52 Junk in the Trunk Areas of Occupation Addressed: - Physical activity Play participation Problem-Solving Supplies Needed - Tissue box String/rope/belt Glue or tape 8 ping pong balls Directions: 1. Attach tissue box to string/rope/belt to make it look like a waist pouch or bum bag 2. Remove plastic from the tissue box so there is a clear opening, and expand the opening of the tissue box into a rectangle shape 3. Put ping pong balls in a tissue box 4. Have player tie box around waist 5. Players get one minute to shake body to try to get ping pong balls out of the box, cannot use their hands! 6. The person who gets the most balls out in a minute is the winner Space Needed Outside 53 Sleeping Beauty Game Areas of Occupation Addressed: - Play participation Creativity Social participation Communication Problem-Solving Decision-Making Supplies Needed - None Directions: 1. One person is sleeping beauty and has to bow their head/lay their head down on table 2. Each player who is not sleeping beauty tries to take a turn waking up sleeping beauty- making them open their eyes, laugh, make a sound, etc. 3. The player who wakes up sleeping beauty gets the turn at being sleeping beauty Space Needed Inside or outside 54 Blindfold Drawing Areas of Occupation Addressed: - Play participation Social participation Creativity Teamwork Problem-Solving Decision-Making Supplies Needed - Paper Drawing utensils Pictures to copy Directions: 1. Divide group into teams of 2 players 2. One player holds a picture. The other player has a piece of paper and a drawing utensil. 3. The player with the picture must not show their other teammate the picture 4. The person with the picture describes to the other person what to draw, but they can not explicitly state what the picture is; they must use adjectives and directions 5. Set a time limit for the teammate to stop drawing, at end of the time limit both players view the picture and draw Space Needed Inside 55 Whats my Name? Areas of Occupation Addressed: - Social participation Play participation Communication Participation Teamwork Problem-Solving Decision-Making Supplies Needed - Name tags/labels Directions: 1. On name tags, write down famous people or stereotypes that all players would know (Moana, Olaf, doctor, athlete, Mickey Mouse, etc.) 2. Can make it Disney-themed so that all players are a Disney character, or more specific like Frozen-themed where all players are a Frozen character 3. Put name tags/labels on players backs so they cannot see who they are 4. Walk around, mingle, answer and ask questions to various players about who they are and who you are 5. Try to figure out your label 6. As each player figures out who they are and guesses correctly, they can exit the game or only answer questions 7. Play until all players figure out who they are Space Needed Inside or outside 56 Who is Most Like the Easter Bunny? Areas of Occupation Addressed: - Leisure participation Peer group participation Play participation Communication Decision-Making Supplies Needed - Pencils, pens, or markers Attached printout or similar optional paper or whiteboard for tallying Directions: 1. Hand out copies of the attached handout for all group members, with writing utensils 2. Instruct members to circle all activities or items on the sheet that match what they are wearing, what they did this week, etc. 3. Consider reading options out loud to make this activity more synchronous 4. Have members tally up all points for the activities they circled and write their score on the blank at the bottom of this sheet 5. The person with the most points wins! Space Needed Indoor or Outdoor, weather permitting 57 58 The M and M Game Areas of Occupation Addressed: - Leisure participation Social participation Peer group participation Teamwork Collaboration Supplies Needed - A bag or two of M and Ms (feel free to substitute with any multi-colored candy if any group members have food allergy concerns) Handout with color definitions below Directions: 1. Distribute a handful of M and Ms to each person 2. Pick one person to start the game by picking up M and M from their pile and answering the question corresponding to the color of M and M they chose 3. Refer to the attached handout for color questions. Again feel free to modify colors if using different candies. 4. Repeat around the group as each member chooses a color and answers the question This builds team member familiarity and increases social participation with peers Space Needed Indoor or Outdoor, weather permitting 59 60 SPUD Areas of Occupation Addressed: - Play participation Leisure participation Friendships Peer group participation Teamwork Communication Supplies Needed - One soft or squishy ball Directions: 1. Have the group stand in a circle and choose one person from the group to be it 2. The it person gets the ball and stands in the center of the circle 3. The it person throws the ball in the air and calls one persons name while everyone runs as fast as they can. 4. The new person whose name is called runs back to the center and grabs the ball, yelling STOP. 5. As soon as STOP is called, everyone freezes in place. 6. The new it person with the ball can take four big steps to reach the closest person (SPUD, four letters and four steps) 7. AFter these steps, the new it person tosses the ball and tries to hit the closest person and tag them out. 8. If the closest person dodges the ball or catches it, the new it person is out and the closest person is now it 9. If the closest person is hit with the ball, they are out and the new it person remains it 10. Everyone forms a new circle and the game starts again 11. Keep playing until there is one player left Space Needed Outdoor parking lot or grass space 61 Staring Contest Areas of Occupation Addressed: - Social participation Leisure participation Play participation Peer group participation Friendships Eye contact - communication Supplies Needed - None Directions: 1. Divide group members into pairs and have them sit or stand facing each other 2. On the count of three, have each pair maintain eye contact without blinking for as long as they can 3. For each pair, the person who blinks first is out 4. Pair winners from each pair with the winner from another pair and repeat the staring contest 5. Continue until there is one person left, the ultimate staring contest winner Space Needed Indoor or Outdoor, weather permitted 62 Up and Down the River Card Game Areas of Occupation Addressed: - Social participation Leisure participation Play participation Peer group participation Decision-Making Problem-Solving Supplies Needed - Deck of cards Directions: Preparing a score sheet: 1. Take a blank page and write all the names of players at the top of it. 2. On the left-hand side, make a column to write the number of rounds being played. 3. Start with the number 10 and continue writing the numbers in descending order. 4. Once you reach 1, start writing the numbers again in ascending order till 10. 5. In total, you will have 19 rounds. Playing the Game 1. Players take a seat in a circle. 2. A dealer is chosen among the 3. 4. 5. 6. players to shuffle the deck and pass around 10 cards to each player. The players can look at their cards. Rest of the deck is kept in the middle with the top card turned face up. This card is not used in the game. The suit of that card will be considered a trump suit for that round of the game. It means that while playing the tricks or hands, any card from that suit will beat other suits of cards. After the revelation of the trump card, each player bids the number of tricks he believes he can win. 63 The bid can vary from zero to 10 as players have 10 cards each. 7. After the bidding, a player sitting on the left of the dealer will begin a new trick of the round. He will draw a card from his stack and place it in the middle. 8. The turn will go clockwise as every player will draw 1 card each. 9. After cards from each player are drawn, the player who has the highest card in the drawn stack wins that trick or hand. 10. The winner gets a chance to draw a card for a new trick. 11. The game continues till all the cards are taken. 12. The cards from the trump suits are used to win the hands. However, if the hand contains more than one trump card, the trump card of the highest value wins that hand. 13. As the game is being played, each player needs to collect as many hands or win as many tricks as he had bid at the beginning of the round. 14. At the end of one round, the scores are tallied and written on the score sheet. 15. After all the 19 rounds end, the highest scorer wins the game. Rules and scoring for the game: Ace is the highest, while two is the lowest. Trump cards are used to win the hand while playing tricks. While playing a trick, if a player draws a trump card, it will win that player that trick even if the other 64 Space Needed cards of different suits are higher in value. Each won trick earns a point for the player. A player needs to win as many tricks as he bids. This earns him bonus points. For example, if a player bids 5 tricks when won, he earns 5 points plus 10 bonus points. If a player wins more tricks than he had actually bidden, he loses points. For example, if the player has bid for only 5 tricks, but wins 7, then he gets only 2 points. If a player bids 0 tricks and succeeds in winning no trick, he receives 5 points. Indoor or outdoor, weather permitting 65 Name that tune Areas of Occupation Addressed: - Social participation Leisure participation Teamwork Decision-Making Communication Supplies Needed - A phone to play music Directions: 1. Split your group into two teams. Teams will be playing head to head in this game the entire time. 2. Play your first song from your playlist. When you play a song, teams will try to be the first ones to shout out the name and artist of the song. The first team to guess the song and artist will earn points for their team. 3. Points can be split across the two teams for each song if one team guesses the song first and one song guesses the artist. You can also give additional points if the song is from a movie, Broadway musical, etc. but its completely up to you. Space Needed Indoor or Outdoor, weather permitted ...
- Creator:
- Anna Slusser
- Date:
- 2022-05
- Type:
- Capstone Project
-
- Keyword matches:
- ... 1 The Role of Occupational Therapy in the Care of Post-Thrombectomy Patients: A Narrative Review Sara Skarshaug, OTS May 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Katie Polo, DHS, OTR, CLT-LANA 2 Abstract Cerebrovascular accidents (CVA), also known as strokes, are the leading cause of neurological impairment in adults in the world. As a result, stroke treatments have evolved to reduce strokerelated disabilities in patients. The current standard of care includes mechanical thrombectomies for patients who qualify. Occupational therapy (OT) practitioners and other rehabilitation professionals are skilled at restoring function by adapting tasks and environments and remediating skills lost due to stroke. However, the role of OT practitioners in the care of postthrombectomy patients is not well documented in the literature. This narrative review discusses the frequency and timing of OT services, as well as potential interventions used by OT practitioners with post-thrombectomy patients. Suggestions for future research, limitations of current literature, and limitations of the present paper are discussed. Keywords: occupational therapy, thrombectomy, stroke rehabilitation 3 Background Cerebrovascular accidents (CVA), also known as strokes, are the leading cause of neurological impairment in adults in the world (Feigin et al., 2017). When a patient presents to the hospital with stroke-like symptoms, there are many different treatment options, depending on the type of stroke and the duration of the symptoms. In the care of patients who have had a stroke, early intervention is crucial. Currently, mechanical thrombectomies are the standard of care for patients who present to the hospital within 24 hours of symptom onset, and it involves a quick procedure in which a neurosurgeon removes a blood clot from a cerebral artery or vein (Oliveira-Filho & Samuels, 2022). Mechanical thrombectomies paired with medical management post-procedure are associated with lower incidences of disability after 3 months, compared to medical management alone, and earlier procedures are associated with better functional outcomes (Saver et al., 2016). These procedures are also associated with shorter hospital stays (Fuhrer et al., 2019), causing stroke rehabilitation hospitals worldwide to add these procedures to their services (Mathews & De Jesus, 2022). In 2018, the Joint Commission established a Thrombectomy-Capable Stroke Center certification program to designate hospitals that are capable of performing this service (Joint Commission, 2021). Hospitals who receive this designation perform mechanical thrombectomies 24 hours per day, 7 days per week, and have an acute stroke team present at bedside within 15 minutes (Joint Commission, 2021). In Michigan, where this narrative review took place, there are three Thrombectomy-Capable Stroke Centers (Michigan Department of Health and Human Services, 2021). Across the country, 44 hospitals are Thrombectomy-Capable Stroke Centers, and this number will likely grow as the procedure becomes more widely utilized (Baker et al., 2020). 4 Post-thrombectomy, a multidisciplinary rehabilitative care team is necessary, including occupational therapy (OT), physical therapy (PT), and speech therapy (ST) (Leslie-Mazwi et al., 2017). Due to the growing popularity of the thrombectomy procedure, it is important to understand the role that each member of the rehabilitation team has in recovery to minimize any complications. Potential complications post-thrombectomy include hemorrhages, reocclusion of the vessel, cerebral edema, and complications with the access site, typically the femoral artery (Krishnan et al., 2021). In this paper, I will discuss the role of OT in post-thrombectomy recovery. Needs Assessment With the growing prevalence of thrombectomies in stroke rehabilitation, the current practice guidelines for post-thrombectomy care do not include OT specifically (Jadhav et al., 2018; Leslie-Mazwi et al., 2017). Additionally, rehabilitation services are not always mentioned beyond early mobilization protocols, which are controversial in their effectiveness (Jadhav et al., 2018). For this reason, a review of the literature is warranted to determine the role of OT practitioners in the functional independence and mobility of these patients. This narrative review took place in a regional hospital in Michigan that performs thrombectomies but is not classified as a Thrombectomy-Capable Stroke Center. Much of the literature surrounding successful thrombectomies highlights a quick return to functional independence and increased use of upper extremities (Fuhrer et al., 2019; Pego Prez et al., 2021). However, the literature surrounding the impact of the rehabilitation team, particularly OT practitioners, is less prevalent. Chang et al. (2020) noted that successful thrombectomies are associated with increased scores on functional measures such as the Barthel Index. However, the authors did not discuss the role that rehabilitation professionals have in maximizing functional outcomes (Chang et al., 2020). 5 Given OT practitioners clear role in general stroke rehabilitation (AOTA, 2015), it is likely that the profession has a significant role post-thrombectomy as well. However, it is unclear whether there are certain precautions or considerations that OT practitioners need to be aware of with these patients and there is a paucity of literature reviews on this topic. The purpose of this narrative review is to investigate the available literature regarding the role of OT in stroke rehabilitation post-thrombectomy, and the interventions that OT practitioners commonly implement. The presence of this literature may reinforce the need for OT with this population and begin the discussion for formalized best practices to guide practitioners in their interventions. Theoretical Base The Occupational Therapy Intervention Process Model serves as a guide for this review as this model identifies the unique focus of OT in helping to restore function, which is the goal of this narrative review. According to Fisher (1998), OT practitioners utilize a top-down approach in four domains: exercise, contrived occupation, therapeutic occupation, and adaptive occupation (p. 509). The model also discusses the OT practitioners role throughout the evaluation, intervention, and discharge process, including specific factors relating to the patients personal context and the specifics of their diagnosis (Fisher, 1998). The model exemplifies the goal of this narrative review in delineating OT practitioners unique role in the rehabilitation process, this review will specifically investigate the role of OT practitioners in the care of postthrombectomy patients. The Motor Learning frame of reference serves as a guide for this review as the goal is to determine the role of OT in post-thrombectomy recovery and, more specifically, the different tasks and interventions that are involved in regaining function. The ultimate goal of this frame of 6 reference is for patients to achieve recovery, where their post-stroke functioning is the same as their pre-stroke functioning (Cole & Tufano, 2008). Patients can achieve recovery through continuous practice of skills until a transfer of learning occurs, whereby the patient is able to perform tasks in a variety of environments (Cole & Tufano, 2008). Methods Given the wide scope of this review, articles met the inclusion criteria if they included OT or rehabilitation in their analyses of adult post-thrombectomy patients, or if they used an outcome measure used by OT practitioners (i.e. Barthel Index, Functional Independence Measure, AMPAC), and they must be written in English if they are international articles. Articles were excluded if they did not mention rehabilitation therapies, if they did not include patients received thrombectomies, or if they were below a Level IV evidence rating according to the Johns Hopkins Evidence-Based Practice Model (Johns Hopkins University School of Nursing, 2017). The aim of this paper is to review the available literature on OTs role in the care of postthrombectomy patients, and the types of interventions used with these patients. Databases used for the article search included CINAHL, Medline, and Academic Search Complete databases, as well as Google Scholar. Filters included publications within the last 10 years, peer-reviewed articles, and articles in English. Keywords included occupational therapy and thrombectomy, and rehabilitation and thrombectomy. Thirty-one studies were included in the initial analyses with a full article review, and fourteen articles were included in the final analysis. Articles were then synthesized into an evidence chart and organized into themes for further discussion. See Table 1. for information on the articles retrieved. 7 Table 1 Articles Retrieved from Literature Search Database Used Keywords Filters Used Articles Remaining after Filters Full-articles Reviewed Articles Included in Appraisal UIndy Library Database Occupational therapy and thrombectomy Last 10 years, peer-reviewed, English 14 4 3 UIndy Library Database Early mobilization and thrombectomy Last 10 years, peer-reviewed, English 24 2 2 Google Scholar Occupational therapy and thrombectomy Last 10 years, peer-reviewed, English 2,360 25 9 Note. One researcher participated in retrieving and appraising all articles. Results Fourteen articles were included in the final analysis discussing the role of OT in postthrombectomy care. Five themes emerged from the analyzed articles: frequency and timing of OT services, OT as a part of the interdisciplinary care team, ADL independence after thrombectomy, upper extremity function after thrombectomy, and psychosocial symptoms after thrombectomy. See Appendix A. for a summary table of each article in terms of bias and quality of evidence. Frequency and Timing of Occupational Therapy Services Nine articles included in the final analysis discussed frequency and timing of OT services. This theme contained three articles of Level II evidence, five articles of Level III evidence, and one article of Level IV evidence, ranging from moderate to high quality (Johns 8 Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes, selection bias or missing information due to retrospective study designs, limited generalizability due to highly specialized study sites, and limited discussion of patients with poor outcomes. Frequency and timing of OT services are important clinical decisions in the rehabilitative care plan. Early mobilization is a program that encourages rehabilitation professionals to assist patients with out of bed activity early in the recovery process. OConnor and colleagues (2019) conducted a retrospective case-control study in which one group received early mobilization and one group received routine treatment. The early mobilization group was seen by OT and PT an average of 16 hours sooner and their length of stay was over 1.5 days shorter than those with routine treatment (OConnor et al., 2019). Burch and colleagues (2018) supported these findings by reporting that earlier evaluations from OT and physical therapy (PT) yielded higher functional scores on the Kansas University Hospital Physical Therapy Acute Care Functional Outcomes Tool in a population of 127 post-thrombectomy patients. Patients who did not receive OT and PT evaluations scored higher on the National Institute of Health Stroke Scale at discharge compared to those who did, indicating higher levels of functional independence in patients who were seen by rehabilitation professionals (Burch et al., 2018). Additionally, Thabet and colleagues (2015) recommended OT evaluations within 48 hours post-thrombectomy to determine discharge plans and any safety concerns that arise. These findings highlight the importance of early participation with therapy when working with post-thrombectomy patients. However, Stuchiner and colleagues (2019) found that mobilization within 24 hours with postthrombectomy patients did not have a significant impact on 90-day outcomes. Regarding frequency, there is evidence that intensive rehabilitation is effective in improving functional outcomes (Belgaje et al., 2014). Researchers conducted a study in which 9 participants in skilled nursing facilities (SNF) and inpatient rehabilitation facilities (IRF) with similar medical comorbidities were compared based on their functional outcomes. Researchers found that patients discharged to a SNF were less likely to achieve a good outcome compared to those discharged to IRFs, with 25% of patients in SNFs and 46% in IRFs achieving good outcomes (Belgaje et al., 2014). Chiu and colleagues (2021) reaffirmed the idea that early and intensive rehabilitation yields more favorable outcomes by comparing a group of patients that did not receive acute rehabilitation with a group that did. Those who received acute rehabilitation experienced shorter stays in the hospital and were able to transfer to intensive inpatient rehabilitation facilities more quickly (Chiu et al., 2021). Occupational Therapy as a Part of the Interdisciplinary Care Team Four articles included in the final analysis discussed OT as a part of the interdisciplinary care team. This theme contained four articles of Level II evidence ranging from moderate to high quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes, selection bias due to retrospective study designs, limited generalizability due to highly specialized study sites, and a limited discussion of patients with poor outcomes. OT is an established profession in stroke rehabilitation, including after endovascular treatments including thrombectomies (Leslie-Mazwi et al., 2017). Leslie-Mazwi and colleagues (2017) emphasized the importance of OT evaluations in their practice guidelines for neuroradiologists, neurologists, and neurointerventionalists working with post-thrombectomy patients. Specifically, researchers stated that all post-thrombectomy patients should be seen by an interdisciplinary rehabilitation team, including OT, PT, and speech therapy, while in the acute care setting (Leslie-Mazwi et al., 2017). In multidisciplinary practice guidelines created by the Society for NeuroInterventional Surgery, Pierot and colleagues (2018) restated the role of OT in 10 the care of the post-thrombectomy patient, specifically in rehabilitating the patient and assisting with community reintegration following discharge. The two practice guidelines shared the belief that an OT practitioner should, at minimum, evaluate the patient acutely to identify barriers for safety at discharge, and ideally provide intensive rehabilitation services post-thrombectomy (Leslie-Mazwi et al., 2017; Pierot et al., 2018). However, researchers stated that more research is needed on this topic since the widespread usage of mechanical thrombectomies is still relatively new (Pierot et al., 2018). Chiu and colleagues (2021) emphasized the importance of OT practitioners and the rest of the rehabilitative care team in ensuring favorable outcomes. Researchers found that a cohesive rehabilitation care team is essential to establishing a care plan for patients to support a safe discharge to the community (Chiu et al., 2021). Chu and colleagues (2020) supported the recommendation for a comprehensive rehabilitation team including OT. Specific recommendations for OT interventions included posture training, transfer training, ADL training, cognitive training, and constraint-induced movement therapy (Chu et al., 2020). Reuter and colleagues (2016) reported a 30% undersupply of OT practitioners in a large hospital network in Germany, which has implications for stroke rehabilitation. The result of this is that patients with either very favorable or very unfavorable outcomes are less likely to receive OT in an attempt to optimize resources when there is a shortage of practitioners (Reuter et al., 2016). Specifically, stroke patients with a modified Rankin score from two to five at discharge received the highest number of therapy sessions compared to patients who fully recovered or died in the hospital (Reuter et al., 2016). 11 ADL Independence After Thrombectomy Four articles included in the final analysis discussed ADL independence after thrombectomy. This theme contained one article of Level I evidence, one article of Level II evidence, and two articles of Level III evidence ranging from moderate to high quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes, selection bias due to retrospective study designs, limited generalizability due to highly specialized study sites, and participant attrition due to changes in neurological status. Maximizing intervention time by focusing on high-value interventions is crucial. According to Aoki and colleagues (2019), an early focus on training in activities of daily living (ADLs) and swallowing function during feeding is fundamental to ensuring safe discharges to the home setting. Since OT practitioners are skilled in providing intervention surrounding ADLs, they are a valuable component of the multidisciplinary rehabilitation team and supporting independence at discharge. Independence in ADLs is crucial for a safe discharge home, as patients need to take care of themselves or have the support at home to complete these tasks. Revert-Vallarroya and colleagues (2020) found that thrombectomy treatments compared to best medical treatment yielded increased functional independence, as evidenced by scores on the Barthel Index three months post-stroke. Researchers also identified significantly greater improvements in scores on the National Institute of Health Stroke Scale, modified Rankin Scale, and Stroke Impact Scale after three months in the thrombectomy group (Revert-Villarroya et al., 2020). A major limitation of this study was the lack of discussion on rehabilitation professionals role in these improvements. It is unclear whether OT practitioners were involved during the participants 12 hospital stay, but it is possible due to the use of the Barthel Index as an outcome measure, a commonly used OT assessment for ADL independence (Revert-Villarroya et al., 2020). Belgaje and colleagues (2014) advocated for the implementation of intensive therapies post-thrombectomy due to their impact on return to ADL independence during recovery. Researchers attributed good outcomes to the presence of intensive rehabilitation services, including OT, PT, speech therapy, and physical medical and rehabilitation physicians (Belgaje et al., 2014). Chiu and colleagues (2021) supported these findings by highlighting the impact that post-acute care rehabilitation has on functional outcomes, especially Instrumental Activities of Daily Living (IADLs). Patients that received post-acute care rehabilitation improved significantly more in all functional outcomes including ADL performance, oral intake, cognitive function, IADLs, quality of life, and balance, compared to those who did not receive post-acute care rehabilitation (Chiu et al., 2021). Upper Extremity Function After Thrombectomy Two articles included in the final analysis discussed upper extremity function after thrombectomy. This theme contained two articles of Level III evidence, both of moderate quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes and selection bias due to retrospective study designs. A necessary component of ADL training post-stroke is increasing function and involvement of the affected upper extremity. Branco and colleagues (2021) recommend a variety of interventions for OT practice including bimanual coordination, mirror therapy, transcranial magnetic stimulation, and constraint-induced movement therapy if appropriate. Researchers emphasized the importance of therapeutic intervention in the first twelve weeks post-stroke, the period of time in which the most functional gains typically occur (Branco et al., 2021). Additionally, those who underwent a 13 successful mechanical thrombectomy demonstrated greater improvements than those who did not (Branco et al., 2021). Conversely, Tokuda and colleagues (2021) found no significant differences in improvements in upper extremity function between patients who underwent mechanical thrombectomy and patients who did not. However, both groups demonstrated significant gains in upper extremity function according to the Fugl-Meyer Assessment following 20-40 minute sessions with OT five to six times per week for approximately six weeks (Tokuda et al., 2021). Psychosocial Symptoms After Thrombectomy Two articles included in the final analysis discussed psychosocial symptoms after thrombectomy. This theme contained one article of Level I evidence and one article of Level IV evidence, both of moderate quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include a lack of appraisal of articles reviewed by Thabet et al. (2015) and participant attrition due to changes in neurological status. Psychosocial concerns post-stroke are another common place for rehabilitation professionals to assess and intervene. According to Thabet and colleagues (2015), 30% of post-stroke patients may experience symptoms of depression, requiring the need for skilled intervention. Researchers also stated that this is within the scope of rehabilitation professionals including OT practitioners (Thabet et al., 2015). Regarding interventions, one study compared health related quality of life (HRQoL) and coping strategies between post-thrombectomy patients and patients who received best medical treatment (Revert-Villarroya et al., 2020). Researchers found that HRQoL was higher among the post-thrombectomy patients and the best medical treatment group demonstrated higher levels of coping skills (Revert-Villarroya et al., 2020). However, Revert-Villarroya and colleagues (2020) discussed how this may be because post-thrombectomy patients are not required to develop coping skills due to their quick functional improvements. Nevertheless, 14 coping skills, specifically problem-based coping skills, are important for approaching and overcoming challenges related to potential post-stroke deficits, and should be addressed by rehabilitation professionals when assessing for safety upon discharge from the hospital (RevertVillarroya et al., 2020). Discussion Since thrombectomies are the standard of care currently (Oliveira-Filho & Samuels, 2022), it is essential that the role of each healthcare professional is clearly delineated. As outlined in this paper, OT practitioners and rehabilitation professionals in general have a large role in the care of post-thrombectomy patients. With the growing amount of literature on the effectiveness of thrombectomies in stroke treatment, further delineation of OTs specific role in their rehabilitation post-operation is warranted. The analyzed studies discussed the role of OT in the care of post-thrombectomy patients and delineated some common interventions or assessments. The findings of the discussed studies have multiple implications for OT practice. First, there was a consensus among the studies that frequent OT intervention is indicated for a return for functional independence (Thabet et al., 2015; Burch et al., 2018; OConnor et al., 2019), however the impact of earlier evaluations on functional outcomes is inconsistent (Stuchiner et al., 2019). The importance of high frequency interventions places a greater role on the OT practitioner and other rehabilitation professionals to advocate for IPR placements for these patients (Beljage et al., 2014; Chu et al., 2020; Chiu et al., 2021). Second, OT practitioners should focus on ADL training, UE strengthening and coordination, and discussions surrounding coping and mental health in their interventions (Aoki et al., 2019; Revert-Vallarroya et al., 2020; Branco et al., 2021; Tokuda et al., 2021). The OT interventions discussed in the analyzed studies are congruent with current practice guidelines for stroke rehabilitation in general (AOTA, 15 2015). In practice, OT practitioners should pay close attention to the precautions and guidelines provided by the endovascular neurosurgeon, while utilizing current best practices for stroke rehabilitation with post-thrombectomy patients. Limitations One common limitation to the articles analyzed was that many of them were retrospective studies (n= 7), so the researchers had no control over the treatment protocols given to their participants. Very few studies (n= 3) had a control group. Only one study included randomization in their study design. Small sample sizes also limited several of the discussed studies (n= 5). The present paper has limitations. First, only one researcher reviewed and selected each article, leaving room for potential selection bias. To limit this bias, I used guidelines from the Johns Hopkins University School of Nursing (2017) to appraise articles. However, bias may still exist. Second, due to the limited literature available on the topic, the inclusion criteria widened after the search process began. This resulted in the inclusion of articles that may not describe OT in detail but may have discussed concepts associated with OT, including ADLs and functional independence. A common limitation with narrative reviews in general is a lack of systematic methods relating to the acquisition of articles (Pae, 2015). However, this paper utilized recommendations from Green et al. (2006) which describes a systematic protocol for searching for and reviewing articles, including using a variety of databases and clearly outlining all methods. Future Research Due to the limitations of the discussed studies, more research is needed to solidify the role of OT in the care of post-thrombectomy patients. The benefit of OT with post- 16 thrombectomy patients is not fully understood and the profession would benefit from further investigation. Specifically, information regarding the efficacy of high value interventions is largely missing from the literature currently. With a deeper understanding of the interventions that yield the highest functional improvements, practice guidelines for OT practitioners can be established. Future research should specifically include randomized controlled trials in their methodology in order to provide consistent, high-level evidence pertaining to the timing, frequency, and focus of OT interventions. Conclusion OT practitioners play an important role in the care of post-thrombectomy patients. The current literature has some significant gaps regarding the specific interventions for postthrombectomy patients and the efficacy of those interventions. With the prevalence of strokes projected to continue increasing (Kuriakose & Xiao, 2020), understanding the role of rehabilitation professionals after stroke treatment is crucial. Current literature discusses the benefits of early, high frequency, high intensity rehabilitation targeting ADLs and upper extremity function. OT practitioners can use this information to maximize interventions and restore function in patients. 17 References American Occupational Therapy Association. (2015). The role of occupational therapy in stroke rehabilitation. American Occupational Therapy Association. Retrieved January 17, 2022, from https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/stroke.aspx Aoki, K., Suzuki, H., Miyata, T., Ogino, T., & Iguchi, A. (2021). Predictors of discharge outcomes following percutaneous mechanical thrombectomy in patients with acute ischemic stroke: Comparisons between the home discharge group and hospital transfer group. The Showa University Journal of Medical Sciences, 33(1), 914. https://doi.org/10.15369/sujms.33.9 Baker, D. W., Tschurtz, B. A., Aliaga, A. E., Williams, S. C., Jauch, E. C., & Schwamm, L. H. (2020). Determining the need for thrombectomy-capable stroke centers based on travel time to the nearest comprehensive stroke center. The Joint Commission Journal on Quality and Patient Safety, 46(9), 501505. https://doi.org/10.1016/j.jcjq.2020.06.005 Belagaje, S. R., Sun, C.-H. J., Nogueira, R. G., Glenn, B. A., Wuermser, L. A., Patel, V., Frankel, M. R., Anderson, A. M., Thomas, T. T., Horn, C. M., & Gupta, R. (2014). Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis. Journal of NeuroInterventional Surgery, 7(2), 99103. https://doi.org/10.1136/neurintsurg-2013-011045 Branco, J. P., Rocha, F., Sargento-Freitas, J., Santo, G. C., Freire, A., Lans, J., & Pscoa Pinheiro, J. (2021). Impact of post-stroke recanalization on general and upper limb functioning: A prospective, observational study. Neurology International, 13(1), 4658. https://doi.org/10.3390/neurolint13010005 18 Burch, D., Drake, A., Steuber, T., Nihart, J., Abner, E., Stafford, W. L., & Fraser, J. (2018). Abstract TP157: Patient and physical therapy/occupational therapy characteristics associated with functional mobility outcomes after mechanical thrombectomy. Stroke, 49(Suppl_1). https://doi.org/10.1161/str.49.suppl_1.tp157 Chang, Y.-J., Liu, C.-K., Wu, W.-P., Wang, S.-C., Chen, W.-L., & Lin, C.-M. (2020). The prediction of acute ischemic stroke patients long-term functional outcomes treated with bridging therapy. BMC Neurology, 20(1). https://doi.org/10.1186/s12883-020-1610-1 Chiu, C.-C., Wang, J.-J., Hung, C.-M., Lin, H.-F., Hsien, H.-H., Hung, K.-W., Chiu, H.-C., Jennifer Yeh, S.-C., & Shi, H.-Y. (2021). Impact of multidisciplinary stroke post-acute care on cost and functional status: A prospective study based on propensity score matching. Brain Sciences, 11(2), 161. https://doi.org/10.3390/brainsci11020161 Chu, C.L., Chen, Y.P., Chen, C.C.P., Chen, C.K., Chang, H.N., Chang, C.H., & Pei, Y.C. (2020). Functional recovery patterns of hemorrhagic and ischemic stroke patients under Post-Acute Care Rehabilitation program. Neuropsychiatric Disease and Treatment, 16, 19751985. https://doi.org/10.2147/ndt.s253700 Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Slack. Feigin, V.L., Abajobir, A.A., Abate, K.H., Abd-Allah, F., Abdulle, A.M., Abera, S.F., Abyu, G.Y., Ahmed, M.B., Aichour, A.N., Aichour, I., Aichour, M.T.E., Akinyemi, R.O., Alabed, S., Al-Raddadi, R., Alvis-Guzman, N., Amare, A.T., Ansari, H., Anwari, P., rnlv, J., Vos, T. (2017). Global, regional, and national burden of neurological disorders during 19902015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurological, 16, 877897. doi: 10.1016/S1474-4422(17)30299-5 19 Fisher, A.G. (1998). Uniting practice and theory in an occupational framework. American Journal of Occupational Therapy, 52(7), 509521. doi: https://doi.org/10.5014/ajot.52.7.509 Fuhrer, H., Forner, L., Pruellage, P., Weber, S., Beume, L.-A., Schacht, H., Egger, K., Bardutzky, J., Weiller, C., Urbach, H., Niesen, W.-D., & Meckel, S. (2019). Long-term outcome changes after mechanical thrombectomy for anterior circulation acute ischemic stroke. Journal of Neurology, 267(4), 10261034. https://doi.org/10.1007/s00415-01909670-w Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peerreviewed journals: Secrets of the trade. Journal of Chiropractic Medicine, 5(3), 101117. https://doi.org/10.1016/s0899-3467(07)60142-6 Jadhav, A. P., Molyneaux, B. J., Hill, M. D., & Jovin, T. G. (2018). Care of the postthrombectomy patient. Stroke, 49(11), 28012807. https://doi.org/10.1161/strokeaha.118.021640 Johns Hopkins University School of Nursing. (2017). Johns Hopkins nursing evidence-based practice: Appendix D. The Johns Hopkins Hospital. https://www.mghpcs.org/eed/ebp/Assets/documents/pdf/2017_Appendix%20D_Evidence %20Level%20and%20Quality%20Guide.pdf Joint Commission. (2021, April 20). The Joint Commission stroke certification programs Program concept comparison. Oakbrook Terrace; The Joint Commission. Krishnan, R., Mays, W., & Elijovich, L. (2021). Complications of mechanical thrombectomy in acute ischemic stroke. Neurology, 97(20 Supplement 2), S115-S125. 20 Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and treatment of stroke: Present status and future perspectives. International Journal of Molecular Sciences, 21(20), 7609. https://doi.org/10.3390/ijms21207609 Leslie-Mazwi, T., Chen, M., Yi, J., Starke, R. M., Hussain, M. S., Meyers, P. M., McTaggart, R. A., Pride, G. L., Ansari, S. A., Abruzzo, T., Albani, B., Arthur, A. S., Baxter, B. W., Bulsara, K. R., Delgado Almandoz, J. E., Gandhi, C. D., Heck, D., Hetts, S. W., Klucznik, R. P., Fraser, J. F. (2017). Post-thrombectomy management of the Elvo Patient: Guidelines from the Society of Neurointerventional Surgery. Journal of NeuroInterventional Surgery, 9(12), 12581266. https://doi.org/10.1136/neurintsurg2017-013270 Mathews S, & De Jesus O. (2022) Thrombectomy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562154/ Michigan Department of Health and Human Services. (2021, October 11). Michigan stroke hospitals. Lansing; Michigan Department of Health and Human Services. O'Connor, K., Frazure, A., Campbell, M., Polly, M., Reckner, K., & Lee, J. D. (2019). Abstract TP345: Early mobilization following recombinant tissue plasminogen activator administration and/or mechanical thrombectomy reduces length of stay. Stroke, 50(Suppl_1). https://doi.org/10.1161/str.50.suppl_1.tp345 Oliveira-Filho, J., & Samuels, O.B. (2022). Mechanical thrombectomy in acute ischemic stroke. In J.F. Dashe (Ed.), UptoDate. Pae C. U. (2015). Why systematic review rather than narrative review?. Psychiatry Investigation, 12(3), 417419. https://doi.org/10.4306/pi.2015.12.3.417 21 Pego Prez, E. R., Fernndez, I., & Pumar, J. M. (2021). Functional outcomes of patients with stroke treated with thrombectomy by aspiration. Brain Injury, 35(4), 476483. https://doi.org/10.1080/02699052.2021.1887519 Pierot, L., Jayaraman, M. V., Szikora, I., Hirsch, J. A., Baxter, B., Miyachi, S., Mahadevan, J., Chong, W., Mitchell, P. J., Coulthard, A., Rowley, H. A., Sanelli, P. C., Tampieri, D., Brouwer, P. A., Fiehler, J., Kocer, N., Vilela, P., Rovira, A., Fischer, U., Karel, T. (2018). Standards of practice in acute ischemic stroke intervention: International recommendations. Journal of NeuroInterventional Surgery, 10(11), 11211126. https://doi.org/10.1136/neurintsurg-2018-014287 Reuter, B., Gumbinger, C., Sauer, T., Wiethlter, H., Bruder, I., Diehm, C., Ringleb, P. A., Hacke, W., Hennerici, M. G., & Kern, R. (2016). Access, timing and frequency of very early stroke rehabilitation insights from the Baden-Wuerttemberg Stroke Registry. BMC Neurology, 16(1). https://doi.org/10.1186/s12883-016-0744-7 Revert-Villarroya, S., Dvalos, A., Font-Mayolas, S., Berenguer-Poblet, M., Sauras-Coln, E., Lpez-Pablo, C., Sanjuan-Menndez, E., Muoz-Narbona, L., & Suer-Soler, R. (2020). Coping strategies, quality of life, and neurological outcome in patients treated with mechanical thrombectomy after an acute ischemic stroke. International Journal of Environmental Research and Public Health, 17(17), 6014. https://doi.org/10.3390/ijerph17176014 Saver, J. L., Goyal, M., Van der Lugt, A. A. D., Menon, B. K., Majoie, C. B., Dippel, D. W., Campbell, B.C., Nogueira, R.G., Demchuk, A.M., Tomasello, A., Cardona, P., Devlin, T.G., Frei, D.F., de Rochemont, R.D.M., Berkhemer, O.A., Jovin, T.G., Siddiqui, A.H., van Zwam, W.H., ... & HERMES Collaborators. (2016). Time to treatment with 22 endovascular thrombectomy and outcomes from ischemic stroke: A meta-analysis. JAMA, 316(12), 1279-1289. Stuchiner, T. L., Clark, D., Lucas, L., Robison, J., & Yanase, L. (2019). Abstract TP380: Impact of early mobilization on 90-day outcomes in thrombectomy patients. Stroke, 50(Suppl_1). https://doi.org/10.1161/str.50.suppl_1.tp380 Thabet, A., Josephson, S., & Meisel, K. (2015). Acute care of ischemic stroke patients in the hospital. Seminars in Neurology, 35(06), 629637. https://doi.org/10.1055/s-00351564301 Tokuda, K., Takebayashi, T., Koyama, T., Fujita, T., Hanada, K., & Okita, Y. (2021). Effects of mechanical thrombectomy for post-stroke patients with upper limb hemiparesis: Use of propensity score matching. Clinical Neurology and Neurosurgery, 202, 106520. https://doi.org/10.1016/j.clineuro.2021.106520 23 Appendix A: Evidence Table 24 25 26 Appendix B: DCE Weekly Planning Guide Wee k 1 DCE Stage (orientation, screening/ evaluation, implementation, discontinuation, dissemination) Weekly Goal Objectives Orientation 1) Complete Meet with orientation by site mentor the end of the and OT staff. week Begin to shadow OTs to meet patients and educate them on the goal of my DCE. Screening/ Evaluation 2) Complete Needs Assessment by the end of the week 2 Screening/ Evaluation 1) Begin faceted search for narrative review Begin looking into resources provided by the site for patient handouts. Finalize questions for Needs Assessment Select databases to use Tasks Date comple te Attend morning huddle meetings to learn about how the OT staff functions. 1/10 Ensure all paperwork for orientation is complete. 1/10 Tour the facility 1/11 Observe team meeting with various departments Determine what resources to focus on during DCE. Ask site mentor Needs Assessment questions Search databases and determine which ones are appropriate for finding articles regarding OTs 1/10 1/13 1/13 1/21 27 role with postthrombectomy patients. 3 2) Update MOU Determine specifics for updated project and experience. Discuss needs established with site mentor from last week, and determine goals for project and experience. 1/17 3) Conduct needs assessment with OT staff Determine usage of patient binders by OT staff Determine inclusion and exclusion criteria of articles Create and disseminate survey 1/18 Document inclusion and exclusion criteria 1/26 Determine usage of patient binders by OT staff Determine quality and level of evidence found Analyze responses from survey (ongoing) 1/242/10 Analyze articles using John Hopkins tool 2/3 Synthesize articles using evidence chart 2/3 Screening/ Evaluation 1) Conduct literature search 2) Conduct needs assessment with OT staff 4 Implementation 1) Continue literature search 2) Begin interdisciplin ary outreach 3) Continue working with Seek PT and Attend PT huddle SLP feedback to educate about with survey survey 2/1 Begin looking into resources that 1/31 28 the patient binder 5 Implementation 7 Implementation Implementation Begin updating resources Continue updating resources 1) Continue working with patient binder 2) Determine OTs role in care of postthrombectom y patients at site. 6 need to be updated in the patient binder 3) Consolidate information gathered from survey 1) Consolidate information gathered from neuro team Get feedback from neuro team on therapies Set up meeting with neurosurgery team Attend meeting with neurosurgery team Finish presentation with information from survey Prepare for meeting next week with therapy team Create presentation with information on thrombectomy update 2) Consolidate information from updated patient handouts Organize handouts with folders for before and after to present to OT team next week 3) Share survey results 1) Continue work on narrative review Meet with DOR to discuss survey results Finish introduction/ background section 2/2 2/11 2/8 2/10 2/11 2/18 2/18 2/18 2/25 29 8 Implementation 2) Evaluate progress on patient handouts and patient binders 1) Continue work on patient binders Present updates to OT team Attend team meeting and present handouts Clarify schedule sheet on front of binders Create updated schedule sheet 2/28 Present updated schedule sheet to OTs 3/2 Pass folder with updated handouts around in the OT offices to obtain feedback (ongoing) Complete methods section 2/283/13 Find template for narrative review presentation 3/7 Create outline for presentation 3/8 Email neurosurgery PA to ask about plans for the stroke centers growth Finish background slide in presentation. 3/7 Double check guidelines for reporting results 3/15 2) Seek final feedback on handout updates 9 Implementation 1) Continue work on narrative review 2) Begin presentation for OT role in postthrombectom y patients 3) Continue research on thrombectomi es at my site 10 Implementation 1) Continue narrative review presentation 2) Edit narrative Research leading hospitals for thrombectom ies 2/23 3/8 3/16 30 review as needed 3) Continue updates to patient handouts 11 12 13 Discontinuation Discontinuation Dissemination from narrative review. Take in feedback from therapists on handouts Decide what changes are necessary 3/14 Make updates to patient handouts with guidance from therapists feedback. Place an order with the printing company 3/17 Shadow therapists/assist with treatments 3/24 & 3/25 1) Finalize handouts Prepare handouts for the file cabinet 2) Get more experience with patient care 1) Finalize narrative review presentation Identify therapists to shadow Finish all slides for site mentor review next week 3/29 2) Finish full draft of narrative review Prepare paper Finish abstract to send to Katie for Finish conclusion review Finish results 3/28 1) Continue review process of narrative review paper Receive feedback from faculty mentor 2) Disseminate patient handouts Finalize file cabinet (Attend AOTA Conference) Send draft to Katie for review Receive handouts from printing company 3/23 3/29 3/28 3/304/3 4/5 4/4 31 Organize final handouts in file cabinet 3) Finalize presentation for OTs Began 4/5 Send presentation to site mentor for review 4/4 Discuss edits for presentation with site mentor 4/5 Add personal/professio 4/6 nal takeaways from DCE experience 14 Dissemination 1) Continue dissemination of patient handouts 2) Disseminate presentation to OTs 3) Shadow OTs Gain clinical experience in acute/ IPR settings Send presentation to site mentor for dissemination Finish organizing file cabinet 4/7 Site mentor will send presentation to OTs 4/11 Shadow on ortho floor 4/11, 4/12, 4/15 Shadow on surgical floor 4/14 4/13 ...
- Creator:
- Sara Skarshaug
- Date:
- 2022-05
- Type:
- Capstone Project
-
- Keyword matches:
- ... SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA Social Participation Interventions for Quality of Life Among Individuals with Dementia Elizabeth Siegfried May 4, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Brenda Howard, DHSc, OTR, FAOTA 1 SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 2 Abstract Dementia is an irreversible disease that impacts individuals in all areas of life and decreases quality of life (QOL) (Hsiao et al., 2018). I have identified that there is limited research stating specific ways to increase QOL and improve social participation among individuals with more progressed dementia. Utilizing the Functional Behavior Profile (FBP), I identified five individuals who required assistance and had more progressed dementia. I participated in activities such as exercise classes, crafts, and baking, alongside specific residents and utilized visual, verbal, and tactile cues as well as minor activity modifications when needed to create a just-right challenge. This promoted increased activity satisfaction and overall mood. I monitored individuals activity enjoyment via perceived satisfaction and their reports. This research provided evidence that continued participation in social activities with adaptations improves QOL. I recommend further research at a larger scale to expand on the effects of social activity interventions on QOL among older adults with progressed dementia. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 3 Social Participation Interventions for Quality of Life Among Individuals with Dementia Alzheimers disease (AD) and dementia are irreversible illnesses (Hsiao et al., 2018). Although reversing memory illness is not an option, there are numerous non-pharmacological ways to slow the progression or potentially delay onset (Hsiao et al., 2018; Letts et al., 2011; Quail et al., 2020). Non-pharmacological activities can include physical, kit-based, leisure, activities of daily living (ADLs), instrumental activities of daily living (iADLs), musicstimulated family visits, and dance (Charras et al., 2020; Huang et al., 2020; Jones et al., 2020; Letts et al., 2011; Shigihara et al., 2020; Smit et al., 2016). Activity participation typically involves physically and mentally participating in an activity, but Beerens et al. (2018) discuss that engagement via observation of activity performance feels like participation for many. Meanwhile, for some residents, structuring activities to meet their abilities will provide greater success and promote more active than passive participation (Kolanowski & Buettner, 2009). Considering both active and passive activity participation is important to identify because as adults age, they may not find themselves able to or interested in participating; rather, observing loved ones and other residents engage together is providing them with mood satisfaction and activity enjoyment (Beerens et al., 2018). Benefits of Activity Participation Activity participation provides numerous benefits for older adults, especially those with dementia. In some instances, skilled nursing facilities and assisted living facilities focus on medical care, but there are rising concerns regarding psychological care. Participating in meaningful activities can contribute to increased psychological well-being, quality of life (QOL), and better sleep performance (Beerens et al., 2018; Huang et al., 2020; Jones et al., 2020; Letts et al., 2011; Smit et al., 2016). In research by Charrass et al. (2020), their original hypothesis SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 4 focused on dance interventions promoting physical well-being. Their research ultimately did not support this hypothesis, but it supported increased positive self-perception in older adults. Specifically, dance as an activity intervention helped older adults with dementia improve their behavior, cognition, QOL, social participation, and self-perceived balance (Charrass et al., 2020). Beerens et al. (2018) discussed the importance of activity engagement and social interaction. Researchers identified a positive correlation between participation and older adults' mood with increased engagement (Beerens et al., 2018). Participating in meaningful activities is important and stimulating for both the individual with the disease as well as their caregivers. By modifying occupations and leisure activities to promote participation from the older adult with dementia, caregivers felt a greater sense of satisfaction for their loved ones (Letts et al., 2011). Benefits of Social Participation Beerens et al. (2018) identified that the type of activity that older adults with dementia participate in is as essential as social engagement. Social participation can be beneficial to slow the loss of verbal expression and reduce cognitive decline, both being common symptoms of AD (Duong et al., 2017; Letts et al., 2011; Quail et al., 2020). Activity engagement with a socialbased approach can include any activities that an older adult finds interesting and involve communication. Quail et al. (2020) specifically discussed validation therapy, music therapy, art therapy, reminiscence therapy, talking therapy, reality orientation, cognitive training, smell therapy, food therapy, sensory stimulation, garden therapy, and physiotherapy (p. 2). Meaningful occupations that promote physical activity can also contribute to strengthening meaningful relationships and promote more social participation, as well as reduce depression and increase ADL performance (Huang et al., 2020). Challenges with Activity and Social Participation SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 5 Activity engagement and social participation are significant factors in psychological wellbeing and QOL if they are activities or topics that are interesting and provide the appropriate cognitive stimulation for the older adult participating (Smit et al., 2016). Creating client-centered activities of interest is important, but for them to be entirely meaningful and reach the overall goal of engagement, the activities must meet the just-right challenge for one's cognitive status (Beerens et al., 2018; Cole & Tufano, 2008). While numerous researchers have collectively confirmed that activity and social participation are positively correlated with increased QOL and satisfaction (Huang et al., 2020; Letts et al., 2011; Smit et al., 2016), Beerens et al. (2018) also identified that an increased negative mood often occurs when older adults with dementia attempt to socially participate and receive no response. Identifying the challenge that social participation can present is essential to understanding that a balance between engagement and disengagement is necessary for QOL (Beerens et al., 2018). Respecting an older adults need for mental relaxation is person-dependent and crucial to promoting activity engagement (Beerens et al., 2018). Overview of Site Clarendale St. Peters is an independent and assisted living facility with a wing devoted to memory care located in St. Peters, Missouri. Clarendale has approximately 40 beds for memory care, with 20 occupied at the time of research (M. Bruner, personal communication, March 3, 2021; R. Muzzey, personal communication, January 27, 2022 ). Facility leaders divided the memory care side into two neighborhoods to provide a smaller, more intimate experience. Uniquely, if spouses both have dementia, they can reside in a larger room together in memory care. Muzzey discussed that he encourages this in many situations because it is a level of familiarity that will help with transitioning (R. Muzzey, personal communication, February 15, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 6 2022). Clarendale employees encourage activity participation among all residents in memory care, regardless of cognitive level. Activities in the memory care neighborhood are planned monthly and posted on calendars throughout the neighborhoods so residents and families can look ahead if interested, but are often not discussed until the day prior and that morning to avoid confusion. When meeting with Muzzey, Director of Memory Care, he identified a need for small group activity adaptations and additional supports that promote social participation among individuals in memory care neighborhoods who require more visual, verbal, and tactile cues as well as more time to process these cues. These activities are essential contributions to Clarendale because social connections tend to decline as dementia progresses, leading to quicker cognitive regression (Dyer et al., 2021; Hsiao et al., 2018). Muzzey reports an interest in ways to maintain inclusivity by integrating these residents more successfully into group activities. Theory and Application The Person-Environment-Occupation (PEO) Model and Allen's Cognitive Levels (ACL) Frame of Reference are essential to guide the construction of activity adaptations and supportive cueing for individuals with dementia. The PEO model focuses on an individual's occupational performance formed from interactions between the person, environment, and occupation. At the center of the PEO model is participation with the goal being to guide occupational therapists in helping individuals create and maintain a level of involvement (Degenholtz et al., 2006). ACL Frame is a beneficial frame of reference to utilize for older adults with memory illnesses because it focuses on one's cognition, routines, physical context, social context, and activity demand (Cole & Tufano, 2008). Using ACL Frame to evaluate one's cognitive ability serves as a guide to promoting meaningful participation in activities at a just-right challenge level. Encouraging SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 7 participation in activities that meet one's level of capacity motivates individuals to utilize their cognitive abilities (Cole & Tufano, 2008). Utilizing the PEO model and ACL Frame to guide the Doctoral Capstone Experience will ensure client-centeredness and the ability to screen and evaluate which individuals qualify for the interventions. This client-centeredness will lead to the outcome goal of providing appropriate visual, verbal, and tactile cues for older adults with more progressed dementia to improve social activity participation, thus increasing their QOL. Expanding Research There is an abundance of research on the importance of activity engagement amongst older adults with dementia. However, there is limited research regarding benefits of small group social activities and levels of assist for older adults who benefit specifically from more support and cueing. This Doctoral Capstone Experience is intended to expand on current research to identify the benefits of social participation on QOL among a specific group of individuals with dementia. Project Design Clarendale St. Peters Memory Care is devoted to providing activities for residents to participate in, both individually and in the group setting. I created this project because there was an identifiable need for support and activities that meet the just-right challenge of older adults with more progressed dementia. Prior to this research experience, some residents participated passively due to needing more cueing to be successful and there was not an employee who was designated to offer these supports. In some instances, some residents chose to participate passively or observe because the activity may not meet their interests or needs. Outcome Assessments SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 8 First, to identify residents who meet the qualifications of the research, I utilized the FBP to gain information about ADLs, cognition, functional mobility, life participation, patient satisfaction, problem-solving, and social relationship (Functional Behavior Profile, n.d.). These are all areas of an individuals life that can affect ones QOL. Nursing staff and activities coordinators collaborated to complete the FBP because they are ultimately the day-to-day caregivers and know each resident deeply and personally. Residents who scored at or below 50% (22/24) in Task Performance or Social Interaction qualified for my program development, which was working side by side with individuals to provide more assistance and cueing to promote more social engagement and activity participation. I utilized the FBP to identifying individuals who would benefit from additional cues and modifications during small group activities to promote satisfaction and improved QOL in events related to weaker areas of performance. This may include cognition, activity participation, following commands, socializing when others initiate the conversation, and time spent attending tasks (Baum et al., 1993). Project Implementation Employees at Claredale in the memory care neighborhoods work closely with the residents every day and build strong relationships with them and their families. Thus, were excellent resources for information regarding each residents personality, challenges, and preferences. Every day is incredibly structured for the activities coordinators because they are the only ones leading activities every day except when they take a lunch break. The nursing staff is also incredibly busy throughout the day. The activities coordinators answered most questions, allowing me to ask the nursing staff fewer questions since I do not see them as often so it would SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 9 have been more challenging to find time to discuss more details. It took approximately two weeks to finalize and score all FBP assessments. Utilizing the FBP helped me to identify the common weaker areas among residents, specifically Task Performance and Social Interaction. Often, residents who scored lower were able to complete tasks asked of them with much assistance and additional time. It became apparent that many of the residents who qualified for additional support from me had the physical capabilities to participate. This provided evidence that individuals were capable of some level of participation but would be most successful with additional cueing to support their cognitive level of functioning. Project Outcomes The FBP served as an excellent resource to identify residents who would benefit from additional cues to promote an increased QOL. This gives me a foundation that assists in better understanding residents' current abilities at baseline and how to create the just-right challenge that meets each individuals needs. When observing nursing staff and resident interaction, much of the communication was regarding medication, helping with ADLs, and participating in activities led by activities coordinators. Often, nursing staff provided much encouragement for every resident to participate in all activities but were not considering if each activity would meet the needs of each resident. Activities coordinators reported that some activities are not interesting to each resident and were sometimes not all appropriate for everyones cognitive level of functioning. However, I worked alongside activities coordinators to join in on activities of interest with qualifying residents to potentially improve the QOL among residents through social engagement, activity participation, and minor activity adaptations. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 10 Residents who scored below 50% (22/44) in Task Performance or Social Interaction on the FBP qualified for me to work alongside. It is essential to identify that an individual with dementia will not improve in any areas of the FBP independently due to dementia being a progressive disease. However, in the moment and with assistance, residents can increase their level of participation, thus, improving their QOL through meaningful activities. There are fourteen residents residing at Clarendale St. Peters Memory Care, with five who scored below 50% in Task Performance of Social Interaction on the FBP. Other residents who did not qualify scored between 52% and 79.5% (23/44 and 35/44). The individuals who scored below 50% often appeared isolated. I spoke with activities coordinators and nursing staff, who reported that it is difficult to spend enough time helping individuals with more progressed dementia engage in activities, so they often do not receive the level of assistance needed for engagement. This can contribute to their overall dementia progression (Freak-Poli et al., 2022). I sat next to residents to provide additional cues, serve as a visual aid, and modify activities as needed. This proved to be successful based on residents responses after each activity. I communicated with Muzzey, Director of Memory Care, and Cribb, Activities Coordinator for Memory Care, to discuss ways to gain feedback regarding the success of activity engagement. Immediately at the end of each activity, I asked residents, "Did you enjoy this activity?". This allowed residents at different cognitive levels to respond either verbally or nonverbally. While I participated in activities alongside qualifying residents, I also observed how residents acted during each activity. I looked for facial expressions, eye contact with other residents, and some level of maintained engagement. For individuals with dementia, working with them to create an increased QOL is dependent on that specific moment in time because that is what they know and are aware of (L. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 11 Cribb, personal communication, January 27, 2022; R. Muzzey, personal communication, February 8, 2022). Muzzey explained that individuals with progressed dementia often cannot look beyond the current moment but happiness in a specific moment can increase their mood for some time after the activity, even if the resident cannot express or recall why they are happy (R. Muzzey, personal communication, February 8, 2022). Therefore, evaluating a resident's perceived satisfaction and QOL must occur during and immediately after each activity. While working alongside activities coordinators and nursing staff, I helped identify ways to adapt current activities for all residents to participate in. This includes visual aids for the entire group, sitting next to the individuals who need more auditory cues, visual cues, hand-over-hand tactics, explaining directions simply, and frequently prompt one-on-one conversations. Employees of Clarendale and myself identified a need for an additional activities coordinator with a background in dementia to promote greater activity engagement and improved QOL. Muzzey and Cribb complete paperwork with families that identify residents backgrounds, careers, and areas of interest. They utilize these to create daily activities. This may be a contributing factor to why my research was successful. Many of the residents enjoy all the activities and the level of socializing they offer. During 10 weeks of research implementation, I successfully incorporated the qualifying residents into the activities and assisted with providing additional cueing, leading them to actively participate more. When reviewing the data, I identified that 85% of the times I participated in activities alongside residents to provide support, the residents reported satisfaction and displayed enjoyment throughout the activity. One resident reported being bored throughout craft activities. When I asked her if she would be interested in participating, she often said yes and attended but then quickly lost interest. Through discussions with the family, I learned crafts have never been a strong interest. I continued to be mindful by SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 12 still inviting her to join but also asking if she would like to sit and watch others participate. It was very common for all residents, not just those who I was working with, to observe an activity that they did not want to participate in. Muzzey often encourages this because it still provides more opportunities for conversation and social interaction. Limitations Although there were identifiable limitations, they were minimal. Muzzey, Cribb, and I identified that one resident often had anxiety attacks in the mornings if she was wearing a specific pair of jeans. We believed they were too tight or rough, leading to increased levels of sensory stimulation. To limit this and increase her opportunity to participate in morning activities, Muzzey talked with nursing staff to not encourage her to wear those pants. Another limitation was hospital visits. If a resident was taken to the hospital then later returned, it reduced the residents level of interest in activities, leading them to require more encouragement to participate and attempt to return to their baseline. These limitations are valid but were unaccounted for during research preparation. Discussion Activity participation is crucial for residents days in a memory care neighborhood. Participating in activities provides meaningful engagement and a purpose for many residents while improving their QOL (Huang et al., 2020; Letts et al., 2011; Smit et al., 2016). However, I have identified that meeting the just-right challenge is necessary for all meaningful activities. Throughout the program development, I identified that if an activity was too challenging or there was no one to assist the resident, they may become frustrated and cease participating entirely. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 13 Utilizing the FBP to identify lower scoring individuals and provide appropriate intervention proved successful in contributing to increased QOL and small group engagement. Residents who utilized additional support during activities were inclined to participate and socialize throughout the activity more than prior to research interventions. Individuals participating either verbalized, nodded, or gave a thumbs up or down to report their small group activity enjoyment. Researchers identified that for some with more progressed dementia, observing someone participate provides the same level of satisfaction and socializing (Beerens et al., 2018). Two individuals often participated passively in this program development due to their medical status and progression. I maintained my level of assistance alongside the residents and observed resident satisfaction throughout the activities, more so than prior to the program development and implementation. These residents often held more eye contact with other residents that typically expected, as well as laughed more than employees have reported observing in some time. To further summarize, I determined that activity participation for all residents, specifically residents with more progressed dementia, contributed to increased QOL and perceived satisfaction. It provides evidence that verbal, visual, and tactile cues contribute to more participation and comfort with activities in small groups. I believe having an additional life enrichment coordinator provides dignified support during activities, thus, leading more residents with progressed dementia to feel comfortable and willing to participate and enjoy their day, overall increasing their QOL. Conclusion In conclusion, my research provides evidence that additional cues and support during activities can improve QOL and activity satisfaction among residents with more progressed SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 14 dementia. St. Peters Clarendale activities coordinators benefitted from observing this research, improving many older adults' level of participation and satisfaction. Employees have learned how to adapt activities and offer additional support to meet the needs of every resident who wants to participate. Overall, residents with more progressed dementia had increased activity participation and reported satisfaction immediately following the activity. Further work on a larger scale is necessary to expand research on the benefits of increased activity participation on QOL among older adults with advanced dementia. However, this research is an excellent start to providing evidence that additional support during activities is not only an advantage but a crucial part of improving overall QOL among older adults with more progressed dementia. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 15 References Baum, C., Edwards, D. F., & Morrow-Howell, N. (1993). Identification and measurement of productive behaviors in senile dementia of the Alzheimer type. The Gerontologist, 33(3), 403408. https://doi.org/10.1093/geront/33.3.403 Beerens, H. C., Zwakhalen, S. M. G., Verbeek, H., E.S. Tan, F., Jolani, S., Downs, M., de Boer, B., Ruwaard, D., & Hamers, J. P. H. (2018). The relation between mood, activity, and interaction in long-term dementia care. Aging & Mental Health, 22(1), 2632. https://doi.org/10.1080/13607863.2016.1227766 Charras, K., Mabire, J.-B., Bouaziz, N., Deschamps, P., Froget, B., de Malherbe, A., Rosa, S., & Aquino, J.-P. (2020). Dance intervention for people with dementia: Lessons learned from a small-sample crossover explorative study. The Arts in Psychotherapy, 70, 101676. https://doi.org/10.1016/j.aip.2020.101676 Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Degenholtz, H. B., Miller, M. J., Kane, R. A., Cutler, L. J., & Kane, R. L. (2006). Developing a Typology of Nursing Home Environments. Journal of Housing For the Elderly, 20(12), 530. https://doi.org/10.1300/J081v20n01_02 Duong, S., Patel, T., & Chang, F. (2017). Dementia: What pharmacists need to know. Canadian Pharmacists Journal / Revue Des Pharmaciens Du Canada, 150(2), 118129. https://doi.org/10.1177/1715163517690745 Dyer, A. H., Murphy, C., Lawlor, B., & Kennelly, S. P. (2021). Social networks in mild-tomoderate Alzheimer disease: Longitudinal relationships with dementia severity, cognitive SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 16 function, and adverse events. Aging & Mental Health, 25(10), 19231929. https://doi.org/10.1080/13607863.2020.1745146 Functional Behavior Profile. (n.d.). Shirley ryan ability lab. Retrieved February 9, 2022, from https://www.sralab.org/rehabilitation-measures/functional-behavior-profile Freak-Poli, R., Wagemaker, N., Wang, R., Lysen, T. S., Ikram, M. A., Vernooij, M. W., Dintica, C. S., Vernooij-Dassen, M., Melis, R. J. F., Laukka, E. J., Fratiglioni, L., Xu, W., & Tiemeier, H. (2022). Loneliness, not social support, is associated with cognitive decline and dementia across two longitudinal population-based cohorts. Journal of Alzheimers Disease: JAD, 85(1), 295308. https://doi.org/10.3233/JAD-210330 Hsiao, Y.-H., Chang, C.-H., & Gean, P.-W. (2018). Impact of social relationships on Alzheimers memory impairment: Mechanistic studies. Journal of Biomedical Science, 25(1), 3. https://doi.org/10.1186/s12929-018-0404-x Huang, X., Li, B., Yu, F., Zhou, J., Wan, Q., & Chang, H. (2020). Path analysis from physical activity to quality of life among dementia patients: A dualpath mediating model. Journal of Advanced Nursing, 76(2), 546554. https://doi.org/10.1111/jan.14260 Jones, C., Liu, F., Murfield, J., & Moyle, W. (2020). Effects of non-facilitated meaningful activities for people with dementia in long-term care facilities: A systematic review. Geriatric Nursing, 41(6), 863871. https://doi.org/10.1016/j.gerinurse.2020.06.001 Kolanowski, A., & Buettner, L. (2008). Prescribing activities that engage passive residents. An innovative method. Journal of gerontological nursing, 34(1), 1318. https://doi.org/10.3928/00989134-20080101-08 Letts, L., Edwards, M., Berenyi, J., Moros, K., ONeill, C., OToole, C., & McGrath, C. (2011). Using occupations to improve quality of life, health and wellness, and client and SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 17 caregiver satisfaction for people with Alzheimers disease and related dementias. American Journal of Occupational Therapy, 65(5), 497504. https://doi.org/10.5014/ajot.2011.002584 Quail, Z., Carter, M. M., Wei, A., & Li, X. (2020). Management of cognitive decline in Alzheimers disease using a non-pharmacological intervention program: A case report. Medicine, 99(21), e20128. https://doi.org/10.1097/MD.0000000000020128 Shigihara, Y., Hoshi, H., Shinada, K., Okada, T., & Kamada, H. (2020). Non-pharmacological treatment changes brain activity in patients with dementia. Scientific Reports, 10(1), 6744. https://doi.org/10.1038/s41598-020-63881-0 Smit, D., de Lange, J., Willemse, B., Twisk, J., & Pot, A. M. (2016). Activity involvement and quality of life of people at different stages of dementia in long-term care facilities. Aging & Mental Health, 20(1), 100109. https://doi.org/10.1080/13607863.2015.1049116 SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 18 Appendix Doctoral Capstone Experience Project Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal 2 Orientation 1. Complete orientation and tour by the end of the week 2. Meet with Site Mentor and key personnel, introduce Complete myself, provide Needs education as to Assessment what my role is and intended DCE. 3. Discuss workspace, dress code, dementia training course. 4. Review and edit Needs assessment questions Safety training 1. Finish identifying any Observe new literature residents, make notes 2. Establish outcome Complete assessment tool literature search 3. Touch base with mentor Finalize MOU regarding possible Evaluate and changes to score FBP, MOU identify and Complete orientation Screening/Evaluation Screening/Evaluation Objectives Tasks Date complete Identify key 1/15/22 points to discuss in meeting with site mentor Have a meeting with my site mentor Discuss sites needs and plans for observing OTR Get to know residents, understand their interests and level of function Organize new literature Save outcome assessment tool, discuss it with mentor Review MOU in greater detail 1/21/22 SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA compose list of residents who qualify, discuss 4. Become familiar with results with residents who mentor qualify for research 5. Observe qualifying residents 3 Implementation 4 Implementation 5 Implementation 1. Increase social Provide cues participation and participate amongst group alongside members residents with more progress dementia Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower Complete screening on just-right challenge tasks for residents Discuss areas of interest for residents participating Utilize verbal, visual, and tactile cues to maintain participation Utilize verbal, visual, and tactile cues to maintain participation 19 1/28/22 2/4/22 2/11/22 Utilize verbal, visual, and tactile cues to maintain participation, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 20 functioning skills 6 7 8 Implementation Implementation Implementation Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower 2/18/22 Utilize verbal, visual, and tactile cues to maintain participation, 2/25/22 Utilize verbal, visual, and tactile cues to maintain participation, 3/4/22 Utilize verbal, visual, and tactile cues to maintain participation, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 21 functioning skills 9 10 11 Implementation Implementation Implementation Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower 3/11/22 Utilize verbal, visual, and tactile cues to maintain participation, 3/18/22 Utilize verbal, visual, and tactile cues to maintain participation, 3/25/22 Utilize verbal, visual, and tactile cues to maintain participation, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 22 functioning skills 12 Implementation 13 Discontinuation 14 Dissemination Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction Finish small group activity modifications and assist for residents with lower functioning skills Present findings to 4/1/22 Utilize verbal, visual, and tactile cues to maintain participation, 1. Collect/organize Organize 4/8/22 all information spreadsheet regarding with activities, level residents of participation, (initials used and subjective for privacy), feedback activities they participated in, their subjective rating of the activity, and how I perceived their participation, enjoyment, and satisfaction 1. Confirm date, 4/15/22 Create time, and handouts, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA leaders of memory care department regarding my findings location of presentation, prepare notes, and handouts answer any final questions, provide copies of handouts and relevant resources 23 ...
- Creator:
- Elizabeth Siegfried
- Date:
- 2022-05-04
- Type:
- Capstone Project
-
- Keyword matches:
- ... 1 Myofascial Release as a Treatment Option for Tongue Ties and Other Congenital Issues Lyndsay Shepherd April 22, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Taylor Gurley, MS, OTR, OTD, CEIM 2 Abstract This doctoral capstone project focuses on tight fascia as a secondary concern to tongue ties, torticollis, and other congenital issues and the benefits of utilizing myofascial release (MFR) to treat these populations. IU Norths Outpatient (OP) Clinic expressed interest in learning more about MFR to gain referrals and meet the needs of these populations. The researcher utilized a cost-benefit ratio and acceptability-perception survey to identify the need for and benefits of utilizing MFR in the OP clinic. The cost-benefit analysis results indicated that the benefit of utilizing MFR would outweigh the costs of training needed to practice in this area. The acceptability perception survey results indicated that the occupational and physical therapists were very likely to utilize MFR if given the appropriate training and patient population. Through this doctoral capstone project, IU Norths Outpatient Clinic gained several resources and further knowledge on tongue ties, tight fascia, and myofascial release. Keywords: tongue tie, ankyloglossia, myofascial release, outpatient therapy 3 Introduction The Indiana University (IU) Health North Outpatient (OP) Pediatric Clinic, located in Carmel, IN strives to ensure that the highest quality of individualized, developmentally supportive, and family-centered care is provided for all patients (H. Krodel, personal communication, February 23, 2021). Common diagnoses within the outpatient pediatric clinic include, but are not limited to, autism spectrum disorder (ASD), down syndrome, neonatal abstinence syndrome (NAS), developmental delay, cerebral palsy (CP), sensory processing disorder, chromosomal abnormalities, and other genetic disorders (H. Krodel, personal communication, February 23, 2022). Occupational therapists utilize a holistic approach and work collaboratively with speech-language pathologists, physical therapists, and families to provide specialized care to every patient (Krodel, 2021). Occupational therapy practitioners play a crucial role as developmental specialists in addressing skills needed to achieve developmental milestones in self-care, play, leisure, and social participation (AOTA, 2016). This doctoral capstone project focuses on myofascial release (MFR) as a treatment option for tight fascia secondary to tongue ties, torticollis, and other congenital issues. According to H. Krodel (personal communication, January 20, 2022), several previous babies discharged from the NICU return to the OP clinic as toddlers with concerns often associated with congenital issues. This raised the initial question, why are we not catching these issues sooner? According to K. Thomas (personal communication, January 27, 2022), lactation consultants often refer babies to OP pediatric therapy services to address tight fascia secondary to tongue tie, torticollis, and other congenital issues. However, IU Norths OP Pediatric clinic has not received many, if any, of these referrals. This raised additional questions: what training is needed to address these issues, and how can IU North become a referral source for these patients? This paper addresses 4 secondary concerns associated with congenital issues, treatment options to address these issues, reason(s) for referrals to occupational therapy services by lactation specialists, and the costbenefit ratio of implementing MFR to address tight fascia secondary to tongue tie, torticollis, and other congenital issues. Background When picturing the tongue, and the role it plays within the human body, many think of the oral cavity, chewing, swallowing, breathing, and speaking (Bordoni et al., 2018). However, according to Bordoni et al. (2018), the tongue interacts with the entire body and even plays a role in muscle strength and posture. The omohyoid muscle and anterior belly of the digastric muscle allow movement between the tongue and neck when flexing, extending, and rotating the neck and cervical tract. Furthermore, the fascia involved with the tongue connects to the sternocleidomastoid muscle and musculature within the thoracic outlet. Bordoni et al. (2018) state that muscles, whether in direct or indirect contact with the tongue, produce contractile tonus to allow the tongue to work effectively via the central and peripheral nervous system. Mills et al. (2019) describes that lingual frenulum as a dynamic structure formed by a central fold of fascia that spans the floor of mouth and together with the overlying oral mucosa it forms the roof of the sublingual space. Ankyloglossia, or tongue-tie, involves this part of the tongue. Kotlow (2004) describes the four classes of tongue tie as: (Class IV) mild: 10-12 mm, (Class III) moderate: 7-9 mm, (Class II) severe: 4-6 mm, and (Class I) complete: 0-3 mm. According to Birch et al. (2021), tongue ties affect up to 11% of infants, with males typically affected more than females. However, a limited number of trained professionals exist to address tongue ties, causing difficulty for this population to access services (Birch et al., 2021). 5 According to H. Krodel (personal communication, February 23, 2021), IU Norths outpatient pediatric therapists noticed several infants born at IU North Hospital returning to the outpatient clinic as toddlers with issues associated with tongue ties and other congenital issues. Some common issues noted during assessment of these toddlers included abnormal body postures, delayed gross motor skills, poor tolerance of prone positioning, and delayed mobility due to tightness or rigidity. This raised the question: why is this concern not caught sooner, and how can we catch this concern sooner? One possible solution to address these concerns sooner involves referrals from lactation specialists. Lactation specialists play an important role in addressing breastfeeding concerns related to tongue ties (Birch et al., 2021; K. Thomas, personal communication, January 27, 2022). In speaking with IU Norths lactation coordinator, she mentioned that common issues associated with tongue ties include, but are not limited to: reflux, swallowing difficulties, jaw development, tightness, fatigue when nursing, fussiness and arching away from the breast, and easily falling asleep at the breast (K. Thomas, personal communication, January 27, 2022). Lactation specialists offer specialized services to address these concerns and often refer infants for frenotomies depending on the severity of the tongue tie. Despite the frenotomy procedure and receiving specialized care from lactation specialists, some infants continue to experience issues associated with the tongue tie. Several infants with moderate to severe tongue ties experience tight fascia that often causes tightness or rigidity elsewhere in the body (K.Thomas, personal communication, January 27, 2022). According to K. Thomas (personal communication, January 27, 2022) myofascial release targets tight fascia within the body and helps to alleviate postural issues. Freed & Coulter-OBerry (2006) and Park et al., (2006) also found MFR to be an effective treatment 6 option for infants with torticollis. According to Barnes (n.d.), myofascial release is defined as, a safe and very effective hands-on technique that involves applying gentle sustained pressure into the myofascial connective tissue restrictions to eliminate pain and restore motion. Watts & Lagouros (2020) report that an infants tightness often releases quickly with little force applied. Myofascial release for infants typically focuses on the thoracic inlet. The MFR technique to address this population consists of the following steps: (1) reach over the top of the infant's shoulders and places fingertips on the chest wall over the upper ribs with the thumbs lying overtop the shoulder blade, (2) engage the superficial layers of skin and fasciae and move hands gently toward the infant's head, then feet, then to the left, and to the right, (3) feel for areas of restriction, and (4) rotate the fasciae into a position of ease or of greatest laxity, gently moving the tissue until that familiar release is felt (Watts & Lagouros, 2020). The two main goals of this MFR technique include: (1) loosening tissue surrounding the lymphatic duct and (2) reducing mechanical strain to improve breathing, sucking, and swallowing when breast or bottle feeding. Currently, little to no peer-reviewed research articles focus on the role occupational and physical therapists play in utilizing MFR to address issues associated with tongue ties. IU Norths lactation coordinator refers approximately fifteen infants suffering from issues associated with tongue ties to an MFR therapist each month (personal communication, January 27, 2022). Approximately 90% of Thomas patients referred to this therapist saw improvements post treatment (K. Thomas, personal communication, January 27, 2022; L. Lafuze, personal communication, February 8, 2022). Given the high number of referrals and long waitlists, the lactation coordinator expressed the need for more therapists to utilize MRF in treating issues associated with tongue ties (K. Thomas, personal communication, January 27, 2022). The goal of 7 this project is to gather enough evidence to support the use of myofascial release to gain referrals and treat issues associated with tongue ties and other congenital issues early on at IU Norths OP Pediatric Clinic. The Ecology of Human Performance (EHP) model helped guide the students doctoral capstone experience. This model describes dysfunction as the disruption between the person, context, and tasks (Cole & Tufano, 2008). Dysfunction leads to flawed human performance. If the infant or toddlers personal factors do not support their participation in feeding, social bonding, and play, there will be flaws in their performance. The EHP model helped identify how tight fascia may hinder the infants participation in everyday occupations such as feeding and play. The biomechanical frame of reference (FOR) also guided the students doctoral capstone experience. This FOR addresses deficits with range of motion (ROM), strength, and endurance (Cole & Tufano, 2008). Dysfunction occurs when restriction in ROM, strength, or endurance impacts the individuals participation in everyday occupations (Cole & Tufano, 2008). Utilization of this FOR helped the student understand how tight fascia limits participation in ones occupations due to restricted ROM and endurance. The student utilized the biomechanical FOR and collaborated with IU Norths OP team to identify techniques for improving ROM and endurance in patients that suffer from tight fascia secondary to tongue tie, torticollis, and other congenital issues. Project Design and Implementation Development of this project consisted of identifying the need, completing extensive research on the need, identifying ways to address the need, determining outcome measures, and meeting with the lactation specialist, myofascial release therapist, site mentor, faculty mentor, 8 and professor of the DCE class. According to L. Lafuze (personal communication, February 08, 2022) and K.Thomas (personal communication, January 27, 2022), several infants with moderate to severe tongue tie and torticollis experience secondary concerns such as feeding dysfunction, reflux, irritability, poor endurance, arching, and tightness. Despite these additional concerns, IU Norths OP Pediatric Clinic receives little to no referrals on this population until later in the childs life. Singh & Anekar (2018) discuss the importance of intervening earlier in a childs life to enhance their cognitive, physical, social, and emotional skills needed to meet developmental milestones. This identified the need for IU Norths OP Pediatric Clinic to investigate the reasoning for the lack of referrals and answer the question, How can we see this population sooner? Lactation specialists often work with infants with tongue ties to address breastfeeding concerns (Birch et al., 2021). If the infants deficits exceed the lactation specialists scope of practice, the lactation specialists often refer the infant to outpatient therapies such as occupational therapy, physical therapy, or speech therapy (University of Michigan, 2016). The student set up a meeting with the lactation coordinator at IU North Hospital to gain more information on this population. The lactation coordinator offered a wealth of information regarding the population she serves, common concerns noted among this population, and the treatment options available. She reported referring several infants with secondary concerns related to tongue-tie to myofascial release services each month and mentioned the desire for IU Norths OP pediatric clinic to begin utilizing this type of treatment (K. Thomas, personal communication, January 27, 2022). After meeting with the lactation coordinator, the student reached out to the physical therapist that receives referrals for this population and asked to discuss her method of treating 9 this population. This physical therapist owns a non-affiliated private practice and solely utilizes myofascial release to treat tight fascia secondary to congenital issues. She provided detailed examples on the purpose of using myofascial release to treat infants with tight fascia and described the referral process, billing codes, typical goals, and average number of MFR sessions needed to treat this population. To further the students knowledge on myofascial release, the physical therapist allowed the student to observe three sessions and receive myofascial release herself. After meeting with the lactation coordinator and physical therapist, the researcher gained pertinent information to help guide development of the cost-benefit analysis and acceptability perception survey. The researcher also used this information to locate and identify appropriate MFR resources to provide to the outpatient pediatric therapists during dissemination. The researcher was unable to meet with any additional lactation specialists and myofascial release therapists due to limited time and a limited number of healthcare professionals interested in using myofascial release for tongue-tie related issues. Project Outcomes Assessment Tools After identifying the need, completing extensive research, and determining how to address the need via conversations with the site mentor and faculty mentor, the researcher chose a cost-benefit analysis (Misuraca, 2014) and acceptability perception survey (Proctor et al., 2011) to measure the projects outcomes. The cost-benefit analysis determines if the benefit(s) of a service outweigh the cost(s) to implement that service (Misuraca, 2014). Therefore, the researcher chose the cost-benefit analysis to show the OP staff and rehabilitation manager(s) the 10 benefits of utilizing myofascial release as a treatment option compared to the costs of training OP staff to implement this service. The acceptability perception survey addresses a specific intervention within a particular setting to determine the agreeability, palatability, or satisfactory of implementing that intervention (Proctor et al., 2011). Therefore, the researcher created an acceptability perception survey for IU Norths OP pediatric therapists to determine the agreeability and palatability of implementing myofascial release as a treatment option into the outpatient pediatric clinic. Cost-Benefit Analysis The researcher planned to take the average hourly OP therapist rate (X) average number of referrals (X) average number of visits (X) cost of training and compare this number to the average number of referrals (X) average number of visits (X) insurance reimbursement rate to determine the cost-benefit ratio. Despite great efforts, the researcher was unable to gather information on insurance reimbursement rates and the average hourly OP therapist rate from IU Norths clinic. Therefore, the measurability of the cost-benefit analysis changed from quantitative to qualitative due to this missing information. The researcher decided to include the following information on the cost-benefit spreadsheet: MFR training courses recommended for the pediatric population, cost of each training, benefit of the training, number of referrals made each month for this population, and CPT codes used for MFR treatment (see Appendix B). Although the researcher could not provide a dollar amount for the cost-benefit ratio, the outpatient therapists indicated that their team was less worried about the cost and more worried about the benefits of the service and number of potential referrals. Appendix B provides the breakdown of the cost-benefit analysis provided to the outpatient pediatric therapy team. 11 The results show that approximately fifteen referrals are made to MFR therapy each month due to tongue-tie related issues, and an average of four visits are typically required to resolve these issues. (K. Thomas, personal communication, January 27, 2022; L. Lafuze, personal communication, February 07, 2022). IU Norths OP therapy manager indicated that the hospital has an education fund that often covers training courses for therapists. Therefore, the profit gained from using MFR to treat infants with tight fascia secondary to congenital issues would outweigh the cost of training. Acceptability Perception Survey Four of the five outpatient pediatric therapists responded to the myofascial release acceptability perception survey. Of the respondents, results indicated that 100% of the therapists were very likely to utilize myofascial release techniques if given the appropriate training and patient population. When asked what percentage of their caseload could benefit from myofascial release, three therapists responded 46-60% and one therapist responded +91%. Three of the outpatient therapists reported yes to currently using myofascial release techniques in some of their treatment sessions. Figure 1 Percentage of IU North OP therapists current caseload that could benefit from myofascial release. 12 Figure 2 Percentage of IU North OP Pediatric Therapists Current Caseload Receiving Myofascial Release When asked, On a scale of 0 to 10 (1= nothing at all and 10= everything there is to know), how much do you know about myofascial release, the therapists reported 50% of less. Given these results, the therapist compiled several MFR resources including, but not limited to, articles, websites, FAQ sheets, and therapist-specific information for using myofascial release within their treatment sessions. Several of these resources directly relate to the pediatric population suffering from fascial restrictions secondary to tongue tie, torticollis, and other congenital issues. 13 Figure 3 IU North OP Pediatric Therapists Current Knowledge on MFR Figure 4 Descriptive Analysis of IU Norths OP Therapists Current Knowledge on MFR Techniques (scale 0-10). 14 Summary In this doctoral capstone project, I investigated the cost-benefit analysis of utilizing myofascial release as a treatment option for tight fascia secondary to congenital issues and determined the OP therapists agreeability to utilizing this type of treatment. Birch et al. (2021), found that approximately eleven percent of infants have tongue tie(s). Tongue tie consists of a short lingual frenulum, and depending on the severity, limits the tongues mobility (Fernando, 1998; Rowan-Legg 2015). Severity of a tongue tie depends on the distance of the lingual frenulum between the tongue and floor of the mouth. Infants with moderate to severe tongue tie are often referred to lactation consultants due to breastfeeding concerns (Ricke et al., 2005; Rowan-Legg, 2015). In meeting with IU Norths lactation coordinator, I learned that several babies are referred each month to myofascial release therapy to treat tight fascia secondary to tongue tie. She mentioned one referral source, a physical therapist at a non-affiliated clinic, that utilizes MFR as her primary treatment option for this population. The physical therapist invited me to observe three sessions, receive MFR treatment myself, and ask thorough questions to better understand the details of using MFR for this population. Through extensive research and meeting with the lactation coordinator and physical therapist, I determined that implementation of MFR into IU Norths Pediatric OP clinic would help gain referrals to treat this population at an early age. Appendix B highlights the results of the cost-benefit analysis and suggests that the benefits of implementing MFR into IU Norths OP clinic outweigh the costs of the training courses. The acceptability-perception survey results indicated that the pediatric OP therapy team was very likely to utilize MFR as a treatment option if given the appropriate training and patient population. The therapists also mentioned that 15 MFR training would help advance their skills as a clinician and at least 46-60% of their current caseload could benefit from MFR. Conclusions I collaborated with IU Norths OP pediatric occupational and physical therapists to identify MFR as a beneficial treatment option to utilize with babies with tight fascia secondary to tongue tie, torticollis, and other congenital issues. Through this doctoral capstone project, IU Norths Outpatient Clinic gained several resources and further knowledge on tongue ties, tight fascia, and myofascial release. The occupational and physical therapists can utilize this information to gain referrals and enhance their clinical skills to appropriately treat this these populations. Limitations within this project exist. I did not complete a pre/post survey. Therefore, the participants perspective on the benefits of utilizing myofascial release to address tight fascia secondary to tongue tie, torticollis, and other congenital issues may be skewed secondary to limited knowledge on myofascial release. Only four of the five OP pediatric occupational and physical therapists responded to the acceptability perception. Of those four, 100% reported a 5 or less on a scale of 0-10 on perceived knowledge on MFR. However, 100% of the participations responded very likely to utilize MFR if given the proper training and patient population. Despite these limitations, I identified implications for future practice. IU Norths OP Pediatric Clinic would benefit from further research to determine a combination of treatment techniques to utilize with babies with tight fascia secondary to congenital issues. The clinic would also benefit from further knowledge on how MFR can benefit other patient populations to add to the types of treatment options offered at IU North. 16 References American Occupational Therapy Association (AOTA). (2016). Occupational therapys distinct valueChildren and youth: Resource for administrators and policy makers. American Occupational Therapy Association. https://www.aota.org/~/media/Corporate/Files/Secure/Practice/Children/distinct-valuepolicy-makers-children-youth.PDF. Barnes, J. (n.d.). What is myofascial release? Myofascial Release Treatment Centers and Seminars. https://www.myofascialrelease.com/about/definition.aspx. Birch, A., Bowen, N., Lumsden, H., Penn, K., & Williams, L. (2021). Ankyloglossia management: a collaborative approach to educating healthcare professionals. British Journal of Midwifery, 29(12), 706711. https://doi.org/10.12968/bjom.2021.29.12.706. Bordoni, B., Morabito, B., Mitrano, R., Simonelli, M., & Toccafondi, A. (2018). The Anatomical relationships of the tongue with the body system. Cureus, 10(12), e3695. https://doi.org/10.7759/cureus.3695. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Fernando, C. (1998). Tongue tie: From confusion to clarity. Sydney, Australia: Tandem Publications. Freed, S. S., & Coulter-OBerry, C. (2004). Identification and treatment of congenital muscular torticollis in infants. Journal of Prosthetics & Orthotics (JPO), 16(4 Suppl), S18-s23. https://journals.lww.com/jpojournal/fulltext/2004/10001/identification_and_treatment_of _congenital.7.aspx. 17 Kotlow, L. (2004). Oral diagnosis of abnormal frenum attachments in neonates and infants: evaluation and treatmen of he maxillary and lingual frenum using Erbium: YAG laser. Journal of Pediatric Dental Care, 10, 11-14. Krodel, H. (2021). Occupational therapy in the neonatal intensive care unit. [PowerPoint slides]. ACE@UIndy. https://ace.uindy.edu/portal/site/202020-OTD-583-01. Mills, N., Pransky, S. M., Geddes, D. T., & Mirjalili, S. A. (2019). What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum. Clinical Anatomy (New York, N.Y.), 32(6), 749761. https://doi.org/10.1002/ca.23343. Misuraca, P. (2014). The effectiveness of a costs and benefits analysis in making federal government decisions: A literature review. Center for National Security, The MITRE Corporation. https://www.mitre.org/sites/default/files/publications/cost-benefit-analysisgovt-decisions-14-0929.pdf. Park, T. K., Kim, J. R., Park, R. J., & Cho, M.S. (2006). Effect of myofascial release therapy on newborns and infants with congenital torticollis. The Korean Society of Physical Therapy, 18(5):1-11. http://www.kptjournal.org/journal/view.html?spage=1&volume=18&number=5. Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 6576. https://doi.org/10.1007/s10488-010-0319-7. 18 Ricke, L., A., Baker, N., J., Madlon-Kay, D., J., & DeFor, T.A. (2005). Newborn tongue-tie: Prevalence and effect on breast-feeding. J Am Board Fam Pract. 18(1):1-7. doi:10.3122/jabfm.18.1.1. PMID: 15709057. Rowan-Legg A. (2015). Ankyloglossia and breastfeeding. Pediatrics & child health, 20(4), 209 218. https://doi.org/10.1093/pch/20.4.209. Singh, P., & Anekar, U. (2018). The importance of early identification and intervention for children with developmental delays. Indian Journal of Positive Psychology, 9(2), 233 237. University of Michigan (2016, July). Breast feeding support program. https://medicine.umich.edu/dept/pmr/patient-care/therapeutic-otherservices/occupational-physical-speech-therapy/breast-feeding-support-program. Watts, K. B., & Lagouros, M. (2020). Osteopathic Manipulative Treatment and Breastfeeding. Clinical Lactation, 11(1), 2834. https://doi.org/10.1891/2158-0782.11.1.28. 19 Appendix A 20 Appendix B Cost-Benefit Analysis Spreadsheet 21 22 Appendix C DCE Weekly Planning Guide Week DCE Stage Weekly Goal 1 Complete orientation and onboarding process by the end of the week. Orientation Objectives 2 Tasks Meet the team (OT, PT, ST, RT, Nursing staff, dieticians, lactations specialists, and physicians). Introduce myself and DCE plans. Address supervision plan and MOU with site mentor Familiarize myself with the hospital environment and their policies/procedures Date Completed Introduce self to staff and 01/12/22 build rapport with the team. Set up meetings with essential personnel Create a short elevator speech regarding my project Finalize MOU Ensure Ive completed the onboarding process and am fully ready to begin my project. 01/28/22 01/26/22 01/21/22 Screening/ Evaluation Finish needs assessment by end of the week Finalize the need for my project Screening/ Evaluation Complete additional literature search for program evaluation measurements Establish outcome assessment Review and discuss outcome assessments with the site mentor and faculty mentor 01/28/22 Address referrals for babies with tongue ties Meet with lactation specialists to discuss referrals for tongue-tie related issues 01/27/22 Determine the agreeability and palatability of implementing myofascial release as a treatment option into the Administer survey to OT/PTs in OP clinic regarding their confidence in addressing the target population 03/01/22 Complete referral meeting Create MFR acceptability perception survey 01/26/22 23 outpatient pediatric clinic 3 Screening/ Evaluation Complete data on referral sources 4 Implementation Complete observation and exploration of sites currently receiving referrals related to tongue ties 5 6 Implementation Implementation Understand how, where, and why babies are referred for issues associated with tongue ties Gain insight into best practices for addressing tonguetie related issues Review and compile referral information into document 02/27/22 Visit sites to observe and explore their OP clinic Research sites that currently receive tongue tie referrals Explore MFR and its effectiveness in treating target population 02/09/22 Identify MFR trainings and cost to attend Identify MFR training that are most relevant to treating targeted population Understand MFR mechanisms and techniques utilized during treatment sessions Meet with MFR therapist to gain knowledge and receive treatment Complete outline for best training protocols/programs for OT/PT using MFR to target tight fascia secondary to congenital issues Complete data collection from OT/PT acceptability perception survey 03/04/22 02/08/22 03/14/22 Research and gather additional information on MFR trainings, their cost, and CEU credits Understand MFR on a deeper level by being treated myself Provide staff with MFR training opportunities 03/18/22 Create a document/pamphlet/excel sheet with detailed explanation of trainings offered for therapists interested in treating this population Understand OT/PTs perspectives on implementing MFR Review and compile survey results into document 02/18/22 03/11/22 24 7 Implementation Locate and identify helpful MFR resources Filter through websites, research articles, helpful tips, and other MFR resources Receive feedback from site mentor on cost-benefit analysis Determine best options for dissemination Determine which resources are most beneficial and related to the targeted population 03/11/22 8 Implementation Finalize costbenefit analysis Make changes to costbenefit analysis as appropriate 03/15/22 9 Implementation Create dissemination plans draft Meet with site mentor to discuss ideas for dissemination 03/22/22 10 Implementation Finalize helpful MFR resources Compile and organize resources by topic Create a website to compile and organize gathered MFR resources 03/25/22 11 Implementation Finalize dissemination plans Create dissemination planning guide Send out poll to OP therapy team to determine date and time to meet for dissemination Create handout summarize results 04/01/22 04/01/22 12 Discontinuation Complete project Wrap up project and tie up all loose ends Meet with site mentor to discuss dissemination and final weeks 04/03/22 13 Dissemination Meet with outpatient therapy team Provide team with project results Provide team with handout summarizing project and results 04/06/22 Schedule dates and times to meet with therapy team members Meet with therapy team members to receive and give feedback 04/14/22 14 Dissemination Disseminate project Receive and provide feedback from end users and dissemination partners ...
- Creator:
- Lyndsay Shepherd
- Date:
- 2022-04-22
- Type:
- Capstone Project
-
- Keyword matches:
- ... Title: The Role of Occupational Therapy in the Care of Children with Cortical/Cerebral Visual Impairment; a Narrative Review Daria Seccurro May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Beth Ann Walker, PhD, MS, OTR, QIDP Abstract Objective: This paper describes functional impairments experienced by children with Cortical/Cerebral Visual Impairment (CVI) and how occupational therapists (OTs) play an important role in the evaluation of functional vision and intervention guided by the PersonEnvironment-Occupation (PEO) model. Background: Prevalence of CVI in children is increasing; however, there is lack of consensus on diagnostic practices and few studies evaluating interventions for children with CVI. Some papers discuss the difficulties children with CVI experience in areas such as self-care, play, education, and mobility, but there is minimal evidence to support OT efforts. Methods: A narrative literature review was conducted to identify relevant research. A comprehensive search was performed across multiple databases. Studies that met the inclusion criteria were synthesized for key findings. Discussion: Findings supported that children with CVI face challenges with functional vision impacting daily living skills. These daily skills fall within the OT scope of practice. Although evidence-based interventions specific to OT are limited for CVI, existing literature reports deficits in ADLs, IADLs, play, education, and social participation, emphasizing the need for OT specific interventions for children with CVI. Conclusion: Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, they have a distinct role in caring for this population. Key Words: Cortical Visual Impairment; Cerebral Visual Impairment; children; occupational therapy; rehabilitation Introduction Cortical/Cerebral Visual Impairment (CVI) is the leading cause of visual impairment among children in developed countries (McConnell et al., 2021). CVI is a brain-based visual disorder associated with damage to the posterior portion of the brain, causing the inability to process visual information (Lueck et al., 2019). More than 40% of the brain plays a role in vision and is responsible for visual processing (Dutton et al., 2006). As a result, the brain is unable to process the information coming in from the eyes causing impairments in visual functioning. The impairments associated with CVI vary and span a broad range of severities (Orbitus et al., 2011). The location and extent of the brain insult often plays a factor in the level of impairment (McConnell et al., 2021; Sakki et al., 2022). Vision is a vital sense used in daily activities to interpret the environment. Although most children impacted by CVI often have some level of visual functioning, visual dysfunction plays a significant role in a child's development, learning, mobility, and overall quality of life (Merabet et al., 2017). In addition, CVI profoundly impacts one's ability to complete daily activities which constitute a large portion of life. The daily activities and skills that makeup life are known by occupational therapists as occupations (American Occupational Therapy Association [AOTA], 2020). Within the occupational therapy profession, active engagement in occupations is what supports, facilitates, and promotes participation in life (AOTA, 2020). Occupational therapists have distinct knowledge, skills, and qualities that enhance the occupational process (AOTA, 2020). Contributors in this profession exhibit qualities to complement cornerstones of practice which include but are not limited to client-centered practice, occupation-based practice, evidence-informed practice, theory-based practice, and leadership and professionalism (AOTA, 2020). Occupations are core components to a clients health, identity and sense of competence that are meaningful and viable to that client (AOTA, 2020). Occupations are meaningful everyday activities and include things people need to, want to, and are expected to do (AOTA, 2020). However, a persons context, made up of both personal and environmental factors, largely influences engagement in occupations. Occupational therapists accept the idea that people who achieve full participation must function and engage comfortably in their own contexts (AOTA, 2020). As a person enters different stages of life, their occupations may shift depending on their roles and responsibilities. Occupations commence in infancy and develop throughout life. Although a childs occupations may look vastly different from those later in life, occupations are present across the entire lifespan. A child's daily activities and occupations involve learning, playing, exploring, eating, crawling, among many others. Unfortunately, CVI impacts a child's ability to perform these occupations. However, adapting the activity and/or environment can make it easier for children with CVI to visually process, and increase participation in the activity. The unique needs of children with CVI are often affected by their environment, impacting their ability to function; however even small changes in ones environment positively impact a child (Tsirka et al., 2020) The principle of recognizing the environment's impact on participation in occupation provides a holistic perspective and distinguishes occupational therapists from other professionals trained to care for children with CVI. According to the Person-Environment-Occupation (PEO) Model, occupational performance is the outcome of the interaction between a person, their environment, and an occupation or task (Law et al., 1996). Assumptions from this model presume that the three components continuously overlap to enhance or impede ones ability to achieve occupational performance throughout life. In this model, the person is defined as a unique individual made up of various qualities, experiences, and skills that influence the capacity to engage in occupations and interact with the environment (Law et al., 1996). The person is viewed as an ever-developing individual made up of characteristics that can, in some cases, be responsive to change with intervention (Law et al., 1996). The environment is the context in which occupational performance occurs and can positively or negatively impact a person or an occupation (Law et al., 1996). An environment can affect occupational performance but is said to be more easily modified than the person. Last, occupations include the tasks and activities a person engages in across various environments to meet their needs (Law et al., 1996). In regard to the PEO model, the term occupation is described as a complex task or activity that a person engages in throughout the entire lifespan. These three components continuously overlap and adjust as the person, environment, and occupations change. In order to achieve optimal occupational performance in life, one must balance all three components to maximize the personenvironment-occupation fit (Law et al., 1996). The relevance of the PEO model and occupational therapy poses an avenue to help connect the dots to improve the lives of children with CVI and their families. Occupational therapists use the PEO model as a foundation in practice to encourage individualized, patientcentered care (Law et al., 1996). The needs of this population vary depending on the person, the environments they interact, and the occupations meaningful to them. The number of children diagnosed with CVI is increasing due to advances in medical care. Therefore, there is a need to better understand and gain consensus on the methods of diagnosis and increase evidence supporting interventions for this unique population. However, there is a lack of knowledge across the medical field about CVI and even less evidence on the role of occupational therapy practitioners in treating children with CVI. In order to understand the unique role of occupational therapy in children with CVI, one must first understand the needs of this population and the abilities of OT practitioners to meet those needs. This narrative review focuses on the challenges children with CVI face impacting their occupational performance and explores the specific role of occupational therapy in this unique population. Specifically, this narrative review aims to identify the needs of children with CVI that fall under the OT scope of practice which have been documented in previous literature, and explore how these deficits impact the person, environment, and occupation/task indicating an important role for OT in children with CVI. Background Visual processing is different in children with CVI compared to a child with typical vision. Due to the unique characteristics of CVI, this condition can be hard to diagnose and commonly unintentionally missed (Dutton et al., 2017; Williams et al., 2021). Traditionally, the diagnosis of CVI is given by ophthalmologists due to the impact on visual impairment, but neurological components may require involvement of neurologists (Pehere & Jacobs, 2019; Jackel, 2019). A comprehensive evaluation used to diagnose CVI consists of structured history taking to determine factors of predisposal, parent/caregiver reported observations and insights through interview, a functional vision assessment, eye examination, neurological assessment, and may include neuroimaging (Chang & Borchert, 2020; Itzhak et al., 2021). Children with CVI often present with abnormalities in visual processing that are not explained by the eye exam. Children affected by CVI commonly have a variety of comorbid medical conditions that take precedence early on. As a result, children with CVI demonstrate behaviors and characteristics attributed to their co-occurring medical conditions and are not further evaluated or assessed as disruptions in vision (McConnell et al., 2021; Tsirka et al., 2020). The uncertainties and lack of formal diagnostic protocol can sometimes cause a significant gap in receiving a diagnosis and ongoing care for children with CVI (Sakki et al., 2021). The most crucial time for intervention early in life to optimize brain plasticity (Chang & Borchert, 2020; Chokron & Dutton, 2016; McConnell et al., 2021). Therefore, children with CVI should be offered early intervention for the best outcome in visual processing (Roman-Lantzy, 2007). Martn et al. (2016) expressed that now, more than ever, there is a great need for improved accuracy in diagnosing, assessing, and developing compelling education and rehabilitation programs for individuals with CVI. CVI is a dynamic diagnosis that impacts all areas of life making interdisciplinary care important to maximize support for this population (Jayaraman et al., 2021; Pehere & Jacob, 2019). Beyond receiving a diagnosis, interventions and treatments for CVI have been explored in pharmacology and neurology-based approaches but researchers feel evidence-based assessment and intervention strategies are still lacking (Tsirka et al., 2020). Children with CVIs care is managed by various professionals including ophthalmologists, optometrists, pediatricians, occupational therapists, and nurses (Philip & Dutton, 2014). Other medical and educational professionals who commonly provide support for children with CVI include speech-language pathologists, physical therapists, teachers of students with visual impairments (TVIs), assistive technology specialists and orientation and mobility specialists (Blackstone et al., 2020; Jayaraman et al., 2021; Kran et al., 2019). Initial literature searches revealed two studies that involve occupational therapists' caring for children with CVI. Therefore, the present review comprises literature that is not occupational therapy specific but will reflect on impairments and areas of occupation in which OT intervention could be impactful. Additionally, this review will compile previous researchers' findings on the challenges this population faces and explain how occupational therapy practitioners have the unique skill set to address the needs of this population through the lens of the PEO model. Since children with CVI experience complex challenges in many areas of life, greater attention must be brought to the complexity and extent CVI plays on childrens development. As a result, a comprehensive analysis of the functional challenges that commonly occur in children with CVI is needed to identify the methods which lead to acquisition and/or preservation of everyday skills. Finally, this narrative is intended to raise awareness and better inform healthcare professionals across all settings about the unmet needs of children with CVI and their families to inform quality care better. Method A narrative review methodology was used to conduct and report the research findings regarding the role of occupational therapy in children with cortical/cerebral visual impairment. A narrative review is a comprehensive synthesis of literature that has been previously published and aims to present the broad perspectives of a topic and serve as thought-provoking pieces of literature (Green, 2006). According to Ferrari (2015), narrative reviews do not present new data but intend to assess what is already published; therefore, this style is appropriate for the specific aims of this paper. There is relevant literature regarding children with CVI, but few OT-specific publications. However, discuss issues that could be improved by including OT intervention for children with CVI. Narrative reviews have been popular among authors and readers, making up the largest share of all medical text types and impacting doctors in their clinical practice and research, deeming them a staple of medical literature (Baethge et al., 2019). A structured and in-depth literature search focused on the role of occupational therapy in CVI. Due to the limited literature on this topic, no databases were excluded when searching for relevant literature. Similarly, since the current body of evidence on OT for children with CVI is limited and the objectives of this paper are broad, the inclusion and exclusion criteria for this review were flexible. The authors primary search terms included Cortical visual impairment OR cerebral visual impairment, OR brain based visual impairment, OR CVI, AND children, functional vision impairment, functional vision in children, pediatric, childhood. Articles were excluded if the target population included adults because the challenges, presentation, and prognosis for CVI in children are vastly different. Since research relevant to daily life skills and/or functional challenges is sparse in this population, foundational articles from the late 1980s and 1990s were included. Articles that reported on children with low vision or other visual impairments and CVI were included if an accurate definition of CVI was given. Similarly, articles that discussed exclusively children with low vision, ocular visual impairments, or visual acuity were excluded. Line-by-line examination was utilized during full-text review to identify articles with information that could be related to the role of OT in this population or the CVIspecific characteristics and/or challenges related to the OT scope of practice. Person Visual Characteristics in Children with CVI One of the most significant components in children with CVI are their functional vision deficits, noted in literature as early as 1987. Children with CVI have unique visual traits and behaviors that help them function and/or compensate for decreased visual abilities. One of the most considerable challenges associated with children with CVI is the variable visual abilities that can change from one day to the next (Jan et al., 1987). This concept was reported in 1987 by Jan et al. and has since been verified by many of CVIs top researchers (Chang & Borchert, 2020). However, in recent years, researchers have gained an understanding as to why performance of children with CVI appears to vary frequently and have associated reasoning for this phenomenon. In short, it is now understood that the childs ability to use vision depends greatly on their physical environment, biobehavioral state, performance demands of the task, motivation, and their familiarity with the objects and people in which they are interacting (Lueck et al., 2019). The article by Jan et al. (1987) is one of the earliest works of literature that describes the behavioral characteristics seen in children with CVI. Notable findings documented in this article include improved vision in a familiar environment, impaired visual attention and visual curiosity, and signs of fatigue with visual learning (Jan et al., 1987). More than half of children in this study were reported to use touch to supplement vision during exploration and bring items close to eyes to use vision. Other behaviors noted by the researchers include inaccurate depth perception, need for movement of objects, looking away when reaching, light gazing, and restricted visual fields (Jan et al., 1987). Orbitus et al. (2011) echoes similar findings also indicating the child may fatigue easily when using vision, struggles to maintain focus during tasks, and rely on other perceptions to implement for vision. Various studies have been published over the last 30 years reporting similar behaviors and characteristics in children with CVI. In a study by van Genderen et al. (2012) researchers found that more than 40% of the children with CVI in their sample had challenges using vision in complex visual scenes, 53% had impaired visual fields, and 30% had nystagmus. A Delphi study by Pilling (2022) obtained expert input on various skills and behaviors common in children with CVI. Among this list are behaviors such as the child positioning their head in distinct ways to use vision, looking out of the corner of the eye, avoiding visual input by looking away, and commonly bumping into things when walking (Pilling, 2022). Children with CVI often experience high level visual processing issues such as difficulty with visual discrimination, orientation and need for additional visual processing time (Philip & Dutton, 2014). Similarly, children with CVI often display challenges with delayed visual latency, difficulty with facial recognition, navigation challenges, and inability to process moving objects (Good et al., 2001). Philip and Dutton (2014) summarize the varying abilities of children with CVI fall into three categories including children with profound visual impairments, children with impaired functional vision combined with cognitive and sometimes motor challenges, and children who have impaired functional vision but are capable of working at or close to the expected level for their age (Philip & Dutton, 2014). The CVI Range (Roman-Lantzy, 2007) is an assessment tool as well as a method to understand the varying characteristics and abilities of children with CVI by describing functional vision through scores organized into levels. Children with a score 1-2 have minimal visual response, score 3-4 exhibit more consistent visual response, score 5-6 use vision for functional tasks, score 7-8 demonstrate visual curiosity, and score 9-10 spontaneously use their vision functionally during most activities (Roman-Lantzy, 2007). Co-occurring medical conditions and other visual impairments Along with the brain based visual challenges children with CVI face, researchers have revealed most children with CVI have additional diagnoses and/or comorbidities that challenge development. The most common cause of CVI is an injury to the brain due to a lack of oxygen during the birthing process or shortly after birth (Parajuli et al., 2020). Other associated medical conditions include Periventricular Leukomalacia (PVL), Hypoxic Ischemic Encephalopathy, Cerebral Vascular Accident (CVA), Traumatic Brain Injury (TBI), structural malformations, infection, and metabolic disorders (Chang & Borchert, 2020). CVI is also associated with children born premature, and those who have other neurodevelopmental disorders such as cerebral palsy and seizures disorders (Chang & Borchert, 2020). There have also been findings of children with autism spectrum disorder (ASD) (Chokron et al., 2020), hearing impairments (Matsuba & Jan, 2006) and developmental coordination disorder with CVI (Chokron & Dutton, 2016). Vision plays a significant role in learning motor skills. For children with CVI that have co-occurring motor diagnoses like cerebral palsy, physical performance may be impaired. Children with CVI may have difficulties with motor activities such as walking (Jayaraman et al., 2021) and reaching due to the demands of functional vision use (Baker-Nobles & Rutherford, 1995). Lack of motivation to interact with people and objects may be a direct result of visual dysfunction (Fazzi et al., 2015). Many children with CVI are often delayed with fine motor skills such as reaching, grasping, and pointing because of the inability to process stimuli in the environment, limiting their ability to interact with objects though these skills (Fazzi et al., 2015; Chokron & Dutton, 2016). Similarly, researchers have reported how vision plays a large role in learning postural control and stability important for motor tasks in development (Chokron et al., 2021; Guzzetta et al., 2001). Children with CVI also have co-occurring diagnoses impacting cognition. Chokron and Dutton (2016) explain the impact vision has on all areas of development and how failure to address the visual needs of CVI leads to decreased learning and presents as an intellectual deficit. Matsuba and Jan (2006) reported in their study of 423 children, 86.7% also had cognitive impairments classified as moderate to severe. The researchers report that of the remaining children with high cognition had underlying learning difficulties (Matsuba & Jan, 2006). Finally, co-occurring visual impairments may be present in addition to CVI. Pehere et al. (2018) describe the most common disorders of eye movement control in children with CVI include: strabismus, nystagmus, unstable fixation, inaccurate fast eye movements (dysmetric saccades), deficient smooth pursuit movements, and paroxysmal deviations, in which the eyes intermittently deviate upward. The researchers in this study believe that due to the difficulty in examining childrens vision, many visual issues are often missed (Pehere et al., 2018). Sensory, Behavioral, Psychological Challenges When thinking about CVIs impact on a childs sensory system, vision is the most apparent sense associated. Since vision is impacted for these children, their other senses such as touch and sound are often heightened, and the children use them to compensate for their visual deficits and weak vision (Pehere & Jacob, 2019). Therefore, when the other senses are more easily stimulated children can experience sensory processing difficulties requiring minimizing sensory input in order to focus on use of vision (McKillop & Dutton, 2008). For example, some children with CVI may be sensitive to auditory stimuli, and face additional struggles in environments with a lot of auditory stimulation (Morse, 1999). Similarly, many children early on implement the use of other senses or multiple senses to compensate for a lack of vision to explore their environment (Pehere & Jacob, 2019). Adverse behaviors are another area that can be challenging for children with CVI. This is often attributed to external causes such as complex sensory environments, difficulties with communication, and mental health challenges such as frustration, anxiety, and issues with selfesteem (Goodenough et al., 2021; Lueck et al., 2019). Chokron et al. (2021) indicates how humans naturally adapt to the environment they are in, however if a person cannot see their environment, then they are unable to respond to it. Further, they describe how individuals react emotionally when faced with frightening or stressful events, requiring one to adapt behavior appropriately to overcome the circumstance (Chokron et al., 2021). Researchers connecting this scenario back to children with CVI explain that they are similar in the way they react; however it may be viewed as a behavior disorder or concern (Chokron et al., 2021). The difference between other children that display similar behaviors and children with CVI is that their impacted vision is causing these emotions and behaviors. For example, many children with CVI might be easily frustrated due to the constant visual challenges encountered and have been reported to become fearful when certain visual landmarks are removed that they use to help them identify the environment (Lueck & Dutton, 2015). This may lead to misinterpretation of their environment leading to confusion, fear, and being overwhelmed. There is also evidence that due to decreased ability to identify objects/people in public, children with CVI may also have heightened anxiety or fear of getting lost or injured (Lueck et al., 2019). Parents from Goodenough et al. (2021) indicated how anxiety regarding accessibility at school and in the community affected their child. As children with CVI age, many often struggle with self-concept and self-image challenges due to their experiences socially comparing themselves to other children and/or the expectations (Goodenough et al., 2021). Environment A child with CVIs ability to visually process is dependent on the set up and familiarity of their environment. In particular, children with CVI have more difficulty processing in environments that are new, complex, and stimulating. Physical Ones environment plays an important role in how they interact. Children with CVI are no different, except that environmental challenges and barriers are often more influential to their functioning and much harder to overcome. Physical environments most often associated with children are their homes, school, playground, or stores. However, even these frequently visited places can propose environmental barriers based on external factors. For example, crowding and complexity in the environment can have a negative impact on children with CVI (Philip & Dutton, 2014; Roman-Lantzy, 2007). Environmental complexity proposes too many visual stimuli to process at once for the child and complicates use of functional vision. This frequently leads to visual shutdown in children with CVI or other adverse behaviors. For example, a busy playroom with toys all over the floor is very hard for children with CVI to function (Pehere & Jacob, 2019; Philip & Dutton, 2014). Challenges in an environment like this are hard for children with CVI to focus and are overwhelming to visually process. They often experience additional challenges in unfamiliar environments especially during navigation and often prefer familiar toys and faces (Good et al., 2001; Roman-Lantzy, 2007). Other environmental barriers that can create challenges for children with CVI to use their vision are the level of lighting (too low or bright), low contrasting of colors, and noisy environments (Roman-Lantzy, 2007). Children with CVI often need objects and stimuli brought close to them and struggle to function with stimuli at a distance (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). This especially creates challenges in environments like school and stores. Social, Cultural, and Institutional Researchers from an article by Goodenough et al. (2021) facilitated interviews of parents of children with CVI. In this study parents expressed that many medical professionals do not recognize CVI as an actual condition, nor do they understand challenges associated with CVI (Goodenough et al., 2021). This same sentiment was echoed by Pehere et al. (2018) indicating that awareness about CVI needs to increase in the ophthalmic community and also in general society. The same concept was echoed later in the study when a parent explained that within the childs institutional environment at school, there was lack of training and support from staff and professionals causing more challenges for the child (Goodenough et al., 2021). Further, parents from this study go on to reflect the large amount of time they spent communicating and educating others about their childs needs, as well as taking time off work to create and supply learning materials and resources for their child to use in school (Goodenough et al., 2021). In a follow up study, it was reported that children with CVI can also be greatly affected by their social and cultural environment. Socially, the lack of awareness and understanding of CVI can create barriers for this population, as well as unmet expectations from parents and/or teachers (Lueck & Dutton, 2015). Occupations Our daily activities and tasks change throughout life and continue to develop and change. Children with CVI face barriers in various aspects of life affecting their ability to participate in tasks, activities, and occupations. Occupational therapy practice categorizes occupations as activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020). ADLs The challenges associated with CVI impact daily activities that prevent children from interaction and participation in various tasks. Commonly, children with CVI face more challenges with everyday activities such as dressing, grooming, toileting, bathing, and eating. Challenges associated with dressing include orientating garments correctly while putting them on, locating and/or fastening buttons, finding clothing in a pile or closet, locating and putting on shoes and socks, and localizing the position of lower body dressing to put legs in the correct holes (Philip & Dutton, 2014; Salavati et al., 2015). Other tasks associated with dressing such as tying shoes have also been reported as challenging in this population (Orbitus et al., 2011). Other self-care activities that may be problematic include brushing teeth, due to struggles during application of toothpaste, orienting toothbrush correctly, and locating toothbrush on similar colored surfaces (Salavati et al., 2015). Additionally, challenges with brushing hair might also occur if they cannot locate all areas needing brushing or struggle to position brush correctly in relation to their body (Salavati et al., 2015). Toileting is another skill that occurs daily and can be troublesome for children with CVI. Most commonly, navigation to the bathroom, correct orientation of body in relation to toilet (sitting and/or standing), and challenges with adequately performing toileting tasks (Salavati et al., 2015). Functional skills related to bathing may cause obstacles for children with CVI. For example, navigating placement of bath time materials (soap, washcloth, towel, etc.), not being able to determine the height of the bathtub/shower, need for additional lighting, and failing to rinse soap adequately can all cause disturbances during bathing (Philip & Dutton, 2014; Salavati et al., 2015). Children with CVI may also experience adverse challenges associated with feeding and eating due to the inability to see food on plate, using utensils and vision together to obtain food, or seeing a spoon or bottle as it approaches when being fed (Lam et al., 2010; Philip & Dutton, 2014). Other challenges are drinking from a cup with a straw, and frequently spilling food and drinks (Philip & Dutton, 2014; Salavati et al., 2015). Good et al. (2001) reports that another element of feeding that may be impacted in this population is chewing. Due to chewing being partially learned through vision during early development, this can cause challenges with feeding that may lead to other medical issues such as aspiration (Good et al., 2001). Proper positioning during mealtime is also important and may be challenging for children with CVI due to having to focus intensively on vision use, especially when paired with co-occurring motor challenges (Lam et al., 2010). IADLs When performing IADLs, safety is one of the largest areas of concern in children with CVI. Children with CVI may experience problems that could hinder safety such as not seeing traffic because of impaired movement perception, experience difficulty identify the family car in a parking lot, and getting easily lost in crowds or malls due to too much visual input (Philip & Dutton, 2014; Salavati et al., 2015). Similarly, grocery shopping can cause distress from the overwhelming visual and auditory environment combined, inaccurately navigating locations due to inability to interpret signs (Lam et al., 2010; Pehere & Jacobs, 2019; Philip & Dutton, 2014). Education Research also indicates children with CVI struggle with education activities. Some studies that are specific to children with CVI in the school system have shown children experience issues with school related tasks such as reading depending on complexity of books, writing, viewing materials on a board, loud sensory environment of a room, among others (Philip & Dutton, 2014; Swift et al., 2008). Chokron et al. (2021) reviews the common obstacles children with CVI face and the impact they have on issues with reading. Issues in the classroom may also include slower processing time, struggling to see worksheets, trouble staying in the lines, and difficulty copying items from the board (Philip & Dutton, 2014; Swift et al., 2008). Literature indicates most children with diagnosed CVI have an IEP (Jayaraman et al., 2021) and often receive services from a TVI within the school system. Jackel (2019) conducted a survey on parents of children with CVI and found that parents felt their TVI was competent in treating CVI but other school professionals and staff were not. The same study reports that most parents indicated receiving appropriate accommodations for their child within the school system to be very challenging (Jackel, 2019). Researchers from Goodenough et al. (2021) reiterates similar experiences in their study and reports the importance of the parent in the childs success at school. Also not indicated in literature but an issue to think about is the challenges kids have at school with eating, toileting, navigation, and play which also take place at school every day. Some children with CVI need technological accommodations and work better on tablet/ipad/computer (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). It is important to consider that if accommodations are not made at school and in classrooms, children have a decreased chance to learn and gain knowledge (Goodenough et al., 2021; Jackel, 2019). Social Participation Although occupational struggles are not well studied in children with CVI, an occupation that is often mentioned in professional level works is the challenge this population faces with social participation. Pehere and Jacob (2019) explain how most people identify and recognize people through use of vision, as well as gain information about their emotions from body language and facial expression paired with tone of voice. Children with CVI often have difficulty making eye contact and often miss social cues or fast facial expressions impacting social functioning (Morse, 1999; Philip & Dutton, 2014). They may also struggle to look at someone or something while listening at the same time, leading to either looking away or inability to divide attention (Philip & Dutton, 2014). Literature also shows children with CVI often frequently position themselves in unique ways to use their vision best and may not see a hand presented for a handshake if placed in a non-preferred visual field, further leading to embarrassment and/or appearing rude (Philip & Dutton, 2014). Children with CVI struggle to recognize faces, which is one of the largest documented factors associated with their social struggles; therefore, sometimes even recognizing family members or friends can be challenging (Fazzi et al., 2009; Orbitus et al., 2011; Philip & Dutton, 2014). Socially, parents have reported children with CVI have anxiety surrounding unfamiliar social environments due to fear of getting lost or not being able to find their friends (Philip & Dutton, 2014). Functional Mobility Another large area that impacts children with CVI is functional mobility and navigation. Children with CVI often struggle with navigation for many reasons. Most commonly, lower field deficits make navigating different surfaces more challenging and lead to safety concerns. Children with CVI have also been documented to have challenges with mobility on stairs and uneven surfaces (Lam et al., 2010; Orbitus et al., 2011). Additionally, when in an unfamiliar environment, navigation is more challenging, as well as distance vision impacting ability to see signs or familiar landmarks (Lueck & Dutton, 2015). Functional mobility is often impacted in children with CVI with reports of them commonly falling over clearly visual objects and commonly running into things during mobility (Pilling, 2022). Another challenge is transferring most commonly in the bathroom. Children with CVI often run into things and struggle with depth perception making navigation increasingly challenging (Philip & Dutton, 2014). Another aspect of CVI is the inability to realize movement of an object. This is most likely relevant for safety during navigation especially when crossing the street or walking in public due to the inability to recognize moving structures such as a car (Philip & Dutton, 2014) Play The most important occupation for a child is play. Play is not only how children enjoy life and spend their leisure time but is also a huge element connected to cognitive development early on in life. For some children with CVI, play can be difficult. They have issues with structured play like games due to complications following directions (Salavati et al., 2015). Kids may also have challenges with sports due to the environmental factors (Lam et al., 2010). Similarly, children with CVI often struggle to discriminate between 2-D imagery and prefer 3-D items. This is a barrier in tasks such as puzzles, games, and matching activities, due to it being hard for them to process (Orbitus et al., 2011). Other activities that children often enjoy such as riding a bike or kicking a ball can also be hard due to decreased coordination and balance, and difficulty with safe navigation. Philip and Dutton (2014) list similar activities as challenging such as jumping into a swimming pool due to not being able to judge the height of the water and going down a slide from inability to see the slide when seated. Some children with CVI also have delayed/impacted reflexes which may impact tasks like throwing and catching a ball (Philip & Dutton, 2014). Numerous studies have also mentioned challenges of children when finding a toy in a complex environment such as toy box (Bennett et al., 2019; Philip & Dutton, 2014). Occupational Therapys Role A key role in OT intervention planning includes conducting a detailed occupational profile to help understand specifics to improve both visual and functional outcomes (Harpster, in press). Additionally, in order to better understand ways that occupational therapists can adapt environments to better meet the needs of the child and the occupation, they must be informed on appropriate modifications. Use of the CVI Range can be helpful when implementing interventions due to breakdown of phases in the tool (Roman-Lantzy, 2007). The basis for this functional vision assessment examines the 10 key characteristics of CVI including color preference, need for movement, visual latency, visual field preferences, challenges with complexity, need for light, difficulties with distance viewing, atypical visual reflexes, limited visual novelty, and absence of visual motor skills (Roman Lantzy, 2007). Based on assessment of these components, children are placed into a phase to better understand their current level. The three phases are grouped by scores from 0 (no functional vision use) to 10 (typical functional vision for age and no CVI) into five levels, further classified into three phases to target intervention methods (Roman-Lantzy, 2007). Phase I intervention aims to build consistent visual behavior, phase II targets integrating vision with function, and phase III works on refining CVI characteristics (Roman-Lantzy, 2007). Researchers from Salavati et al. (2015) emphasize that due to the high number of children with CP and CVI together, both occupational and physical therapists need assessment tools available that are adapted for children with CVI in order to gain accurate performance results to inform treatment. Similarly, an intervention study focused on telemedicine for children with CVI involved the Canadian Occupational Performance Measure (COPM) as a primary outcome measure (Schwartz et al., 2021). The results of this study indicate occupational therapy interventions via telemedicine can lead to functional improvements and an increase in satisfaction of goal performance through use of the COPM (Schwartz et al., 2021). As previously discussed, OT are skilled in adapting environments to better suit functioning through task and environment modification. Morse (1999) emphasizes how intervention should analyze the environment the child is in, the activities they participate in, the sensory-motor demands, and time pressure and other variables. Similarly, since OT are skilled to treat children with co-occurring diagnosis of CVI (Chang & Borchert, 2020), therefore, they need to know how to incorporate functional vision use during treatments in order to facilitate visual progress while working on other challenges. Another large element that could be beneficial in treatment of children with CVI is parent education. Parents are very important in teaching their challenge and need the knowledge to modify environments and materials correctly to better support the childs functional vision use and improve daily living (Pehere & Jacob, 2019). The engagement of caregivers/parents is essential, and OT can advocate and teach them how to better understand their child and help meet their needs. Discussion Many of these children experience impacts from CVI in all aspects of daily living, creating functional and developmental challenges. Because occupational therapy provides services exclusively for the persons tasks and occupations, the role of occupational therapist in caring for children with CVI is crucial. CVI affects children in a variety of ways and is a diagnosis that varies from person to person requiring client specific care to individualize treatment to best fit their skills and abilities. A key element important in relation to intervention is that visual functioning in CVI has been proven to improve if the child receives specialized care (Roman-Lantzy, 2010). This reiterates that children with CVI can make improvements overtime. Occupational therapy intervention may focus on specific occupations, context, and environments, and/or performance patterns and skills (AOTA, 2020). Common interventions in OT scope include therapeutic use of occupations and activities, interventions to support occupations, education, training, and advocacy (AOTA, 2020). However, OTs expect that due to the dynamic involvement of a person, environment, and the occupation the ability to adapt, change or develop in certain areas will impact other areas (AOTA, 2020). Because occupational therapy practitioners are taught to analyze the physical and environmental demands of an occupation, they can provide a unique insight into appropriate adaptations and modifications needed in children with CVI during engagement in occupations. Through the use of activity analysis, occupational therapy practitioners can assess the physical and contextual demands of an occupation, specific to the client and their abilities (AOTA, 2020). For children with CVI, their ability to engage in an occupation is variable depending on the context and environment they are in. Therefore, intervention for children with CVI cannot solely disassociate the person from the environment or occupation. Instead, intervention for this population must be inclusive of all three components and provide constant reassessment to determine optimal balance to gain occupational performance. However, modification and intervention can be implemented at the person, environment, and occupational level. The next three sections include general recommendations for OT to use at the person, environment, and occupation level, but do not fully capture all recommendations. For the person, some methods might include allowing extra time for visual processing, adequately address cooccurring challenges such as taking sensory breaks to help maintain focus, being aware of the impact of visual fatigue associated with CVI so planning harder activities earlier in sessions, practicing social participation situation with a child to help increase confidence, implementing emotional regulation strategies for the child to use when overwhelmed or frustrated, and provide the child with skills to advocate for themself and their needs, among many others (Baker-Nobles & Rutherford, 1995; Philip & Dutton, 2014; Swift et al., 2008). Environmental modifications can include but are not limited to adapting the light to be more or less stimulating with a light box, decreasing visual clutter by presenting items one at a time, use of contrasting colored backgrounds such as presenting toys in front of black sheet, adding shiny materials that can be eye catching such as holographic tape on the stairs, placing stimuli at close viewing distances, elevating material with slant board, and avoiding patterned tables or flooring (Baker-Nobles & Rutherford, 1995; Pehere & Jacob, 2019; Philip & Dutton, 2014). Occupational and task adaptation during intervention may involve choosing occupations/tasks meaningful to the child, implementing verbal guidance and cueing during activity, using visual attracting elements during activities, ensuring food on a plate is a contrasting color during eating, placing a mirror in front of the child for dressing to help with fastening buttons, giving verbal directions before games to ensure the child understands rules, and implementing consistent routines (Good et al., 2001; Pehere & Jacob, 2019; Swift et al., 2008). Other characteristics important for occupational therapists to consider when providing interventions is that treatment and intervention methods for children with low vision or other visual impairments will not suffice for children with CVI due to the impairments in CVI being at the brain level (Gorrie et al., 2019). Pehere and Jacob (2019) emphasize that whoever is leading intervention for these children should choose stimuli specific to the childs interests and continually make adjustments to facilitate ongoing engagement. They also suggest that intervention for children with CVI should be carried out through regular childhood development tasks including play, learning, communication, and movement. This specific suggestion further validates the role of OT in caring for this population due to centering all treatment around regular tasks and activities, known to them as occupations. OTs are skilled in environmental modification and task adaptation, which are evident as the forefront of CVI functioning. Because OT professionals are trained in adapt environments to better meet the needs of the individual and optimize their independence. Since children with CVI often exhibit many visual challenges, one of the most important intervention methods is environmental adaptation. Although limited evidence has been proven to examine the difference in how these environmental modifications help children with CVI, there are a few works of literature that have explored parent reports about caring for children with CVI. Many of the unique modifications can be recommended by therapists and applied in the childs natural environment. As a profession, occupational therapists pride themselves on implementing evidencebased care for all clients. However, the evidence and literature for tested intervention is minimal, causing the inability to implement evidence-based care for this population (Harpster, In press). Researchers in Williams' (2021) article mention the growing concern about unmet needs, failure to achieve potential, and avoidable mental health problems like anxiety and poor self-esteem that may be seen in children with CVI whose difficulties go unrecognized over time. Due to OT's broad scope of practice, occupational therapists could be the key to bridging these caps and maximizing care. In order for occupational therapy practitioners to obtain competence in caring for this unique population, they must first have evidence-based literature to guide them in care. Conclusion Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, occupational therapists can provide a unique skill set to help this population. The role of OT as part of the interdisciplinary care team for children with CVI is imperative. In order for healthcare providers to ensure children with CVI are receiving quality care, evidence-based interventions need to be explored in the literature. As the increase in CVI continues to rise, the need for research to support treatment for this population should follow. Occupational therapist can be vital assets in the interdisciplinary team that cares for children with CVI to help increase overall quality of life and independence during daily functioning. References Baethge, C., Goldbeck-Wood, S., & Mertens, S. (2019). SANRA-a scale for the quality assessment of narrative review articles. Research Integrity and Peer Review, 4, 5. https://doi.org/10.1186/s41073-019-0064-8 Baker-Nobles, L., & Rutherford, A. (1995). Understanding cortical visual impairment in children. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 49(9), 899903. https://doi.org/10.5014/ajot.49.9.899 Bennett, C. R., Bex, P. J., Bauer, C. M., & Merabet, L. B. (2019). The assessment of visual function and functional vision. Seminars in Pediatric Neurology, 31, 3040. https://doi.org/10.1016/j.spen.2019.05.006 Blackstone, S. W., Luo, F., Canchola, J., Wilkinson, K. M., & Roman-Lantzy, C. (2021). Children with cortical visual impairment and complex communication needs: Identifying gaps between needs and current practice. Language, Speech, and Hearing Services in Schools, 52(2), 612629. https://doi.org/10.1044/2020_LSHSS-20-00088 Chang, M. Y., & Borchert, M. S. (2020). Advances in the evaluation and management of cortical/cerebral visual impairment in children. Survey of Ophthalmology, 65(6), 708724. https://doi.org/10.1016/j.survophthal.2020.03.001 Chokron, S., & Dutton, G. N. (2016). Impact of cerebral visual impairments on motor skills: Implications for developmental coordination disorders. Frontiers in Psychology, 7, 1471. https://doi.org/10.3389/fpsyg.2016.01471 Chokron, S., Kovarski, K., & Dutton, G. N. (2021). Cortical visual impairments and learning disabilities. Frontiers in Human Neuroscience, 15, 713316. https://doi.org/10.3389/fnhum.2021.713316 Chokron, S., Kovarski, K., Zalla, T., & Dutton, G. N. (2020). The inter-relationships between cerebral visual impairment, autism and intellectual disability. Neuroscience and Biobehavioral Reviews, 114, 201210. https://doi.org/10.1016/j.neubiorev.2020.04.008 Dutton, G. N., Chokron, S., Little, S., & McDowell, N. (2017). Posterior parietal visual dysfunction: An exploratory review. Vision Development and Rehabilitation, 3(1), 10-22. https://doi.org/10.3389/fnhum.2021.713316 Dutton, G. N., McKillop, E. C., & Saidkasimova, S. (2006). Visual problems as a result of brain damage in children. The British Journal of Ophthalmology, 90(8), 932933. https://doi.org/10.1136/bjo.2006.095349 Fazzi, E., Bova, S., Giovenzana, A., Signorini, S., Uggetti, C., & Bianchi, P. (2009). Cognitive visual dysfunctions in preterm children with periventricular leukomalacia. Developmental Medicine and Child Neurology, 51(12), 974981. https://doi.org/10.1111/j.14698749.2009.03272.x Fazzi, E., Molinaro, A., & Hartmann, E. (2015). The potential impact of visual impairment and CVI on development. In Lueck A. H., & Dutton, G. N. (Eds.), Vision and the brain: Understanding cerebral visual impairment in children (pp. 83-105). AFB Press. Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24, 230-235. Good, W. V., Jan, J. E., Burden, S. K., Skoczenski, A., & Candy, R. (2001). Recent advances in cortical visual impairment. Developmental Medicine & Child Neurology, 43(1), 5660. https://doi.org/10.1017/s0012162201000093 Goodenough, T., Pease, A., & Williams, C. (2021). Bridging the gap: Parent and child perspectives of living with cerebral visual impairments. Frontiers in Human Neuroscience, 15, 689683. https://doi.org/10.3389/fnhum.2021.689683 Gorrie, F., Goodall, K., Rush, R., & Ravenscroft, J. (2019). Towards population screening for cerebral visual impairment: Validity of the five questions and the cvi questionnaire. PLoS One, 14(3), 0214290. https://doi.org/10.1371/journal.pone.0214290 Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peerreviewed journals: Secrets of the trade. Journal of Chiropractic Medicine, 5(3), 101117. https://doi.org/10.1016/S0899-3467(07)60142-6 Guzzetta, A., Fazzi, B., Mercuri, E., Bertuccelli, B., Canapicchi, R., van Hof-van Duin, J., & Cioni, G. (2001). Visual function in children with hemiplegia in the first years of life. Developmental Medicine & Child Neurology, 43(5), 321329. https://doi.org/10.1017/s0012162201000603 Harpster, K. Lusk, K., Hamilton, S., Seastone, A., Fox, A., Rice, M., & Schwartz, T. (in press). Exploring the need for education on cortical visual impairment among occupational therapy professionals and teachers of students with visual impairment. The Journal of Visual Impairment and Blindness. Itzhak, B. N., Kooiker, M. J. G., van der Steen, J., Pel, J. J. M., Wagemans, J., & Ortibus, E. (2021). The relation between visual orienting functions, daily visual behavior and visuoperceptual performance in children with (suspected) cerebral visual impairment. Research in Developmental Disabilities, 119. https://doi.org/10.1016/j.ridd.2021.104092 Jackel, B. (2019). A survey of parents of children with cortical or cerebral visual impairment: 2018 Follow-up. Seminars in Pediatric Neurology, 31, 34. https://doi.org/10.1016/j.spen.2019.05.002 Jan, J. E., Groenveld, M., Sykanda, A. M., & Hoyt, C. S. (1987). Behavioral characteristics of children with permanent cortical visual impairment. Developmental Medicine and Child Neurology, 29(5), 571576. https://doi.org/10.1111/j.1469-8749.1987.tb08498.x Jayaraman, D., Jacob, N., & Swaminathan, M. (2021). Visual function assessment, ocular examination, and intervention in children with developmental delay: a systematic approach - part 2. Indian Journal of Ophthalmology, 69(8), 20122017. https://doi.org/10.4103/ijo.IJO_2396_20 Kran, B. S., Lawrence, L., Mayer, D. L., & Heidary, G. (2019). Cerebral/cortical visual impairment: A need to reassess current definitions of visual impairment and blindness. Seminars in Pediatric Neurology, 31, 2529. https://doi.org/10.1016/j.spen.2019.05.005 Lam, F. C., Lovett, F., & Dutton, G. N. (2010). Cerebral visual impairment in children: A longitudinal case study of functional outcomes beyond the visual acuities. Journal of Visual Impairment & Blindness, 104(10), 625635. https://doi.org/10.1177/0145482X1010401008 Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The PersonEnvironment-Occupation Model: A transactive approach to Occupational Performance. Canadian Journal of Occupational Therapy, 63(1), 923. https://doi.org/10.1177/000841749606300103 Lueck, A. H., & Dutton, G. N. (2015). Vision and the brain: Understanding cerebral visual impairment in children. AFB Press, American Foundation for the Blind. https://ebookcentral.proquest.com/lib/uindy-ebooks/detail.action?docID=4727805. Lueck, A. H., Dutton, G. N., & Chokron, S. (2019). Profiling children with cerebral visual impairment using multiple methods of assessment to aid in differential diagnosis. Seminars in Pediatric Neurology, 31, 514. https://doi.org/10.1016/j.spen.2019.05.003 Martn, M. B., Santos-Lozano, A., Martn-Hernndez, J., Lpez-Miguel, A., Maldonado, M., Baladrn, C., Bauer, C. M., & Merabet, L. B. (2016). Cerebral versus ocular visual impairment: The impact on developmental neuroplasticity. Frontiers in Psychology, 7, 1958. https://doi.org/10.3389/fpsyg.2016.01958 Matsuba, C. A., & Jan, J. E. (2006). Long-term outcome of children with cortical visual impairment. Developmental Medicine and Child Neurology, 48(6), 50812. https://doi.org/10.1017/S0012162206001071 McConnell, E. L., Saunders, K. J., & Little, J. A. (2021). What assessments are currently used to investigate and diagnose cerebral visual impairment (CVI) in children? A systematic review. Ophthalmic & Physiological Optics: The Journal of the British College of Ophthalmic Opticians (Optometrists), 41(2), 224244. https://doi.org/10.1111/opo.12776 McKillop, E., & Dutton, G. N. (2008). Impairment of vision in children due to damage to the brain: a practical approach. British and Irish Orthoptic Journal, 5, 814. http://doi.org/10.22599/bioj.222 Merabet, L. B., Mayer, D. L., Bauer, C. M., Wright, D., & Kran, B. S. (2017). Disentangling how the brain is "wired" in cortical (cerebral) visual impairment. Seminars in Pediatric Neurology, 24(2), 8391. https://doi.org/10.1016/j.spen.2017.04.005 Morse, M. T. (1999). Cortical visual impairment: Some words of caution. RE: View, 31(1), 21. https://www.proquest.com/scholarly-journals/cortical-visual-impairment-some-wordscaution/docview/222982418/se-2?accountid=28917 Occupational Therapy Practice Framework: Domain and Process-Fourth Edition. (2020). The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 74(Supplement_2), 7412410010p17412410010p87. https://doi.org/10.5014/ajot.2020.74S2001 Ortibus, E., Laenen, A., Verhoeven, J., De Cock, P., Casteels, I., Schoolmeesters, B., Buyck, A., & Lagae, L. (2011). Screening for cerebral visual impairment: value of a CVI questionnaire. Neuropediatrics, 42(4), 138147. https://doi.org/10.1055/s-0031-1285908 Parajuli, R., Adhikari, S., & Shrestha, U. (2020). Profiles of cortical visual impairment (CVI) patients visiting pediatric outpatient department. Nepalese Journal of Ophthalmology, 12(1), 2531. https://doi.org/10.3126/nepjoph.v12i1.28385 Pehere, N., Chougule, P., & Dutton, G. N. (2018). Cerebral visual impairment in children: Causes and associated ophthalmological problems. Indian Journal of Ophthalmology, 66(6), 812815. https://doi.org/10.4103/ijo.IJO_1274_17 Pehere, N. K., & Jacob, N. (2019). Understanding low functioning cerebral visual impairment: An Indian context. Indian Journal of Ophthalmology, 67(10), 15361543. https://doi.org/10.4103/ijo.IJO_2089_18 Philip, S. S., & Dutton, G. N. (2014). Identifying and characterizing cerebral visual impairment in children: A review. Clinical & Experimental Optometry, 97(3), 196208. https://doi.org/10.1111/cxo.12155 Pilling R. F. (2022). Make it easier: 3-word strategies to help children with cerebral visual impairment use their vision more effectively. Eye (London, England), 10.1038/s41433021-01920-4. Advance online publication. https://doi.org/10.1038/s41433-021-01920-4 Roman-Lantzy, C. (2007). Cortical visual impairment: An approach to assessment and intervention. American Foundation for the Blind. Sakki, H., Bowman, R., Sargent, J., Kukadia, R., & Dale, N. (2021). Visual function subtyping in children with early-onset cerebral visual impairment. Developmental Medicine and Child Neurology, 63(3), 303312. https://doi.org/10.1111/dmcn.14710 Sakki, H., Dale, N. J., Mankad, K., Sargent, J., Talenti, G., & Bowman, R. (2022). Exploratory investigation of brain MRI lesions according to whole sample and visual function subtyping in children with cerebral visual impairment. Frontiers in Human Neuroscience, 15, 765371. https://doi.org/10.3389/fnhum.2021.765371 Salavati, M., Waninge, A., Rameckers, E. A. A., de Blcourt, A. C. E., Krijnen, W. P., Steenbergen, B., & van der Schans, C. P. (2015). Reliability of the modified Pediatric Evaluation of Disability Inventory, Dutch version (PEDI-NL) for children with cerebral palsy and cerebral visual impairment. Research in Developmental Disabilities, 37, 189 201. https://doi.org/10.1016/j.ridd.2014.11.018 Salavati, M., Waninge, A., Rameckers, E. A. A., van der Steen, J., Krijnen, W. P., van der Schans, C. P., & Steenbergen, B. (2017). Development and face validity of a cerebral visual impairment motor questionnaire for children with cerebral palsy. Child: Care, Health and Development, 43(1), 3747. https://doi.org/10.1111/cch.12377 Schwartz, T. L., Harpster, K., Long, J., & Gribben, P. (2021). Telemedicine-based approach in children with cerebral visual impairment (CVI). Journal of American Association for Pediatric Ophthalmology and Strabismus, 25(4), 47. https://doi.org/10.1016/j.jaapos.2021.08.179 Swift, S. H., Davidson, R. C., & Weems, L. J. (2008). Cortical visual impairment in children: presentation intervention, and prognosis in educational settings. Teaching Exceptional Children Plus, 4(5). http://escholarship.bc.edu/education/tecplus/vol4/iss5/art4. Tsirka, A., Liasis, A., Kuczynski, A., Vargha-Khadem, F., Kukadia, R., Dutton, G., & Bowman, R. (2020). Clinical use of the insight inventory in cerebral visual impairment and the effectiveness of tailored habilitational strategies. Developmental Medicine and Child Neurology, 62(11), 13241330. https://doi.org/10.1111/dmcn.14650 van Genderen, M., Dekker, M., Pilon, F., & Bals, I. (2012). Diagnosing cerebral visual impairment in children with good visual acuity. Strabismus, 20(2), 7883. https://doi.org/10.3109/09273972.2012.680232 Williams, C., Goodenough, T., Pease, A., Warnes, P., Harrison, S., Pilon, F., Hyvarinen, L., West, S., Self, J., Ferris, J., Watanabe, R., Clark, R., Evans, M., Osborne, D., Edwards, E., Billington, C., Hunn, R., Matharu, G., & CVI Prevalence Study Group. (2021). Cerebral visual impairment-related vision problems in primary school children: a crosssectional survey. Developmental Medicine and Child Neurology, 63(6), 683689. https://doi.org/10.1111/dmcn.14819 ...
- Creator:
- Daria Seccurro
- Date:
- 2022-05
- Type:
- Capstone Project
-
- Keyword matches:
- ... MENTAL HEALTH AT CASS HOUSING 1 An Occupation-Based Mental Health Program for Adults with Developmental and/or Intellectual Disabilities at CASS Housing Kenzie Salzbrenner, OTS May 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Beth Ann Walker, PhD, MS, OTR, FAOTA MENTAL HEALTH AT CASS HOUSING 2 Abstract In this capstone project, I addressed the mental health and overall wellness of Core Members, adults with developmental and/or intellectual disabilities, at CASS Housing using a variety of mindfulness, cognitive-behavioral, sensory modulation, and emotional regulation techniques. CASS Housing creates independent living solutions for these individuals, but Core Members face social and behavioral difficulties due to mental health disparities in this population. This need led to the development of my occupation-based, six-session mental health program called Promoting Healthy Minds which included sessions on emotional regulation, journaling, yoga and meditation, sensory modulation, and self-esteem. Following the program, participants indicated learning and increased confidence in areas of emotional regulation, mindfulness, strategies to improve self-esteem, and the sensory system. Future program developers can use this program as a guide for intervention strategies to address mental health disruptions and, therefore, improve overall occupational participation in this population. Introduction For this capstone project, I used an occupation-based approach to address the mental health and overall wellness of Core Members, adults with developmental and/or intellectual disabilities, at CASS Housing in Fort Wayne, Indiana. CASS is a privately funded non-profit organization whose goal is to create and maintain customizable, affordable, sustainable, and safe living arrangements for individuals with developmental and/or intellectual disabilities that promote independent living skills (CASS Housing, 2021). There are currently 14 Core Members who live at CASS. Along with living arrangements, CASS provides additional services to Core Members including living skills programs and vocational exploration. Each house also receives support from a Steward who lives in an apartment connected to each house and acts as a MENTAL HEALTH AT CASS HOUSING friendly neighbor by providing occasional support with daily living tasks, organizing monthly house outings, assisting to resolve Core Member conflicts, and meeting with the Core Members weekly to touch base on any issues or concerns. During the initial consultation and assessment to determine the needs of CASS, C. Stackhouse (personal communication, March 22, 2021), the Director of Residential Services, indicated that Core Members struggle with mental health issues leading to social and behavioral challenges in the CASS community. Researchers suggest that over 40% of people with developmental disabilities develop mental health difficulties including anxiety, depression, and psychosis compared to 25% of the general population (Currie et al., 2019). To address these mental health disparities, I developed a six-session program to promote the mental health and overall wellness of Core Members using approaches including mindfulness, emotional regulation, and sensory modulation (Currie et al., 2019; Vicker, n.d.; Wallis et al. 2017). I also addressed self-esteem among Core Members in this program. In this project scholarly report, I provide evidence and rationale for the development, theoretical justification, design and implementation, outcomes, and overall conclusions for this mental health program at CASS Housing. Background Through discussion with key stakeholders at CASS, a needs assessment, and a thorough literature review, I gathered relevant and necessary information to support the purpose and design of my mental health program for Core Members with development and/or intellectual disabilities. Developmental disability is an umbrella term for a group of conditions with impairment in physical, learning, language, or behavior areas resulting in developmental delay (Centers for Disease Control and Prevention, 2021). Intellectual disability is a form of 3 MENTAL HEALTH AT CASS HOUSING 4 developmental disability resulting in limited ability to learn at the expected level and function in daily life (Centers for Disease Control and Prevention, 2020). The Core Members have a range of diagnoses including autism spectrum disorder (ASD), Down syndrome, cerebral palsy, and epilepsy. The Founder, D. Buuck (personal communication, February 23, 2021), shared that the average age of Core Members is 32 with the youngest being 26 and the oldest 52. The model of the current homes is for Core Members who are already living independently or could be with minimal support (CASS Housing, 2022). Therefore, Core Members can cook, clean, manage medications, and complete self-care tasks independently. While Core Members demonstrate success with independent living skills, C. Stackhouse (personal communication, March 22, 2021) stated that residents are experiencing mental health challenges with anxiety, self-esteem, coping, and emotional regulation. He stated these challenges cause arguments, conflict, social isolation, and adverse behaviors among Core Members. These concerns, along with my interest in mental health, led to the development of a literature review and capstone project centered around the development and delivery of a mental health program for Core Members. Throughout various studies, researchers indicated the need for mental health programming among adults with developmental and/or intellectual disabilities. I used these current findings to mold my project design and desired outcomes. I addressed key topics of mindfulness, self-esteem, sensory modulation, and emotional regulation throughout my mental health program. McCauley et al. (2017) indicated that social and cognitive limitations associated with ASD and other developmental disorders prevent the development of meaningful selfconcept. For example, factors including loneliness, negative experiences with peers, lack of intimacy and companionship, and delays in the development of executive functioning limit selfesteem among those with developmental disabilities (McCauley et al., 2017; Ryan & Griffiths, MENTAL HEALTH AT CASS HOUSING 5 2015). Researchers also found that intellectual and developmental disabilities were associated with impairments in emotional development, and level of emotional dysregulation was correlated with severity of disability (Sappok et al., 2020). Per Melville et al. (2016), problem behaviors are the most common psychopathology among adults with intellectual disabilities. Researchers findings guided key topics to address in my mental health program and further emphasized the need for this program at CASS. Researchers explored intervention approaches including mindfulness, cognitivebehavioral, and sensory processing strategies to address anxiety, self-esteem, coping, and emotional regulation for those with developmental and/or intellectual disabilities. Mindfulness was defined as non-judgmental and non-reactive attention to experiences in the present moment including bodily sensations, cognitions, emotions, and urges (Cachia et al., 2016). Singh and Hwang (2020) found that both individual and group-based mindfulness practices are correlated with reduced aggression and destructive behaviors among people with intellectual and developmental disabilities. In addition to these findings, researchers identified that mindfulness and cognitive-behavioral techniques such as meditation, deep breathing, body scanning, and journaling decrease symptoms including anxiety, depression, and inadequacy in thinking among individuals with developmental and intellectual disabilities (Cachia et al., 2016; Currie et al., 2019). Along with mindfulness approaches, strategies of sensory processing and improved understanding of the sensory system guided my program. Wallis et al. (2017) explored sensory modulation interventions aimed at reducing anxiety and improving occupational participation for those with mental health difficulties. Sensory modulation activities for adolescents and adults MENTAL HEALTH AT CASS HOUSING 6 that can address mental health include yoga, art therapy/crafts, music therapy, aromatherapy, or sensory kits (Champagne, 2008). All in all, these various intervention approaches guided my mental health program development for Core Members at CASS. My project differed from current findings and programs as I combined a variety of mindfulness, emotional regulation, and sensory modulation interventions into one program. Target outcomes for the program were addressing, educating on, and improving emotional regulation, sensory modulation, mindfulness, and self-esteem among Core Members to improve mental health, wellness, and occupational participation. Guiding Theories The Person-Environment-Occupation-Performance (PEOP) model guided my doctoral capstone project. I selected this model as it uses a systems model to recognize the dynamic and reciprocal interaction between the person (intrinsic factors), environment (extrinsic factors), and occupational performance (Cole & Tufano, 2008). More importantly, this model considers the intrinsic factors of mental health and cognition. At CASS, I needed to consider both intrinsic factors like cognitive levels of Core Members and extrinsic factors like social support of other residents living in the house concerning mental health. Howlett et al. (2014) and McCauley et al. (2014) found that intrinsic factors of cognition, coping skills, and communication and extrinsic factors of companionship and negative experiences with peers can significantly impact individuals with developmental disabilities mental health. These findings validated the use of the PEOP model in the development of my mental health program. I also used the Cognitive Behavioral frame of reference (FOR) to develop my project. The Cognitive Behavioral FOR is important when psychological barriers limit activity MENTAL HEALTH AT CASS HOUSING 7 engagement (Cole & Tufano, 2008). Using this FOR, cognition and emotion are the two focuses of intervention approach (Cole & Tufano, 2008). Approaches that align with the Cognitive Behavioral FOR include mindfulness-based cognitive therapy including yoga, meditation, deepbreathing, and mindfulness (Cachia et al., 2016; Currie et al., 2019; Robertson, 2011). Function in this theory is viewed as one's ability to use cognitive processes to reason and develop accurate self-awareness and realistic perceptions of the environment and others around them; therefore, functional people can control behavior, thoughts, and feelings to promote occupational performance (Cole & Tufano, 2008). Using the PEOP model and Cognitive Behavioral FOR, I developed programming to address the overall mental health, wellness, and occupational performance of CASS core members. Project Design and Implementation I designed this project using a variety of methods including a needs assessment, thorough discussion with CASS directors, and a literature review of mental health approaches for this population as previously described. The overall purpose of this project was to address the mental health and overall wellness of the Core Members at CASS using a variety of mindfulness, cognitive-behavioral, and sensory modulation techniques (Cachia et al., 2016; Currie et al., 2019). The project consisted of six one-hour, in-person sessions with topics of Exploring Emotions, Journaling, Yoga/Meditation, Sensory Kits, Self-Esteem, and a review session. Each session, other than the final review session, consisted of an education portion via PowerPoint presentation, a supplemental video/picture to practice skills learned, and then a hands-on, occupation-based activity implementing strategies and techniques discussed in the session. In Exploring Emotions, we focused on using appropriate words/actions to describe emotions and the use of Zones of Regulation. I provided Core Members with social situations MENTAL HEALTH AT CASS HOUSING 8 that may elicit an emotional response, and they then used colored candies to match their Zone to their emotions about the situation. We then discussed strategies to move from the "bad" Zones of sadness, anger, and fear to the "good" Zone of happiness, contentment, and joy. Oakley et al. (2020) found that many adults with autism spectrum disorders or other social-communication issues struggle with alexithymia, which is difficulty identifying and describing emotions. Further, Romanowycz et al., (2021) indicated that the use of Zones of Regulation correlated with improvements in self-regulation and emotional behaviors among students. In the Journaling, Yoga/Meditation, and Sensory Kits sessions, we focused on intervention approaches of mindfulness-based therapy and sensory modulation that promoted emotional regulation, reduced destructive behaviors, and decreased anxiety in this population (Currie et al., 2019; Wallis et al., 2017). I used intervention approaches including yoga, journaling, deep breathing, meditation, and the creation of sensory kits in these sessions. We explored different graded and adapted mindfulness strategies including chair yoga, journaling phone apps, and using different sensory materials (ex. water beads, sand) for the sensory kits. The Self-Esteem session included activities of discussing core members strengths, completing an About Me journal entry regarding positive things about themselves, and creating a self-esteem vision board. Self-concept is a limitation for many adults with disabilities, so this session specifically targeted that need (McCauley et al., 2017). While the program sessions were successful overall, some various challenges and successes occurred during each session. Challenges of the program included the need to re-word statements to improve understanding, grade activities to meet the cognitive and developmental levels of each Core Member, and encourage Core Members to maintain attention to the task on hand. For example, some of the Core Members struggled to stay on-task and on-topic during the MENTAL HEALTH AT CASS HOUSING 9 program sessions. While it helped to incorporate different activities into the session to maintain interest, I often had to redirect Core Members back to the topic at hand. One of the greatest successes of the program was that the Core Members responded well to the different media I used throughout the sessions. By using a PowerPoint presentation with audio and visual stimuli and accompanying hands-on approaches, I felt that the Core Members demonstrated greater carry-over of learning than they would have if I had only selected one medium. Another success was that participation increased each session, as I only had 4 Core Members at the initial session but had 8 at the final session. For the outcome assessment to measure target goals throughout my program, I developed individual open-ended outcome measures called the Promoting Healthy Minds Questionnaire (PHMQ) specific to each session. I asked these short, open-ended outcome questions before and after each session. Finally, at the end of the program, I used my overall, open-ended questionnaire called the Promoting Healthy Minds Outcome (PHMO) that measured "satisfaction", feedback from participants, and the overall success of the program. In discussion with Dr. Beth Ann Walker (personal communication, 2022), we decided that open-ended questions specific for each session would best measure outcomes in this population due to question complexity, ease of use, and attendance. Ottmann and Crosbie (2013) indicated that open-ended exploratory questions produce adequate outcomes without forced and categorical responses in adults with intellectual disabilities. Further, Braveman and colleagues (2017) described that pretest/posttest use with a single group allows for ease of implementation and success in measuring change over time. MENTAL HEALTH AT CASS HOUSING 10 Outcomes In the first five sessions of the Promoting Healthy Minds program, Core Members indicated their understanding and knowledge of content for each session using a session-specific, open-ended pretest/posttest titled Promoting Healthy Minds Questionnaire (PHMQ). The participants received the session-specific intervention, and data collection occurred before and after each intervention session to measure target goals. Each PHMQ consisted of three to five questions to measure learning, application, and confidence with the topic(s) covered in class. Each PHMQ is outlined in Appendix A. The use of the open-ended PHMQ specific to each session was most appropriate to measure outcomes in this population due to question complexity, ease of use, and varying attendance (Bravemen 2017; Ottman & Crosbie, 2013). For session one, Exploring Emotions, I asked the four participants to describe healthy strategies to describe or show emotions, explain Zones of Regulation, and list ways to move from the Blue/Yellow/Red Zone to the Green Zone. Following the session, participants identified four new strategies to describe/show emotions, identified the color and emotions for each Zone of Regulation, and listed three new strategies to move to the Green Zone. The next day, one Core Member stated, I was able to use my Zones of Regulation paper last night to help me when I was mad and in the red zoneit helped me not act out on my bad feelings. For session two, "Journaling", I asked the seven participants to describe the benefits of journaling, different methods to journal, strategies to be successful with journaling, and confidence with journaling. Following the session, participants identified four new benefits of journaling, four alternative methods to journal, and three strategies for success with journaling. All participants stated they felt more confident about journaling after the session. MENTAL HEALTH AT CASS HOUSING 11 In session three, Yoga and Meditation, eight participants described the benefits of yoga, deep breathing, and meditation, strategies to use these techniques, and their confidence in using these techniques to regulate emotions. Following the intervention, participants indicated five new benefits of yoga, deep breathing, and meditation, five new strategies to use these techniques, and all participants indicated improved confidence in using these techniques to regulate emotions. In session four, Sensory Kits, six participants identified the senses, described the sensory system, and explored ways to calm or excite the sensory system. Following the intervention, participants listed all six senses, described the sensory system as "how my body feels or responds", and listed new ways to calm or excite the sensory system. In session five, Self-Esteem, eight participants were asked to describe self-esteem, why self-esteem is important, and strategies to improve self-esteem. In the pretest, participants could not identify or describe self-esteem. Following the session, participants described self-esteem as the good things about yourself, thinking positive, and setting good goals, indicated why selfesteem is important, and listed five new strategies to improve self-esteem. In the sixth session, participants responded to a final open-ended questionnaire, the Promoting Healthy Minds Outcome (PHMO), to assess overall learning, feedback, and satisfaction with the Promoting Healthy Minds program. The PHMO is outlined in Appendix B. The eight participants stated that the big ideas they learned in this class were handling emotions, yoga, journaling, mindfulness, and the sensory system. Participants identified mindfulness and emotional regulation strategies including yoga, journaling, deep breathing, listening to music, talking with a supportive person, and using Zones of Regulation. Participants indicated that they liked everything about the program and enjoyed spending time with me and my fellow MENTAL HEALTH AT CASS HOUSING 12 capstone student, Anna Slusser. Participants only critique of the class was that they wished there were more sessions. All participants agreed that they felt the Promoting Healthy Minds program improved their mental health and mindfulness skills. One participant shouted, This class helped me learn really important coping skills! Summary Through the development and implementation of my capstone project at CASS Housing, I addressed mental health disparities among the Core Members. CASS Housing creates a customizable, affordable, safe, and sustainable independent living environment for its Core Members. Throughout discussion with key stakeholders at CASS, a needs assessment, and a literature review, I identified that Core Members have mental health disparities in areas of emotional regulation, self-esteem, and anxiety (Hsieh et al., 2020; McCauley et al., 2017). These factors are impacted by disparities including lack of self-concept, poor sensory regulation, and alexithymia (McCauley et al., 2017; Oakley et al., 2020; Vicker, n.d.). As C. Stackhouse (personal communication, March 22, 2021), Director of Residential Services, indicated that Core Members' difficulties with coping and emotional regulation impact their independent living skills, and therefore occupational participation, my six-session Promoting Healthy Minds program included occupation-based mental health and mindfulness interventions to address these areas of need. Following the implementation of the occupation-based, six-session Promoting Healthy Minds program addressing areas of emotional regulation, mindfulness, sensory modulation, and self-esteem, Core Members demonstrated positive outcomes on the PHMQ and PHMO openended questionnaires. Important results included that Core Members identified new strategies to MENTAL HEALTH AT CASS HOUSING 13 describe and show emotions, emotional regulation techniques, strategies to improve self-esteem, and an improved understanding of the sensory system. Participants also indicated improved confidence with and understanding of yoga, meditation, deep breathing, and journaling to promote mindfulness. All in all, participants indicated that the Promoting Healthy Minds program improved their mental health and mindfulness skills. Conclusion Throughout my capstone experience at CASS Housing, I accomplished and learned new skills in program development, advocacy, and leadership. While the development of the Promoting Healthy Minds mental health and mindfulness program was the focus of my capstone experience, I also assisted in writing two grant applications, participated in a variety of CASS Housing life skills programs, organized and led social events for Core Members, completed Independent Living Scales assessments, set up a fundraiser for CASS, and created a mental health and mindfulness resource binder for the Stewards (see Appendix C). These new skills and increased knowledge of community resources for adults with disabilities will translate into my future occupational therapy interventions and education for adults with disabilities. The site benefited from the project through positive mental health and mindfulness outcomes for Core Members, the use of occupation-based approaches in programs, and the creation of the mental health and mindfulness resource binder for the Stewards. As Core Members indicated increased skill and confidence with emotional regulation, sensory modulation, self-esteem, and mindfulness strategies, they will have increased success managing mental health disparities in their independent living settings. The use of occupation-based strategies to engage Core Members in emotional regulation, sensory modulation, self-esteem, MENTAL HEALTH AT CASS HOUSING 14 and mindfulness activities increased engagement, interest, and motivation for Core Members participating in the Promoting Healthy Minds program. Further, the Steward resource binder acts as a supplement for Stewards to assist and support Core Members during times of mental health crises. This program was the first program to address mental health and mindfulness at CASS Housing; therefore, future program leaders at CASS and other supportive housing communities can use it as a guide to discuss and explore these topics among adults with developmental and/or intellectual disabilities. MENTAL HEALTH AT CASS HOUSING 15 References Braveman, B., Saurez-Balcazar, Y., Kielhofner, G., & Taylor, R.R. (2017). Program evaluation research. In R.R. Taylor (Ed.), Kielhofners research in occupational therapy: Methods of inquiry for enhancing practice (pp. 410-423). Philadelphia, PA: F.A. Davis. Cachia, R.L., Anderson, A., & Moore, D.W. (2016). Mindfulness in individuals with autism spectrum disorder: A systematic review and narrative analysis. Rev J Autism Dev Disord, 3(2). doi:10.1007/s40489-016-0074-0 CASS Housing. (2021). About. https://www.casshousing.org/about Centers for Disease Control and Prevention. (2020, November 10). Child development: Intellectual disability. https://www.cdc.gov/ncbddd/childdevelopment/facts-aboutintellectualdisability.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fncbddd%2Fdeve lopmentaldisabilities%2Ffacts-about-intellectual-disability.html Centers for Disease Control and Prevention. (2021, February 26). Developmental disabilities: Key findings. https://www.cdc.gov/ncbddd/developmentaldisabilities/index.html Champagne, T. (2008). The sensory modulation program. OT Innovations. https://www.otinnovations.com/clinical-practice/sensory-modulation/the-sensory-modulation-programfor-adolescents-adults/ Cole, M., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Currie, T.L., McKenzie, K., & Noone, S. (2019). The experience of people with an intellectual disability of a mindfulness-based program. Mindfulness, 10, 1304-1314. https://doi.org/10.1007/s12671-019-1095-4 MENTAL HEALTH AT CASS HOUSING 16 Howlett, S., Florio, T., Xu, H., & Troller, J. (2014). Ambulatory mental health data demonstrates the high needs of people with an intellectual disability: Results from the New South Wales intellectual disability and mental health linkage project. Australian & New Zealand Journal of Psychiatry, 49(2). doi:10.1177/0004867414536933 Hsieh, K., Scott, H.M., & Murthy, S. (2020). Associated risk factors for depression and anxiety in adults with intellectual and developmental disabilities: Five-year follow up. Am J Intellect Dev Disabil, 125(1), 49-63. doi:10.1352/1944-7558-125.1.49 McCauley, J.B., Harris, M.A., Zajic, M.C., Swain-Lerro, L.E., Oswald, T., McIntyre, N., Trzesniewski, K., Mundy, P., & Solomon, M. (2017). Self-esteem, internalizing symptoms, and theory of mind in youth with autism spectrum disorder. Journal of Clinical Child & Adolescent Psychology, 48(3), 400-411. https://doi.org/10.1080/15374416.2017.1381912 Melville, C.A., Johnson, P.C.D., Smiley, E., Simpson, N., Purves, D., McConnachie, A., & Cooper, S.A. (2016). Problem behaviours and symptom dimensions of psychiatric disorders in adults with intellectual disabilities: An exploratory and confirmatory factor analysis. Research in Developmental Disabilities, 55, 1-13. dx.doi.org/10.1016/j.ridd.2016.03.007 Oakley, B.F., Jones, E.J., Crawley, D., Charman, T., Buitelaar, J., Tillmann, J., Murphy, D.G., & Loth, E. (2020). Alexithymia in autism: Cross-sectional and longitudinal associations with social-communication difficulties, anxiety and depression symptoms. Psychological Medicine, 1-13. doi: 10.1017/S0033291720003244 Ottmann, G., & Crosbie, J. (2013). Mixed method approaches in open-ended, qualitative, exploratory research involving people with intellectual disabilities: A comparative MENTAL HEALTH AT CASS HOUSING 17 methods study. Journal of Intellectual Disabilities, 17(3), 182-197. doi: 10.1177/1744629513494927 Romanowycz, L., Azar, Z., Dang, H., & Fan, Y. (2021). The effectiveness of the Zones of Regulation curriculum in improving self-regulation and/or behaviour in students. The Allied Health Scholar, 2(2). https://ojs.unisa.edu.au/index.php/tahs/article/view/1595 Robertson, B. (2011). The adaption and application of mindfulness-based psychotherapeutic practices for individuals with intellectual disabilities. Advances in Mental Health and Intellectual Disabilities, 5(5), 46-52. doi:10.1108/20441281111180664 Ryan, T.G., & Griffiths, S. (2015). Self-advocacy and its impacts for adults with developmental disabilities. Australian Journal of Adult Learning, 55(1), 31-53. Retrieved March 25, 2021, from https://eric.ed.gov/?id=EJ1059141. Sappok, T., Heinrich, M., & Bohm, J. (2020). The impact of emotional development in people with autism spectrum disorder and intellectual developmental disability. Journal of Intellectual Disability Research, 64(12), 946-955. https://doi.org/10.1111/jir.12785 Singh, N.N., & Hwang, Y.S. (2020). Mindfulness-based programs and practices for people with intellectual and developmental disability. Current Opinion in Psychiatry, 33(2), 86-91. doi:10.1097/YCO.0000000000000570 Vicker, B. (n.d.). Behavioral issues and the use of social stories. Indiana Institute on Disability and Community. https://www.iidc.indiana.edu/irca/articles/behavioral-issues-and-theuse-of-social-stories.html Wallis, K., Sutton, D., & Bassett, S. (2017). Sensory modulation for people with anxiety in a community mental health setting. Occupational Therapy in Mental Health, 34(2), 122137. https://doi.org/10.1080/0164212X.2017.1363681 MENTAL HEALTH AT CASS HOUSING Appendix A Promoting Healthy Minds Questionnaire (PHMQ) for Sessions 1-5 Session 1: Exploring Emotions What is an emotion? What are strategies to describe or show emotions? What are Zones of Regulation? What are strategies to move from the Blue, Yellow, or Red Zone to the Green Zone? Session 2: Journaling What are benefits of journaling? Can you list some different ways/options to journal? What are some strategies you can use to be successful with journaling? Do you feel confident about being able to journal? Session 3: Yoga and Meditation What are benefits of yoga? What are benefits of deep breathing? What are benefits of meditation? What are some different ways to use yoga, deep breathing, or meditation? Do you feel confident about your ability to use yoga, deep breathing, or meditation to regulate emotions/stress/anxiety? Session 4: Sensory Kits Can you list all your senses? What is the sensory system? What are some ways to calm your sensory system? What are some ways to excite it? Session 5: Self-Esteem What is self-esteem? Why is self-esteem important? What are some strategies to improve self-esteem? 18 MENTAL HEALTH AT CASS HOUSING Appendix B Promoting Healthy Minds Outcome (PHMO) for Session 6 What are some big ideas you learned in this program? What is the most important thing you learned from this program? What are some mindfulness strategies you learned in this program? What are some emotional regulation strategies you learned in this program? What did you like about this program? What did you not like about this program? Do you think this program improved your mental health and mindfulness skills? 19 MENTAL HEALTH AT CASS HOUSING 20 Appendix C Mental Health and Mindfulness: Steward Resource Binder Mental Health and Mindfulness: Steward Resource Binder CASS Housing Created by Kenzie Salzbrenner, Occupational Therapy Student, University of Indianapolis MENTAL HEALTH AT CASS HOUSING 21 Emotional Regulation and Mental Health in Adults with Developmental and/or Intellectual Disabilities When addressing emotional regulation and mental health in adults with developmental and/or intellectual disabilities, these are main considerations: Mental Health o Over 40% of people with developmental disabilities develop mental health difficulties including anxiety, depression, and psychosis (lose touch with reality) compared to 25% of the general population (Currie et al., 2019) o Factors that influence the rate of mental illness in this population include lack of coping skills, poor communication, and physical health conditions Stress/Anxiety o Causes for the development of anxiety in this population are atypical sensory function leading to hyperresponsivity to stimuli (increased sensitivity and reactions), difficulty identifying and labeling emotions, and discomfort with unknown situations Emotional Regulation o Many adults with autism spectrum disorders or other social-communication issues struggle with alexithymia, which is difficulty identifying and describing emotions Symptoms of alexithymia include lack of emotional recognition, decreased empathy, and flat affect Self-Esteem o Social and cognitive limitations associated with autism spectrum disorder and other developmental disorders prevent development of meaningful self-concept o Factors including loneliness, negative experiences with peers, lack of intimacy and companionship, and delays in the development of executive functioning may limit self-esteem among those with developmental disabilities MENTAL HEALTH AT CASS HOUSING 22 Self-Advocacy o Self-advocacy can be hindered by lack of self-awareness, self-concept, and informed decision-making Productive Responses to Emotional Dysregulation When addressing emotional dysregulation, sensory outbursts, or behaviors in adults with developmental and/or intellectual disabilities, these are main considerations/techniques: View behavior as communication o There is a negative perception that adverse behaviors mean the individual is difficult, hard to manage, or aggressive o Do not take this viewpoint, rather consider that this population often has difficulty managing emotions, sensory input, and anxiety and ask yourself what are they trying to say with their behavior? Is there an unmet need, is the sensory environment too stimulating, are they having trouble describing how they are feeling? MENTAL HEALTH AT CASS HOUSING Ask them their thoughts and allow them to answer; do not put words into their mouth o Recognize they may have difficulty using appropriate words to describe emotions, see Zones of Regulation section of this binder o Give extended time to answer, this population often requires increased time to process or think of their response View them as your peers rather than talking down to or at them Encourage positive coping strategies o Journaling, yoga/meditation, deep breathing, and sensory kits are detailed throughout this binder Establish set rules/boundaries o Adults in this population do not like uncertainty/unknown or sudden changes Consider their sensory environment and its impact on their behavior or emotions o Is the sensory environment too stimulating or not stimulating enough? o Do they need space to resolve the issue? o See the Modifying the Sensory Environment section of this binder 23 MENTAL HEALTH AT CASS HOUSING 24 Zones of Regulation Zones of Regulation can provide vocabulary or a method to describe/explain emotions, as this population often has difficulty finding the words to describe how they are feeling o They can point to a Zone to show how they feel o They can use color words to describe how they feel I am in the Red Zone right now! You can use Zones of Regulation to discuss how to move from the Blue, Yellow, or Red Zone to the Green Zone o For example, I see that you are in the Red Zone, what can you do to get to the Green Zone? Go on a walk, spend time with friends, deep breathing, yoga/meditation, journaling, call a family member or friend, look at pictures of pets/things you like, find a quiet room MENTAL HEALTH AT CASS HOUSING Journaling Approaches Journaling can be used to reduce stress/anxiety, express emotions, gain selfconfidence, reflect on growth, boost mood, and clear the mind This population may need to use alternative journaling methods for ease of use: o o Artistic Options Pictures Coloring Stickers Phone App Options Speech to Text+ Cappuccino Audio recording journal Can create a group to journal your day and make cappuccino with coffee beans Can share audio stories, life updates, jokes Can use creative prompts to challenge friends Mahalo Video journal app Focus on gratitude Daily prompts, or can use your own prompts/journal ideas Happyfeed Journal Record images each day with a prompt/personal journal Makes a feed where you can see your images/posts from each day DailyBean Pick your daily beans with little bean emojis to show your mood/emotions from the day Puts beans in overall calendar so you can see how your month has been Can pick from a variety of bean categories including weather, social, friends, emotions/moods, food, exercise 25 MENTAL HEALTH AT CASS HOUSING Yoga and Meditation Approaches Benefits of yoga, deep breathing, and meditation: stress relief, reduces anxiety, improves energy, improves focus Yoga Techniques 26 MENTAL HEALTH AT CASS HOUSING 27 Deep breathing techniques o Belly breathing - focus on deep belly breaths, moving belly in and out o Lions breath - release a growl, snarl, loud sound with tongue out when exhaling o Shoulder roll breathing MENTAL HEALTH AT CASS HOUSING o 5-finger breathing o Body scanning How does each body part feel? Start at toes and move up, exploring if each body part is tense/relaxedrelax each body part Mindfulness- breathing Close eyes, find a quiet space, focus on deep breathing Loving kindness Positive affirmation to self and others For example, I hope that my roommate has a great day today o o 28 Meditation techniques Modifying the Sensory Environment Consider each sense when modifying the sensory environment in response to sensory dysregulation or emotional disturbances (sight, smell, taste, touch, hearing, movement) Each persons sensory system is DIFFERENT Ways to calm the sensory system: o Quiet space Sound machines, white noise o Dark space o Tactile Sensations Deep pressure/deep touch Example: weighted blankets, deep massage Warmth MENTAL HEALTH AT CASS HOUSING Fidgets Sensory boxes o Rock/swing forward and backwards o Calming, minimal tastes or smells Example: essential oil diffuser (lavender, eucalyptus) Ways to excite the sensory system: o Loud space o Bright space Colorful, changing, bright lights o Rock/swing side to side (left to right) o Light touch o Jumping o Strong tastes or smells Self-Esteem Methods to improve self-esteem: o Positive self-talk o Gratitude journal o Focus on positive rather than negative o Set achievable goals o Stay physically active o Surround yourself with positive people 29 MENTAL HEALTH AT CASS HOUSING 30 Appendix D DCE Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evalua tion, implementation, discontinuation, dissemination) Orientation Weekly Goal Complete orientation to site/staff/core members Develop plan for project Objectives 2 Orientation Continued orientation with site Foster relationships with core members Finalize program plan/schedule Meet with site mentor, staff, and core members to introduce myself and educate them on my purpose Update MOU with site mentor Discuss possible outcome measures and needs assessment Shadow each director to understand roles Tasks Participate in programs with core members Assist core members with work in gardens Observe Independent Living Skills assessment Present program idea to board members Date complete 1/14/22 Set up additional meetings with key personnel Finalize and submit MOU Find 2 additional grant sources Edit presentation of capstone project plan for presentation to board members Observe house tour Introduction 1st Draft 1/21/22 Create weekly planning guide for project Create a talking point for meeting people Finalize MOU Ensure that paperwork for orientation is complete Research grant sources MENTAL HEALTH AT CASS HOUSING 3 Screening/Eval uation& Program Development 4 Program Development Complete search of literature for program evaluation/outco mes measures Complete pretest/screening Continue development of program plan Finalize program plans and schedule Review literature on mental health programs/interven tions for mental health and adults with developmental/int ellectual disabilities 31 Establish outcomes measures Establish key talking points/topics for first 3 sessions Needs Assessment Finalize calendar with site mentor and core members Finalize list of required items/supplies Develop plan for final 3 sessions for program 5 Implementation Implement session 1 6 Implementation Implement session 2 Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Practice program Finalize supplies for program Meet with core members to introduce program Review outcomes measures with site mentor and faculty mentor Plan first 3 sessions for program Background 1st Draft 1/28/22 Meet with core members, site mentor, and additional staff to finalize program calendar/schedule Discuss possible weaknesses/areas of improvement in project Meet with core members to introduce program plans Project Design 1st Draft Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program 2/4/22 2/11/22 2/18/22 MENTAL HEALTH AT CASS HOUSING 32 7 Implementation Implement session 3 8 Implementation Implement session 4 9 Implementation Implement session 5 10 Implementation Implement session 6 Meet with site mentor for final suggestions Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Record observations during program Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Draft of outcomes Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Dissemination plan Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions 2/25/22 3/4/22 3/11/22 3/18/22 MENTAL HEALTH AT CASS HOUSING 11 Discontinuation Complete posttest/screening 33 Gather data on post-test/screening measures Gather feedback on programs 12 Discontinuation Develop binder with program guides/additional resources Meet with core members to discuss end of program 13 14 Dissemination Dissemination Present program outcomes to staff, core members, site mentor Develop first draft of poster and VoiceThread for dissemination Meet with core members to determine layout of binder Meet with site mentor for assistance with literacy/format of binder Meet with core members to discuss findings of program Create presentation of program and findings Create PowerPoint of program and findings Create first draft of poster Create first draft of VoiceThread Meet with core members to implement posttest/screening for outcome measures Meet with staff for feedback on program Begin data analysis of findings Gather supplies for binder Meet with staff to determine additional needs to be met in binder Form binder Print supplies/materials Gather program feedback from core members 3/25/22 4/1/22 Schedule time to meet to disseminate program to board, staff, core members Finalize presentation and PowerPoint 4/8/22 Meet with site and faculty mentors for feedback on first draft of poster and VoiceThread 1st Draft of Abstract/Summary/ Conclusion 4/15/22 ...
- Creator:
- Kenzie Salzbrenner
- Date:
- 2022-05
- Type:
- Capstone Project
-
- Keyword matches:
- ... IMPLEMENTING A LIFE SKILLS CIRRICULUM 1 Implementing a Life Skills Curriculum to Young Adults and Teens Experiencing Homelessness Megan Rooks May 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Alissia Garabrant, OTD, MS, OTR IMPLEMENTING A LIFE SKILLS CIRRICULUM 2 Abstract Youth experiencing homelessness are faced with a multitude of challenges including finding safe shelter, obtaining income, and often trying to finish high school. (Marshall & Rosenberg, 2014). KIC-IT is a not-for-profit organization that provides coaching services and resources for young adults and teens experiencing homelessness. The purpose of this project was to fill a gap in services provided at KIC-IT by developing and implementing a life skills curriculum. Within the curriculum clients learned to prepare meals using the appliances available to them and foods available at a food pantry. Within the curriculum they also learned budgeting skills and were provided developmental handouts to aid in child rearing. After engaging in the curriculum, clients reported gaining skills in some area of cooking or budgeting. Along with gaining new skills, engaging in cooking classes was a way to build a rapport with staff to facilitate improved ability to work towards meeting goals. IMPLEMENTING A LIFE SKILLS CIRRICULUM 3 Implementing a Life Skills Curriculum to Young Adults and Teens Experiencing Homelessness In 2019, 35,038 youth in the United States ranging from ages 18-24 were considered homeless at some point throughout the year (National Alliance to End Homelessness, 2017). A person falls under the category of being homeless when they do not have access to safe shelter and are currently residing in a place not meant for human habitation (National Alliance to End Homelessness, 2017). Kids in Crisis Intervention Team (KIC-IT) is a not-for-profit organization based out of Johnson County Indiana, which provides services to help young adults and teens experiencing homelessness. KIC-IT has a mission to create a network of support and empowerment for youth to break the cycle of homelessness and promote independence (KIC-IT, 2020). KIC-IT offers case management services, immediate assistance through a drop-in center, and education through an outreach program for their clients. (KIC-IT, 2020). Once a client has started receiving coaching services from KIC-IT the three main goals they are working towards are gaining employment, safe shelter, and budgeting skills (K. Sparks, personal communication, February 12, 2021). Along with the drop-in center, KIC-IT also has transitional houses where their clients can stay up to a year to gain practice with managing bills and home maintenance before moving to a more permanent independent living situation. The purpose of this project was to develop a life skills curriculum for the clients of KICIT. The focus of the curriculum is meal preparation, grocery shopping, and child rearing. Cooking classes were held to teach meal preparation skills, and a cookbook was developed and utilized during these classes. The recipes focused on items that can be found at a food pantry and IMPLEMENTING A LIFE SKILLS CIRRICULUM 4 only require a microwave. Information about how to shop on a budget and ways to reduce their grocery bill were provided at the cooking nights. Childhood development handouts were also created for the clients of KIC-IT. Many of the clients have infants or young children but are lacking in education and resources about their childs developmental needs. These handouts will allow the clients to not only have an idea of what their child should be doing developmentally, but also included information on activities to help enrich their childs development. Background Homelessness in youth and young adults looks different than what is typically thought of when referring to someone who is homeless. Young adults and teens often couch surf between friends homes until their options run out (Schifalacqua et al., 2019). Experiencing homelessness, especially at such a young age, is a traumatic experience that has detrimental effects on an individuals life (Marshall & Rosenberg, 2014). Experiencing this type of living situation causes an individual to be placed under constant stress about meeting basic physiological needs such as a place to sleep at night or where their next meal will come from (Hopper et al., 2010; Levenson, 2017; Brothers et al., 2020). Along with a prevalent history of trauma, many young adults who are experiencing homelessness also have a much higher risk of having a meatal health diagnosis and externalizing behaviors such as substance abuse and high-risk sexual behaviors (Omery et al., 2020; Milburn et al., 2019). This is seen in the clients served at KIC-IT, as many of them have a diagnosis of depression, anxiety, or PTSD. When working with individuals who have a history of trauma, it is essential to approach the situation with care and compassion. Trauma-informed care (TIC) is a method of providing IMPLEMENTING A LIFE SKILLS CIRRICULUM 5 services that view an individuals current problem in the context of their past traumatic experience, which shifts the focus away from addressing and intervening on past trauma (Levenson, 2017). TIC focuses on creating an environment that fosters safety, trustworthiness, choice, collaboration, and empowerment (Fallot & Harris, 2009). When working with individuals who are experiencing homelessness, it is important to not only address the immediate physiological needs of the client but also consider the underlying psychological needs that come from a history of trauma (Hopper et al, 2010). Prestidge (2014) found that by incorporating the TIC approach into interventions for chronically homeless individuals, the recipients of the services can use services more effectively and move towards independence quicker. TIC is an essential part of this capstone project as it is the foundation for all interactions between the clients and capstone student. Many teens and young adults who are homeless are completely on their own without a strong support system. Even though these teens live alone, they often lack the necessary skills to successfully live independently (Thompson et. al, 2018). A person who is experiencing homelessness has little control over the occupations they are engaging in as a majority of their time is spent trying to secure housing, finding opportunities to make income, or functioning in a shelter (Marshall & Rosenberg, 2014). This lack of engagement in many occupations may lead to a decrease in skills needed to successfully live independently (Marshall & Rosenberg, 2014; Chan et al., 2007). This decrease in occupational engagement supported the need for this project to be completed. The clients at KIC-IT were already receiving coaching services on obtaining employment and budgeting skills, and one area staff felt was missing was teaching the clients skills that would be needed once they were able to secure more permeant housing. This capstone IMPLEMENTING A LIFE SKILLS CIRRICULUM 6 project provides the clients of KIC-IT with opportunities to learn new skills to be successful on their way to independence. Not only is one worried about meeting their own basic needs while being homeless, but many of these individuals are parents to multiple young children. Mothers with young children represent the fastest growing section of the homeless population (David et al., 2012). At KIC-IT a majority of the clients have children or are expecting a child. Mothers who are experiencing homelessness are often lacking in the proper resources and education (David et al., 2012). Children who are raised by mothers who are homeless are at a higher risk for developing problems such as developmental delays, poor school performance, and behavior problems (Haber & Toro, 2004). Through completion of the capstone project the clients of KIC-IT who are mothers of children now have access to materials about their childs developmental needs. Along with gaining education on their childrens developmental needs, parents are also gaining information on age-appropriate activities to help their child meet the developmental milestones. This capstone project meets needs that have not been met in previous studies by providing services that allow clients to gain education and obtain new skills along with resources to utilize in their own environment. This capstone project meets the needs of the clients by being flexible in service delivery as sessions were ran when most clients were coming into the youth drop-in center for their coaching meetings. Providing clients with educational materials and resources to take home allowed them to take information as needed to not become overwhelmed with the abundance of new information at once. Theory IMPLEMENTING A LIFE SKILLS CIRRICULUM 7 The Ecology of Human Performance (EHP) was used to guide the development of this doctoral capstone project. EHP is based on the idea that the interaction between a person and environment impacts performance in occupations, and that performance cannot be understood outside of context (Dunn et al., 1994). Within EHP, a person uses their skills and abilities to accomplish specific tasks or occupations, through their current context (Dunn et al., 1994). An individuals performance range is the current tasks they are able to complete which they derive meaning from (Dunn et al., 1994). Within EHP, intervention occurs as a collaborative process between the person and therapist with a main goal to facilitate occupational performance (Abiodun et al., 2021). EHP does not take the approach to fix the individual as some other theories do but considers a holistic view of their current situation (Dunn, 2017). When a person is experiencing homelessness, their context is severely limiting the ability of tasks they can complete. By being homeless they are not able to access many resources that allow for meaningful engagement in valued occupations. Interventions within EHP are in five categories: establish/restore, alter, adapt, prevent, and create (Abiodun et al., 2021; Dunn et al., 1994). For this DCE project the cooking classes and the developmental handouts that were created were developed within the establish/restore category of interventions. The goal of this type of intervention within the model is to restore function by improving abilities and skills within context (Abiodun et al., 2021; Dunn et al., 1994). By teaching these clients new skills they will be set up for more success while living independently. Project Clients at KIC-IT receive coaching from staff on how to manage the current crisis they are in, gain employment and learn the beginning stages of budgeting money. Through the coaching provided at KIC-IT clients talk through various skills needed to live independently but IMPLEMENTING A LIFE SKILLS CIRRICULUM 8 are never given direct instruction or practice in these skills. Along with coaching services, KICIT has a transitional housing program where clients live with two to three other clients in the same home. Many of these clients who live in these houses have never lived independently and have not had to complete home management tasks such as preparing meals. Through this capstone project cooking classes were developed to fill the gap in services provided to clients and to provide them with the skills necessary to be successful in living independently. The cooking classes were hosted once a month on nights that many clients had meetings at the youth center. Developing the project around the clients schedule allowed for a higher percentage of clients to be able to attend. Classes were hosted at the youth drop-in center and were an hour long each. A pre- and post-class survey was developed to assess the clients knowledge on cooking, staying within budget, and utilizing the food received from a pantry. Post-class survey questions assessed if clients had gained knowledge in the areas listed on the pre-class survey. Cooking nights were advertised at the youth center through flyers and by speaking with clients about the events. Recruitment of participants for these classes was difficult across the course. Many of the clients expressed interest in the classes, but on the night of the events they did not show up. Communication via text messages to remind clients about the event was another way to try to increase participation. Gift cards, raffle prizes, and a free meal were promoted at these events to try to overcome the challenge of increasing the clients engagement in the program. Another barrier that arose while hosting these cooking nights was the clients did not all show up at the same time. On some nights one client would show up at the start time, and then one would show up 15 or 20 minutes after, and some would even show up five minutes before IMPLEMENTING A LIFE SKILLS CIRRICULUM 9 the event ended. Trying to incorporate the clients who did not show up on time the activity was challenging. Clients who showed up with only a few minutes left of the activity were excluded from participating in an attempt to promote better time management skills and responsibility. Overall, talking to the clients about the cooking nights while they were already in the youth center was one of the most beneficial ways to recruit clients. Consistently promoting the gift cards and free dinner were the incentives that lead to increased engagement in the cooking nights across the capstone experience. Project Outcomes Before the cooking class started clients filled out a survey assessing their knowledge on a variety of cooking tasks. A 5-point Likert scale was used to assess clients in the areas of: ability to follow a recipe, ability to use appliances in their current living space, ability to cook a variety of meals at home, confidence in cooking, using ingredients at home to make a meal, and staying within budget while grocery shopping. After completing the session, clients answered questions on knowledge gained in the same areas they were asked about on the pre class assessment. The pre and post session surveys allowed an assessment to be completed at each session. This was vital to the project due to the inconsistencies in attendance with very few clients attending more than one session. The pre and post session surveys also allowed each client to be assessed at their current skill level since each client is coming to the cooking classes with different levels of skills. This method of assessment also allowed for cooking skills gained in the class as well as knowledge about budgeting while grocery shopping to be assessed. A total of five clients attended the cooking classes, with none of them attending more than one session. Before attending the cooking classes, all five clients reported agree or IMPLEMENTING A LIFE SKILLS CIRRICULUM 10 strongly agree on their ability to follow a recipe and to use the current appliances in their home. Areas where all five clients reported disagree or neutral were cooking a variety of meals at home and staying within budget while grocery shopping. After completing the cooking session, all clients increased in their knowledge on budgeting while grocery shopping as well as using ingredients they currently have to prepare a meal. A key observation throughout the course of the cooking nights was how the clients were able to have meaningful conversations with the staff during the events. Many of the clients found cooking to be relaxing and allowed them to open up to the staff to deepen their relationship. The relationships built through these conversations allowed the staff at KIC-IT to better serve the clients by knowing them on a more intimate level. Summary One in ten young adults ages 18 to 25 experience some form of homelessness throughout the year (Voices of Youth Count, 2017). Working with a vulnerable population such as young adults and teens who are experiencing homelessness comes with a myriad of challenges to ensure quality care is provided to them. These individuals often have either recent or past trauma that has led to their current state of homelessness (Schifalacqua et al., 2019). Understanding and addressing the underlying trauma is vital to developing rapport with these individuals (Hopper et al., 2010). Due to an unstable environment during vital developmental years, these individuals often lack the skills, education, and experience to overcome the barriers they are challenged with to break the cycle of homelessness on their own. KIC-IT provides coaching services to help these individuals gain safe and secure housing, employment/education, and develop budgeting skills. This capstone project developed a cooking curriculum along with developmental guidelines to IMPLEMENTING A LIFE SKILLS CIRRICULUM 11 fill a gap in service delivery. This curriculum also empowered these induvial with life skills needed to be successfully independent. Incentives of a free meal and a grocery gift card were used to increase client attendance at the cooking nights. The most successful way to recruit participants was through informal conversations at the youth center. Clients completed a pre- and post-class assessments to assess a variety of cooking and budgeting skills before and after each cooking session. Five clients attended at least one of the cooking skills nights, and each reported gaining life skills in these sessions. All participants of the cooking nights reported gaining skills in shopping within their budget and using ingredients they have at home to create a meal. Along with gaining practical life skills, clients were able to deepen their relationship with the staff at KIC-IT in a low-stress environment. This connection allows staff to better understand clients and help them make progress towards their goals which can lead to more positive client outcomes (Curry et al., 2021). Conclusion Positive outcomes look different when looking at results in an emerging practice area compared to a more traditional medical model for occupational therapy. The results of this capstone project display how impactful it is to help enable an individual to gain life skills necessary for independent living. Throughout the 14-week capstone experience a cooking curriculum and cookbook were developed and implemented to give clients at KIC-IT skills to successfully live independently. Along with this, clients were also given access to a developmental guide that also provides examples of developmentally appropriate activities to complete with their children. This curriculum filled a gap in service delivery for the current services that were being provided at IMPLEMENTING A LIFE SKILLS CIRRICULUM KIC-IT. Clients who engaged in the cooking curriculum reported learning skills to help them stay on budget by and increasing their cooking skills. Along with gaining hands on skills at the cooking nights, clients were able to connect with the staff at KIC-IT and deepen their relationship. By better understanding the clients, staff is able to provide more holistic and successful case management services for their clients. 12 IMPLEMENTING A LIFE SKILLS CIRRICULUM 13 References Abiodun, O. Y., Odunayo, A. C., Ayub, S., & Kumari, M. (2021). Disaster Management and Working with Displaced Persons (Methodological Paper). Open Journal of Therapy and Rehabilitation, 9(2), 29-41. Brothers, S., Lin, J., Schonberg, J., Drew, C., & Auerswald, C. (2020). Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention. Social Science & Medicine, 245, 112724. Chan, K. P., Garland, K., Ratansi, K., & Yeres, B. (2007). Viewing youth homelessness through an occupational lens. Occupational Therapy Now, 9(4), 14. Curry, S. R., Baiocchi, A., Tully, B. A., Garst, N., Bielz, S., Kugley, S., & Morton, M. H. (2021). Improving program implementation and client engagement in interventions addressing youth homelessness: A meta-synthesis. Children and youth services review, 120, 105691. David, D. H., Gelberg, L., & Suchman, N. E. (2012). Implications of homelessness for parenting young children: A preliminary review from a developmental attachment perspective. Infant Mental Health Journal, 33(1), 1-9. Dunn, W. (2017). The ecological model of occupation. Perspectives on human occupation: Theories underlying practice, 207-235. Dunn, W., Brown, C., McGuigan, A., (1994). The ecology of human performance: A framework for considering the effect of context. The American Journal of Occupational Therapy. 48 (7), 595-607. IMPLEMENTING A LIFE SKILLS CIRRICULUM 14 Haber, M. G., & Toro, P. A. (2004). Homelessness among families, children, and adolescents: An ecologicaldevelopmental perspective. Clinical Child and Family Psychology Review, 7(3), 123-164. Hopper, E.K., Bassuk, E.L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The open health services and policy journal, 3(1). Levenson, J. (2017). Trauma-informed social work practice. Social Work, 62(2), 105-113. Marshall, C. A., & Rosenberg, M. W. (2014). Occupation and the process of transition from homelessness: Loccupation et le processus de transition de litinrance au logement. Canadian Journal of Occupational Therapy, 81(5), 330-338. Milburn, N. G., Stein, J. A., Lopez, S. A., Hilberg, A. M., Veprinsky, A., Arnold, E. M., ... & Comulada, W. S. (2019). Trauma, family factors and the mental health of homeless adolescents. Journal of Child & Adolescent Trauma, 12(1), 37-47. National Alliance to End Homelessness. (2017). Youth and Young Adults. https://endhomelessness.org/homelessness-in-america/who-experienceshomelessness/youth/ Omerov, P., Craftman, . G., Mattsson, E., & Klarare, A. (2020). Homeless persons' experiences of healthand social care: A systematic integrative review. Health & social care in the community, 28(1), 1-11. Prestidge, J. (2014). Using trauma-informed care to provide therapeutic support to homeless people with complex needs: a transatlantic search for an approach to engage the nonengaging. Housing, Care and Support, 17(4), 208214. https://doi.org/10.1108/HCS-092014-0024 IMPLEMENTING A LIFE SKILLS CIRRICULUM 15 Schifalacqua, M., Ghafoori, A., & Jacobowitz, M. (2019). A hidden healthcare crisis: Youth homelessness. Nurse Leader, 17(3), 193-196. Thompson, H. M., Wojciak, A. S., & Cooley, M. E. (2018). The experience with independent living services for youth in care and those formerly in care. Children and Youth Services Review, 84, 17-25. Voices of Youth Count (2017). Missed opportunities: Youth homelessness in America. https://voicesofyouthcount.org/wp-content/uploads/2017/11/ChapinHall_VoYC_1Pager_Final_111517.pdf IMPLEMENTING A LIFE SKILLS CIRRICULUM 16 Appendix A DCE Weekly Planning Guide Week DCE Stage Weekly Goal Objectives 1 Orientation Orientation to site Meet with site mentor and faculty to explain what I will do over the next 14 weeks Learn roles of each staff member Create plan for implementing life skills class 2 Evaluation 3 Evaluation 4 Review what is currently addressed through coaching program Understand process of becoming Kic-It client Implementation Create materials needed for cooking class Update MOU and literature review Tasks Set up meetings to finalize understand roles at KICIT Date complete 1/14 Research financial literacy and update MOU goals and objectives Finalize MOU Updated due 1/21 MOU and send to all mentors 1/21 Learn current materials provided to clients when starting program Create list of sponsors for programs and materials 1/28 Set up meetings with sponsors for materials 2/4 Create flyer for group cooking classes Create layout of cooking classes Create format for cookbook Set up time for Family Night IMPLEMENTING A LIFE SKILLS CIRRICULUM 5 Implementation Develop cookbook 6 Implementation Finalize plans and lessons for group cooking classes Develop child development handout 7 Implementation Lead group cooking classes 8 Implementation Create materials for group cooking class 9 10 11 Continue to develop cookbook and developmental guide Practice session of group cooking class 17 Add recipes to 2/11 cookbook Purchase materials needed For group session Create developmental guide for family night Create pre and Clean youth post center after assessments classes Continue to develop cookbook and developmental guide Implementation Organize Meeting with materials from mentor over classes and group cooking review group classes cooking classes with mentor 2/18 2/25 Continue to 3/4 add to cookbook developmental guide Set up 3/11 meetings with sponsors for materials Set up meeting with mentor Implementation Finalize group Practice Purchase 3/18 cooking session of materials classes group cooking needed class Add to developmental milestones Implementation Lead classes Administer Add recipes to 3/25 QoL survey cookbook Purchase materials for session IMPLEMENTING A LIFE SKILLS CIRRICULUM 12 Implementation Hand out developmental guides at youth center 13 Discontinuation Finalize materials created 14 Dissemination Present Provide information on developmental milestones to families and ageappropriate activities for their children Organize google drive with updated materials and content for clients Dissemination of project to site 18 Print materials 4/1 Print out 4/8 cookbook and developmental milestone handouts Practice presentation to site 4/15 ...
- Creator:
- Megan Rooks
- Date:
- 2022-05
- Type:
- Capstone Project