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11. Clinical Instructors’ Descriptions of Student Physical Therapist Assistants’ Clinical Reasoning
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- ... Clinical Instructors Descriptions of Student Physical Therapist Assistants Clinical Reasoning Skills Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Marjorie Britt, PT, MHS Copyright April 3, 2024 By: Marjorie Britt, PT, MHS All rights reserved. Approved by: Jessica Emlich Jochum, PhD, LAT, ATC Committee Chair ______________________________ Lisa Borrero, PhD, FAGHE Committee Member ______________________________ Peggy B. Gleeson, PT, PhD Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ STUDENT CLINICAL REASONING 1 Clinical Instructors Descriptions of Student Physical Therapist Assistants Clinical Reasoning Skills Marjorie A. Britt Department of Interprofessional Health and Aging Studies, University of Indianapolis STUDENT CLINICAL REASONING 2 Abstract Introduction: Clinical reasoning (CR) is a complex process the lacks a consistent definition. The result is variability in both the way in which it is taught and assessed. As physical therapy education works toward competency based education, clearly defined skills are imperative. The clinical instructors (CI) expectations related to the physical therapist assistant (PTA) students CR skill development for robust acute care clinical setting preparation needs defined. Objective: This qualitative study investigated the CI expectations of the CR skills that PTA students need prior to beginning their final acute care clinical rotation. Method: Homogenous purposive sampling was used to identify participants, with recruitment carried out by contacting CIs at acute care facilities in Indiana. Nine licensed PTs and PTAs from a narrowly defined population of acute care CIs participated in virtual individual interviews with the researcher using a semistructured interview guide. Dedoose, a web-based software application, was used for secure storage and data analysis, including coding and theme development. Results: Three themes emerged from the study data: assimilation, communication, and safety. CIs expected PTA students to assimilate information from the chart review and communication into a mental picture, provide safe basic interventions, and adapt care to the patients treatment response. Conclusions: This study identified activities for PTA faculty that foster PTA students CR skills for the acute care clinical setting. The findings aligned with master adaptive learning literature with potential for implementing competency-based education models in PTA education. Keywords: clinical reasoning, acute care, clinical instructor, expectations STUDENT CLINICAL REASONING 3 Acknowledgements The success of this study was possible because of an incredible support network. I want to express my deepest gratitude to the dissertation committee, Chair Dr. Jessica Jochum, Analysis Expert Dr. Lisa Borrero, and Content Expert Dr. Peggy Gleeson. The prompt, gracious, and thorough feedback provided by this committee was second to none and I am forever grateful. I want to thank Dr. Lindsey Kojich for gathering the clinical instructor contact information for participant recruitment. I am grateful to the participants in the study who volunteered their time and provided valuable experience, insight, and expertise during the interviews. It is their voices that resonate in the findings of this study. I would also like to thank my academic mentors who provided guidance and encouragement throughout the process, Dr. Julie Gahimer, Dr. Stephanie Miller, Dr. Tammy Simmons, Dr. Michelle Voight and Dr. Eric Wymer. These individuals assisted me in keeping my momentum and focus throughout my doctoral journey. I want to express my deepest gratitude to my husband, Joe Britt, without whom I would not have been able to achieve my goal. His undying support, encouragement, and patience never waned over the last five years. I am immensely thankful to my children, extended family, and friends who prayerfully supported me and offered frequent words and acts of encouragement and support. Lastly, I want to express my thankfulness to the Kendrick Foundation for the scholarships which enabled me to afford this incredible opportunity. STUDENT CLINICAL REASONING 4 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgements ......................................................................................................................... 3 Chatpter 1: Introduction: Clinical Instructors Descriptions of Student Physical Therapist Assistants Clinical Reasoning Skills ............................................................................................. 7 Problem Statement .................................................................................................................... 10 Purpose Statement ..................................................................................................................... 10 Research Questions ................................................................................................................... 10 Significance of the Study .......................................................................................................... 10 Definition of Terms ................................................................................................................... 10 Chapter 2: Literature Review ........................................................................................................ 11 PT Education and Clinical Reasoning....................................................................................... 13 Background ............................................................................................................................ 13 Evolution of Clinical Reasoning and Calls to Action in Physical Therapy Education ......... 14 Clinical Reasoning and the Acute Care Clinical Rotation .................................................... 21 Clinical Reasoning and Acute Care Preparation in Physical Therapist Assistant Education 23 The Next Step ........................................................................................................................ 25 Chapter 3: Method ........................................................................................................................ 26 Study Design ............................................................................................................................. 26 Participants ................................................................................................................................ 26 Setting........................................................................................................................................ 27 Procedures ................................................................................................................................. 27 Sampling and Recruitment .................................................................................................... 27 STUDENT CLINICAL REASONING 5 Informed Consent .................................................................................................................. 30 Data Collection ...................................................................................................................... 31 Data Management and Analysis ............................................................................................ 32 Rigor/Trustworthiness ............................................................................................................... 34 Chapter 4: Results ......................................................................................................................... 35 Theme A: Assimilation ............................................................................................................. 36 Sub-theme A1: Anticipate ..................................................................................................... 37 Sub-theme A2: Facilitators and Barriers ............................................................................... 39 Theme B: Communication ........................................................................................................ 40 Sub-theme B1: Collaborate ................................................................................................... 41 Sub-theme B2: Anticipate ..................................................................................................... 42 Sub-theme B3: Facilitators and Barriers ............................................................................... 43 Theme C: Safety ........................................................................................................................ 43 Sub-theme C1: Anticipate ..................................................................................................... 44 Sub-theme C2: Adapt ............................................................................................................ 46 Sub-theme C3: Facilitators and Barriers ............................................................................... 48 Chapter 5: Discussion .................................................................................................................. 52 Question 1: Clinical Instructors Expectations.......................................................................... 53 Question 2: Clinical Instructors Defining Clinical Reasoning .................................................. 55 Question 3: Barriers and Facilitators to Clinical Reasoning ..................................................... 56 Question 4: Recommendations for Effective Student Preparation............................................ 57 Study Limitations ...................................................................................................................... 60 Implications and Future Research ............................................................................................. 60 STUDENT CLINICAL REASONING 6 Conclusions ............................................................................................................................... 62 References ..................................................................................................................................... 64 Table 1 ....................................................................................................................................... 74 Participant Characteristics and Demographics ....................................................................... 74 Figure 1 ..................................................................................................................................... 75 Visual Representation of Themes and Sub-Themes................................................................... 75 Appendix A ................................................................................................................................... 76 Study Information Sheet............................................................................................................ 76 Appendix B ................................................................................................................................... 83 Initial Participant Recruitment Email ........................................................................................ 83 Appendix C ................................................................................................................................... 85 Personal Information Sheet: ID# ............................................................................................... 85 Appendix D ................................................................................................................................... 86 Follow-up Participant Email and Definition ............................................................................. 86 Appendix E ................................................................................................................................... 88 Interview Questions................................................................................................................... 88 Appendix F.................................................................................................................................... 90 Recruitment Flier....................................................................................................................... 90 STUDENT CLINICAL REASONING 7 Clinical Instructors Descriptions of Student Physical Therapist Assistants Clinical Reasoning Skills In 2020, the American Physical Therapy Association (APTA) Academy of Education Physical Therapist Assistant Educators Special Interest Group (PTAE SIG) identified a need for the implementation of a summit task force (Giffin & Levangie, 2022). The PTA Summit Planning Task Force was inclusive of a wide range of stakeholders within PTA education, clinical education, the APTA, Federation of State Boards of Physical Therapy (FSBPT), and Commission on Accreditation in Physical Therapy Education (CAPTE), (Giffin & Levangie, 2022). This Summit put forward a recommendation to move toward competency-based education models and incorporation of entrustable professional activities (Giffin & Levangie, 2022). The higher education landscape is shifting to accommodate an adaptive learning environment which allows for the flexibility of competency-based programs. Competency-based education (CBE) is used to exhibit public accountability through self-regulation by the profession with the goal of error reduction in and optimal implementation of patient care. (Furze et al., 2022; Timmerberg et al., 2022). Furze et al. (2022) advocate for the inclusion of CR in the domains of competency within PT education to foster consistency in how students learn, are taught, and assessed for CR. Timmerberg et al. (2022) describe that CBE allows for learners to demonstrate competence on a variable timeline optimizing practitioner preparation. CBE can be broken down into entrustable professional activities (EPA)s which are tasks the learner must perform independently once competent in the skill (Timmerberg et al., 2022). The emergence of CBE establishes standardization in and assurance of PT graduate proficiency in entry-level knowledge, skills, and behaviors (Smith et al., 2023). The development of consistent competencies across programs will foster a pathway for acceptance of the model STUDENT CLINICAL REASONING 8 (Abraham et al., 2022; Giffin & Levangie, 2022). Competencies ensure that students achieve the necessary skills to enter the clinical environment with the ability to be safe, competent, and professional. The first step toward creating consistent competencies is defining competency. One such example is Bartl et al. (2022) who has defined entry-level competency in cardiovascular and pulmonary physical therapy. Smith et al. (2023) purport that this competency should be utilized to develop EPAs and Doctor of Physical Therapy (DPT) program curricula. There is a broad requirement for the PTA student to demonstrate entry level competency by the end of their final clinical rotation (CAPTE, 2024b). However, the PTA educational outline for a progression toward attainment of competency through skill acquisition does not demonstrate specificity or consistency in a stepwise process (ten Cate, 2018). Clinical reasoning (CR) skills are one piece of the necessary skill acquisition needed for the PTA student to demonstrate competency across clinical settings with unique environments in which to problem solve and clinically reason. The acute care environment requires a high level of adaptability in a complex environment where patients are medically challenged and often critically ill (Foster et al., 2017; Greenwood, 2022). This requires the PTA to have the CR skills to determine when a patient is rapidly declining and needs immediate medical intervention outside of their scope of practice (Greenwood, 2022; Jessee, 2018). The Academy of Acute Care Physical Therapy has published entry level expectations for the PTA in the acute care setting (Foster et al., 2017). This document incorporates the concepts of clinical decision making and CR in collaboration with the supervising PT. While the terms clinical decision making, clinical problem solving, and clinical judgment were historically used by CAPTE and the APTA Clinical Performance Instrument ([CPI] APTA, 2006) in reference to the PTA, the terminology for CR has been used STUDENT CLINICAL REASONING 9 interchangeably in the literature with critical thinking, clinical decision making, diagnostic reasoning, and clinical judgment (APTA Department of Physical Therapy Education, 2009; Christensen et al., 2017; Furze et al., 2015; Venskus and Craig, 2017). The PTA utilizes CR within their scope of practice and under the guidance and in collaboration with the supervising PT (CAPTE, 2024a; Foster et al., 2017). The document provides a solid foundation for developing competencies in preparation for entry level practice. Such competencies would facilitate the robust acute care preparation that sets the stage for PTA students to be successful in their clinical education and foster confidence with and interest in working in the acute care setting (Ohtake, 2021; Greenwood, 2022). While CR does not have an isolated definition, it has a broad conceptualization within physical therapy. This CR conceptualization within the field of physical therapy uses a biopsychosocial lens to view the complex process of incorporating psychomotor, cognitive, and affective skills upon which the clinician self-reflects, monitors, and adapts using a metacognitive approach within the context of clinical practice and management of the patient (Christensen et al., 2017; Furze et al., 2015; Huhn et al., 2019; McDevitt et al., 2022; Reilly et al., 2022). Because the clinical instructors expectations play a role in student success, having a clear understanding of their expectations would not only be helpful, but may lead to decreased stress for the student (Cullen, 2005; Wolff-Burke et al., 2022). While having a clear set of expectations prior to a clinical rotation is beneficial, there was no research found that investigated the expectations of the CIs related to the CR skills needed by the PTA student prior to entering their final clinical rotation. Only one study was found that investigated the PTA student and CR skills; however, there was no involvement of CIs; rather, it was based on program directors perspectives (Cencetti, 2022). STUDENT CLINICAL REASONING 10 Problem Statement CR is a concept that was investigated relative to the PTA student in one study which was not in an acute care setting or related to the viewpoint of the clinical instructor (Cencetti, 2022). PTA education lacks a clear understanding of what the clinical instructor expects of the PTA student as they enter their final acute care clinical rotation. Purpose Statement The purpose of this study was to investigate the clinical instructors expectation of the CR skills that PTA students need prior to beginning their final acute care clinical rotation. Research Questions For clinical instructors, what are the expectations of the PTA student regarding CR skills prior to beginning their final acute care clinical rotation? How do clinical instructors define clinical reasoning? What do clinical instructors perceive as the barriers and facilitators to clinical reasoning among PTA students as they begin their final acute care clinical rotation? What do clinical instructors believe can successfully prepare students within the academic setting prior to beginning their final acute care clinical rotation? Significance of the Study Investigating the PTA students CR skills expected by the clinical instructor in the acute care setting will set the stage for defining and designing robust acute care preparation within the PTA curriculum. The scope of the research is broadened by a novel stakeholder, methodology, and population as it includes the clinical instructor, a qualitative lens, and acute care environment. Definition of Terms STUDENT CLINICAL REASONING 11 Clinical Reasoning the deliberation about a course of action within a specific context with the ability to anticipate outcomes guided by a framework of previous experiences and knowledge of best evidence (Foster et al., 2017, p. 3). Final acute care clinical rotation the final acute care clinical rotation in which students participate following the completion of their didactic curriculum. Literature Review A collaborative effort by the American Council of Academic Physical Therapy (ACAPT), American Physical Therapy Association (APTA), and APTA Academy of Education set forth A Vision for Excellence in Physical Therapy Education (ACAPT et al., 2021, p. 1). There are six pillars designed for physical therapist and PTA education incorporating the vision to build an educational framework which is well-developed that includes education research (ACAPT et al., 2021). The PTA Education Summit Report (Giffin & Levangie, 2022, p. 1) aligned with these six pillars pairing well with education research by recommending the creation of contemporary resources in support of competency-based education (Giffin & Levangie, 2022). According to the PTA Education Trends Task Force, there is a lack of related, published, peer-reviewed articles on PTA education (APTA Academy of Education, 2020, p. 21). The APTA strategic plan for 2022 through 2025 includes goals for the improvement of the long- term sustainability of the profession leading the way for elevating the quality of care provided by PTs and PTAs (APTA, 2022; APTA Academy of Education, 2020). The evidence must be developed to not only elevate the quality but to substantiate the provision of care provided by the PTA (APTA, 2022). To demonstrate evidence of quality, there is a need for the expansion of the body of evidence on PTA education. The APTA Academy of Education (2020) and their task force report the need to "find STUDENT CLINICAL REASONING 12 ways to incorporate PTA education into the work already being done in PT education (p. 13). A recent publication called for action that would ensure DPT graduates prepare as adaptive learners who are competent in multiple domains including CR (Abraham, et al., 2022). There is a wide gap in the educational requirements between the associate degree for the PTA and a doctoral degree for the DPT. However, the CAPTE requires that both DPT students and PTA students engage in full-time clinical experiences and achieve entry level competency within each respective scope of practice prior to graduating (CAPTE, 2024a, 2024b). The DPT student is required to complete a minimum of 960 hours versus 520 hours required for PTA students at the associate degree level (CAPTE, 2024a, 2024b). DPT education research needs to be applied to PTA education (APTA Academy of Education, 2020), but it must be investigated through the lens of an associate degree level and scope of practice. The Commission on Accreditation in Physical Therapy Education (CAPTE, 2024a, 2024b) identified CR as a requirement within both the DPT and PTA curricula. While previously there was a difference in the wording between the PT and PTA documents, the most recent documents use standardized language for both levels of practice. This new document aligns the language and then clearly delineates the scope of practice for the PTA. This delineation frames the use of CR by the PTA stating CR is achieved in collaboration with and under the direction and supervision of the physical therapist (CAPTE, 2024a, p. 40). There is a precedent for the use of CR at variable levels within other healthcare degrees. Both occupational therapy assistant students and associate degree seeking nursing students are expected to implement CR within their respective scopes of practice (Accreditation Council for Occupational Therapy Education [ACOTE], 2020; Booher, 2016; Coviello et al., 2019). In parallel with physical therapy, the field of occupational therapy has degrees beginning with an STUDENT CLINICAL REASONING 13 Associate of Science in Occupational Therapy Assistant (OTA), Bachelor of Science in OTA, entry-level Master of OT, and entry-level Doctor of OT (American Occupational Therapy Association, 2022). CR is an expectation of ACOTE (2022) for all degree levels within occupational therapy. However, the council defined CR based on each respective scope of practice. Similarly, the nursing profession has degrees at associate, bachelor, master, and doctoral levels with the transition from the associate to bachelor level providing a broadened scope of practice and expanding CR skills (American Association of Colleges of Nursing, 2017; Smith-Kimble, 2022). Pursuing further investigation into CR for the PTA student through a scope of practice at the associate degree level under the direction of the PT aligns conceptually with equivalent associate degrees within the healthcare profession and the CAPTE (2024a) standards and required elements. The importance of establishing a broader body of evidence that informs the education of the PTA student is clear. The focus of this study was on CR which aligns with current PT education research pursuits presented below. In preparation for investigating CR and PTA education, a review of the research on CR and PT education was completed. PT Education and Clinical Reasoning Background It is difficult to attach a single definition of CR as it is a complex process that is based on different theories and practice models (Elvn et al., 2019; Furze et al., 2015a; Gilliland & Wainwright, 2020; McDevitt et al., 2022). Not only is there a lack of consensus on the definition of CR, but there is great variability in how PT programs identify, teach, and assess CR (Christensen et al., 2017; Elvn et al., 2019). One explanation of CR was the ability to monitor self, stop the action, bring different frames of perspective to the situation, see the context of the STUDENT CLINICAL REASONING 14 problem, and grapple with the uncertainty of the situation (Furze et al., 2015a, p. 34-35). Researchers identified a need to establish consensus and guidelines for CR and a research agenda for PT education (Christensen et al., 2017; Wainwright & Gwyer, 2017). ACAPT, established to support the PT academic community, moved the development of PT education and research forward through various initiatives (Deusinger and Sanders, 2017). The Clinical Reasoning Curricula and Assessment Consortium (CRCAC), previously a Consortium of ACAPT, reported their purpose was to pursue best practices for teaching and assessing CR skills (ACAPT, n.d., para. 1). In pursuit of a broader consensus, a more current understanding of CR was investigated through a CRCAC member survey (Christensen et al., 2017). Through the investigation, the proposal of the following operational definition of CR was: CR is a nonlinear, recursive cognitive process in which the clinician synthesizes information collaboratively with the patient, caregivers, and the health care team in the context of the task and the setting. The clinician reflectively integrates information with previous knowledge and the best available evidence in order to take deliberate action. Evolution of Clinical Reasoning and Calls to Action in Physical Therapy Education The National Study of Excellence and Innovation in Physical Therapist Education (Jensen et al., 2017b, p. 857) began seeking input for a Carnegie-type study from educators in 2008 at the APTA Education Sections Educational Leadership Conference. The researchers implemented a qualitative multiple-case study design seeking to understand patterns in PT education that yield excellence. Over two years, a team of researchers observed teaching and learning at exemplary programs to discover how these programs achieved excellence (Jensen et al., 2017b). The authors collaborated using conference calls, face-to-face meetings, and external consultations prior to presenting the findings at national conferences. Jensen et al. (2017b) found STUDENT CLINICAL REASONING 15 that exemplary programs fostered a culture of excellence with visionary, creative, and collaborative leadership who focused on the learner and the patient and educated adaptive learners. The utilization of feedback elicited at the conferences contributed to a refined educational model. Out of this study, a call to reform PT education was made by Jensen et al. (2017a) for pursuing excellence through a transformative agenda which included a focus on evidenced based teaching that fosters CR and adaptive learners. CR is further investigated and presented as a component of clinical readiness in several studies with the focus primarily on the cognitive domain (Dupre et al., 2020; Erdman et al., 2020; Timmerberg et al., 2019). A systematic concept analysis resulted in a broad conceptualization of CR integrating two additional domains (Huhn et al., 2019). This conceptualization was officially adopted as the understanding of CR by the CRCAC: Based on the concept analysis and the themes and patterns that emerged, clinical reasoning in physical therapy could be conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management. (Huhn et al., 2019, p. 447) Historically the process for PT student assessment has focused primarily on identifying the one right answer to a question or scenario (Furze, et al., 2015b). Alternatively, CR incorporates the base knowledge and connects it to a problem-solving process involving student identification of knowledge or understanding gaps (Furze, et al., 2015b; Reilly et al., 2022). In place of teaching basic attainment of knowledge and skills, CR would be better implemented STUDENT CLINICAL REASONING 16 beginning with deductive and moving toward inductive reasoning by teaching to incorporate clinical narratives and cases to develop reflection-for-action and moving forward on a continuum of reflection-on-action to reflection-in-action (Furze et al., 2015b; Reilly et al., 2022). This is best implemented by incorporating understanding in an environment where fear of providing a wrong answer does not limit adaptation (Furze et al., 2015b; Greenwood, 2022). In 2022, Reilly and colleagues developed the Clinical Reasoning Across the Continuum of Physical Therapist Education: A Blueprint for Teaching, Learning, and Assessment. The development of this tool included a four-phase process incorporating expert analysis, expert validation, and stakeholder input developed around the framework of the Clinical Reasoning Assessment Tool (McDevitt et al., 2022, p. 57; Reilly et al., 2022). Expert and stakeholder qualifications included the following: DPT and PhD preparation, individuals with less than 10 years to greater than 20 years of experience, participants employed at universities and as clinicians, authors with publications on CR which were peer reviewed, clinical experts with American Board of Physical Therapy Specialty certifications, academic faculty, DPT students, and clinical instructors (Reilly et al., 2022). This blueprint identifies CR target categories encompassing content knowledge, procedural knowledge and skills, and conceptual reasoning (Reilly et al., 2022, p. 44) which are each assessed at the level of the learner in four categories: beginner, intermediate, competent, and proficient (Reilly et al., 2022, p. 5). In developing this blueprint for teaching clinical reasoning, Reilly et al. (2022) reported that their research heeded the call to reform by Jensen et al. (2017a) and Christensen et al. (2017) for the development of a comprehensive method for teaching, learning, and assessing CR (Reilly et al., 2022). The blueprint demonstrates the multiple components, domains, and levels of learning involved in fostering adaptive learners who implement CR as PT students and has the potential to be STUDENT CLINICAL REASONING 17 implemented as a guide for developing CR within curriculum in competency-based education (Reilly et al., 2022). The master adaptive learner incorporates CR skills into evidenced based interventions while reflecting, problem solving, adjusting, and implementing adaptations to meet the demands of the ever-changing clinical environment and patient care. A call to action was made by Abraham et al. (2022) for the education of DPT students. The authors focused on developing adaptive learning skills that would enable the students to adjust in dynamic situations ensuring excellence in patient care. Implementing models of education that train students in CR skills through adaptive and competency-based implementation requires a shift in perspective. By utilizing hypothetico-deductive reasoning at the onset of learning with a focus on basic skills followed by the progression through stages of learning, students can begin the process of selfreflection, development of metacognitive skills, inductive reasoning, and becoming master adaptive learners who identify and subsequently fill gaps in understanding (Furze et al., 2015a; Kirk-Sanchez et al., 2022; Reilly et al., 2022). Amundadottir et al. (2018) reported that physical therapists implemented the use of CR while treating critically ill patients in the acute care environment by continually monitoring vitals, hemodynamic stability, and the patient response. The authors reported that the physical therapists utilized the patients response to treatment throughout the session regarding how to optimize mobility progression while keeping the patient safe. This type of CR aligns with reflection-in-action as the PT adapts the interventions while engaged in the treatment session to optimize care. Students must learn to envision a plan and anticipate what they will do in a treatment session, reflect on what they have done, and think about what might be done differently to STUDENT CLINICAL REASONING 18 improve outcomes. This process where they improve outcomes by adapting interventions during a treatment session moves through reflection-for-action, reflection-on-action, and reflection-inaction (Furze et al., 2015b). The plan of care can be envisioned through developing a mental representation of the patient presentation (Kirk-Sanchez et al., 2022). The mental representation can be framed with the use of illness and movement scripts in physical therapy education to facilitate pattern recognition and intuitive reasoning skills in combination with hypotheticodeductive reasoning when differentiating between similar scripts (Kirk-Sanchez et al., 2022). Deutsch et al. (2022) proposed a revised Integrated Framework for Clinical Decision Making (p. 2) with one of the focus points being on movement as the informant for the physical therapists CR. Observation of the patient moving is a primary component of CR where the patients movement deficits are identified in the context of functional movement (Abrandt Dahlgren et al., 2022; Christensen et al., 2023; Deutsch et al., 2022). Deutsch et al. (2022) states in parallel with gathering information during the interview, the physical therapist observes the persons spontaneous movement, which can inform tasks and tests/measures to be included in the systems review and examination (p. 3). By focusing on the patients movements, the physical therapist breaks down the deficits into components and identifies the source of the movement dysfunction to provide specific interventions which treat the source of the problem (Kirk Sanchez et al., 2022). In the revised Integrated Framework for Clinical Decision Making (p. 2), Deutsch et al. (2022) also places a focus on the importance of implementing a collaborative partnership between therapist and client. Within the updated framework, the authors explain current physical therapy practice should include the physical therapist interviewing the patient to determine the patients frame of reference and preferences. The patients needs and wishes are then aligned STUDENT CLINICAL REASONING 19 with evidenced based practice and a shared decision making process utilized to define the appropriate plan of care collaboratively (Deutsch et al., 2022). The patient centered approach presented by Deutsch et al. (2022) is further substantiated by Abrandt Dahlgren et al. (2022) in a phenomenological study of nine undergraduate physical therapy students in Sweden. Abrandt Dalgren et al. (2022) reported that the physical therapy students CR was in one of two categories: cognitive versus relational processes. The authors presented novice CR as being implemented using hypothetico-deductive reasoning and reflection-on-action while experienced CR utilized pattern recognition, past experiences, and the patient narrative with reflection-in-action. Abrandt Dahlgren et al. (2022) found that the students who used the cognitive process implemented a step-by-step, therapist focused process of CR much like that of the CR utilized by novice physical therapists. Those using the relational process implemented a patient centered approach ensuring a dialogue was implemented with the patient in a collaborative decision making process where the patients voice guided clinical decision making (Abrandt Dahlgren et al., 2022). The authors reported this patient centered relational process aligned with the CR utilized by experienced physical therapists. Similarly, Amundadottir et al. (2018) reported that physical therapists treating critically ill patients in the acute care setting implemented CR by inclusion of the patient in the decision making process when they were cognitively able. Activities for the beginner level master adaptive learner include using basic textbook illness scripts in the context of CR theory to create a scaffolding and reflection on activities (Reilly et al., 2022). These beginner level activities formatted with role playing and problem solving in groups fostered cooperation in low stakes settings with reflection on activities as a basis for metacognitive learning (Reilly et al., 2022). The beginner level master adaptive learner STUDENT CLINICAL REASONING 20 presented by Reilly et al. (2022) implements the cognitive process as described by Abrandt Dahlgren et al. (2022). However, Reilly et al. (2022) takes the beginner learning beyond the basic cognitive process moving toward a relational process (Abrandt Dahlgren et al., 2022) with pattern recognition in the script-based role playing while developing an understanding of the movement system as presented by Kirk-Sanchez et al. (2022). Clinical reasoning with a cognitive process is based on rudimentary step-by-step problem-solving using information in a hypothetico-deductive process that is parallel to the initial learning experiences with the beginner and intermediate master adaptive learners who integrate learning experiences with reflection on activities to create a scaffolding for metacognition (Abrandt Dahlgren et al., 2022; Kirk-Sanchez et al., 2022; Reilly et al., 2022). According to Reilly et al. (2022), during the intermediate level of learning, the master adaptive learner development progresses students from basic role playing of patient scenarios to encountering people with real movement dysfunction (p. 19) with a focus on contextual factors and practicing psychomotor skills in a low stakes environment. Additionally, the student benefits from participating in patient interaction at pro bono clinics and integration of clinical education experiences. At the competent level the master adaptive learner engages in more complex patient care simulation during labs moving beyond the basic contextual factors and handling skills to decision making and implementing interventions and real patient care during clinical rotations. Related to patient engagement, the beginner level master adaptive learner participates in learning through role playing by the instructor who simulates the patients needs where the patient is an active contributor to the conceptualization of the plan of care (Reilly et al., 2022). This provides scaffolding for CR like the relational process where the patient is the center of care STUDENT CLINICAL REASONING 21 (Abrandt Dahlgren et al., 2022; Reilly et al., 2022). The relational process of CR aligned with that of experienced clinicians and was marked by collaboration with the patient and a problemsolving approach using pattern recognition with progressive illness scripts (Abrandt Dahlgren et al., 2022; Reilly et al., 2022). The progressive illness scripts are presented in the intermediate stage of learning while the reflection-in-action is implemented in the competent stage of learning for the master adaptive learner (Abrandt Dahlgren et al., 2022; Reilly et al., 2022). These concepts align with the mission statement for the APTA which is building a community that advances the profession of physical therapy to improve the health of society (APTA, n.d.). To improve the health of society, the physical therapist has a responsibility as a professional to provide care that is in alignment with the patients specific needs (Berg-Carramusa et al., 2023). To optimize the health of society, the physical therapist should use the relational process with movement as an informant for CR to incorporate a collaborative therapeutic alliance with the patient while ensuring that the patients voice is heard and incorporated into an evidenced based plan of care (Abrandt Dahlgren et al., 2022; Berg-Carramusa et al., 2023; Deutsch et al., 2022; Kirk-Sanchez et al., 2022). Clinical Reasoning and the Acute Care Clinical Rotation The acute care setting is a rapidly paced environment with patients who have complex medical conditions (Costello & Maring, 2018; Greenwood et al., 2014). Amundadottir et al. (2018) found that physical therapists working with critically ill patients in the acute care setting utilized a team approach to care and worked closely with nursing. The high acuity and intense pace require collaboration, teamwork, and communication with the interdisciplinary team to ensure patient success (Greenwood, 2022). According to Berg-Carramusa et al. (2023), it is the responsibility of educators to develop active listeners who are competent in communicating STUDENT CLINICAL REASONING 22 interprofessionally and collaboratively with a team of clinicians. The acute care environment requires adaptive learners who can identify where their gaps in learning are, seek out strategies to fill those gaps, engage in self-reflection, and then implement adjustments based on those reflections to meet the needs of the patient (Greenwood, 2022). There were no published studies identified which focus solely on CR in the acute care setting during a clinical rotation. The studies found incorporate CR as one component in a larger list of skills across multiple settings including acute care. Timmerberg et al. (2019) and Dupre et al. (2020) investigated the first clinical education experience for DPT students using a Delphi study model which engaged experts on the topic as participants. Both studies had representation from the acute care setting among the participants. Both studies initially included CR as a topic of investigation. CR did not meet the consensus for inclusion in skills for the PT students clinical readiness for a first clinical education experience in the study done by Timmerberg et al. (2019); however, it did meet consensus as one of five clinical readiness objectives in the study by Dupre et al. (2020). Additionally, there was a qualitative study implemented across multiple settings, including acute care (Erdman et al., 2020). It investigated if students who participated in a minimum of 60 hours at a pro bono clinic demonstrated improved preparedness for their first full-time clinical rotation (Erdman et al., 2020). The authors found that CR improvements were achieved by students based on evaluation using the Clinical Performance Instrument (APTA, 2006; Erdman et al., 2020). While the research included information related to the PT student in the acute care setting during clinical rotations, the sole focus of these studies was not CR. Rather, CR represented only a component of the information investigated in each of the studies. Cunningham and Cunningham (2020) completed a study examining the use of standardized patients in a critical care simulation experience with DPT students serving as STUDENT CLINICAL REASONING 23 participants. The study did not directly assess CR; however, it was a topic of discussion with the students during the simulation experience (Cunningham & Cunningham, 2020). The simulations included managing a chest tube and a tracheostomy with simulated body fluids within the devices (Cunningham & Cunningham, 2020). The authors found that students had an increase in their perceived comfort with the skills required for the critical care setting. While these findings are not directly applicable to CR preparation for an acute care clinical rotation, they do provide support for incorporating simulated patient care into the preparation for the physical therapy student during their academic preparation for the acute care setting. Clinical Reasoning and Acute Care Preparation in Physical Therapist Assistant Education Cencetti (2022) notes that the abundant research on CR for PT students versus the lack of similar research for PTA students may suggest that PTA students do not engage in the skill. While the previous edition Standards and Required Elements for Accreditation of Physical Therapist Assistant Education Programs did not utilize the term CR in reference to the PTA, the Standards and Required Elements for Accreditation of Physical Therapist Assistant Education Programs (CAPTE, 2024a) now include this terminology. This affirms the expectation that PTAs develop and utilize this skill within PTA education. The APTA Acute Care Academy published core competencies for both PT and PTA entry level practice (Foster et al., 2017; Greenwood et al., 2015). CR was defined within these documents as the deliberation about a course of action within a specific context with the ability to anticipate outcomes guided by a framework of previous experiences and knowledge of best evidence (Foster et al., 2017, p. 3; Greenwood et al., 2015, p. 5). Because this definition is a component of the document which frames entry level practice in the acute care setting for both the PT and PTA, this definition was the key reference point for CR for the purposes of this STUDENT CLINICAL REASONING 24 qualitative study. While both the PT and PTA core competencies for entry level practice in acute care have the same definition for CR, there are statements providing further direction. For the PT CR is noted within the clinical decision making framework to be the foundation for competency in all areas including communication, safety, discharge planning and patient management (Greenwood et al., 2015, p. 3). According to Foster et al., the PTA utilizes CR relative to being able to function within the PT/PTA team and demonstrate competency in assisting the PT in all areas, including communication, safety, discharge planning, and patient management (Foster et al., 2017, p. 3). There is a clear focus placed on the collaborative effort between the PT/PTA team and the need for the PTA to be competent in assisting the PT (Foster et al., 2017). This document distinguishes between the two terms CR and clinical decision making. Beyond the initial note of CR both documents move to discuss clinical decision making rather than CR. The PT document states that the PT must be able to make high level clinical decisions (Greenwood et al., 2015, p. 2). The PTA document notes that the PTA must be confident and competentwithinan established physical therapy plan of care (Foster et al., 2017, p. 2). As CR investigation is implemented relative to the PTA student, it must be viewed through the lens of the PTA scope of practice which falls directly under the supervision of the PT. The PTA working in the acute care setting makes clinical decisions equating to their competence level to ensure safe, efficient, and effective treatment for patients (Foster et al., 2017, p. 2) using collaborative CR as interprofessional team members (CAPTE, 2024a). While the PTA requires the supervision of a PT, increasing demands on the PTA for treating at a higher level of medical acuity and complexity makes it imperative that they have the CR skills to quickly identify a deterioration of the patients health status when red flag issues arise (APTA STUDENT CLINICAL REASONING 25 Academy of Education, 2020; CAPTE, 2020b; Joplin-Gonzales & Rounds, 2022; Mueller et al., 2012). PTA students need the appropriate skill level of CR upon graduation to perform at entry level to practice under the supervising PT. One published study researched CR and the PTA student used a mixed-methods approach. The concepts for investigating the topic were derived from the CR Curricula and Assessment Research Consortiums operational definition of CR for the PT student reported by Christensen et al. (2017) as well as the Integrated Clinical Education Theory (ICET) derived from nursing education (Cencetti, 2022). Cencetti (2022) recruited PTA program directors via email whose contact information was available within Annual Accreditation Reports from 2017 on the CAPTE website (Cencetti, 2022). Content analysis of the open-ended questions revealed that the 97 program directors who participated had responses that were aligned with CR concepts in both the operational definition of CR and the ICET concepts (Cencetti, 2022). According to Cencetti (2022), the Likert scale results indicated that 100% of program directors were in some level of agreement that there is a need for CR in PTA education and 99% reported that they intentionally integrate CR into the didactic content for their PTA students. The Standards and Required Elements for Accreditation of Physical Therapist Assistant Education Programs CAPTE (2024a) for PTA curriculum, the PTA program directors responses, and the acute care competency for the PTA, all supported CR as a necessary skill for the PTA student to achieve. Cencetti (2022) suggested that other stakeholders including CIs may have valuable perspectives on CR and the PTA student and recommended further research on the topic. The Next Step There are multiple ways to define or conceptualize CR that have been presented in this review. The definition that framed CR within this study was defined by the APTA Acute Care STUDENT CLINICAL REASONING 26 Academy PT and PTA core competencies for entry-level practice in the acute care setting (Foster et al., 2017; Greenwood et al., 2015). This study sought to identify the CIs perceptions and determine if those perceptions were novel or if they aligned with concepts which had already been described. While these explanations were drawn from PT education, the specific components are explored to investigate how they align with the CR skills utilized by the PTA student. This qualitative study investigated the CIs perspectives on what CR skills the PTA student needs prior to the final acute care rotation to ensure clinical education success. Method Study Design A basic interpretive qualitative approach was used to investigate the expectations of clinical instructors regarding CR skills needed for PTA students prior to their final acute care clinical rotation. The process required the CIs to reflect on and draw from firsthand experiences with PTA students. The goal was to set a foundation for the ongoing construction of a body of literature that pursues defining CR skills related to the PTA student. Participants The participants included a homogenous group of nine participants within the field of physical therapy with a narrow aim and dense specificity using focused inclusion criteria. There was diversity in terms of age, years of experience as a clinician, and in years of experience as a CI (see Table 1). All participants met the eligibility criteria, which included: must be either a licensed Physical therapist (PT) or Physical therapist assistant (PTA) worked as a PT or PTA for at least one year in an acute care hospital categorized as nontrauma or trauma level III which is in an urban or rural-mixed county served as a clinical instructor for a minimum of one PTA student who was in their final STUDENT CLINICAL REASONING 27 acute care clinical rotation during the last semester of the program between 2019 and 2022. Setting The researcher recruited participants through acute care hospitals within the state of Indiana. These acute care hospitals were all classified as non-trauma or level III trauma centers which are in urban or rural-mixed counties. Procedures Sampling and Recruitment Recruitment activities began after study approval by the University of Indianapolis Institutional Review Board (IRB). This study selected participants from a narrow subgroup of CIs and acute care hospitals using purposive homogenous sampling to obtain an in-depth description of a specific subgroup and an information rich investigation (Patton, 1990). According to Malterud et al. (2015), the concept of information power is dependent upon aim, specificity, theory, dialogue, and analysis. Information power was used in this study to determine the sample size. Depending upon each component, the information power was either increased or decreased. The participant number requirements were continually evaluated with more participants being required when the information power was lower and tapering the number as the information power was increased. For this study, information power was achieved with a small sample size due to the narrow aim, dense specificity, and rich dialogue. The aim was narrow with a focused group of participants who were all CIs working in an urban or rural-mixed county and a non-trauma or trauma level III inpatient acute care hospital. The specificity was dense as the clinical instructors were interviewed regarding only the PTA students in their final acute care clinical STUDENT CLINICAL REASONING 28 rotation. These factors and the novel nature of this experience description added to the information power of this studys sample. The lack of a single theory, the cross-case analysis, and the researchers minimal experience in qualitative research detracted from the information power. The impact of the researchers limited experience was minimized by the researcher conducting two preliminary interviews with the supervision from an expert in the content area with vast experience in qualitative research. The researchers experience as a PT and CI in the defined setting for the study had a faciliatory impact. This facilitated connections with the participants leading to a greater focus during the interviews yielding in-depth inquiry and responses. Participants were identified first by locating contact information for individual CIs through the University of Indianapolis Krannert School of Physical Therapy PTA programs CORE ELMS database. The approval for accessing this information was obtained through the University of Indianapolis Krannert School of Physical Therapy Chair. The primary researcher requested that the data be retrieved by a member of the Krannert School of Physical Therapys clinical education team. The primary researcher contacted each potential participant via email (see Appendix B), inviting them to participate in the study. The initial email provided the study information sheet (see Appendix A) and recruitment flier (see Appendix F). These attachments described the purpose of the study, its voluntary nature, their right to withdraw at any time, the risks and benefits of participating, and methods that were in place to protect confidentiality. If the participants were interested, they were asked to contact the researcher via their preferred mode of communication. The second method for identifying participants took place through networking with the STUDENT CLINICAL REASONING 29 primary researchers colleagues who work in the setting defined for this study. In doing so, the primary researcher contacted the individuals by telephone to ask if they would send and/or deliver a recruitment flier to those at their clinical site who have been a CI for PTA students from the University of Indianapolis. For colleagues who agreed to contact potential participants at their clinical site, the initial participant email (See Appendix B) was sent to them with the recruitment flier (see Appendix F) and the study information sheet (see Appendix A) attached. The colleague then forwarded information to potential participants. The primary researchers contact information was on the recruitment flier (see Appendix F) so that the potential participants could contact the researcher directly if they were interested. These individuals went through the same process as the initial recruits. Recruitment took place between the second semester of the academic year 2022-2023 and the first semester of 2023-2024. In keeping with homogenous sampling, the aim was for participants to be represented by a narrowly defined selection of hospitals in the state of Indiana which are categorized as urban or rural-mixed counties and non-trauma or trauma level III inpatient acute care hospitals. To ensure that no participants felt coerced into participating, certain strategies were put into place. Because the researcher was the director of the PTA program from which the CIs receive students for their clinical rotations, the study information sheet identified the researcher as the University of Indianapolis PTA Program Director. This was followed by information that explained participation in this study would in no way impact their relationship with the University of Indianapolis, the Department of Interprofessional Health and Aging Studies or the Krannert School of Physical Therapy leadership, faculty, or staff. They were informed that their participation was voluntary and that they were free to discontinue the interview and/or STUDENT CLINICAL REASONING 30 participation at any time without any impact on the relationships. Those who expressed interest in participating were contacted via their preferred method and scheduled for a phone conversation. The initial phone call included a screening for inclusion criteria, review of the information sent via email, including the study information sheet, and an explanation of the definition of CR for this study (see Appendix D). In that discussion, the researcher also explained that the interview would be held via Zoom and would last approximately 45 to 60 minutes. The researcher explained how their information would be kept confidential through password-protected files and storage of information including the interview. It was explained that the interview would be audio recorded on a separate device from the computer on which the Zoom interview was being conducted. They were informed that, in gratitude for their participation, a Starbucks gift card in the amount of $20 would be sent to them via their preferred method after the completion of the interview. The researcher explained prior to publication that they would have the opportunity to review and provide feedback on the initial themes. Once a potential participant was confirmed to be eligible and agreed to participate, a time was arranged for the individual Zoom interview. Those who agreed to participate were sent an email (see Appendix D) after the initial conversation that provided the following information: participant confirmation, Zoom meeting specifics, a request that they completed and returned the personal information sheet (see Appendix C), the study information sheet (see Appendix A), a request that they review the definition of CR provided and print the email (Appendix D) for the Zoom meeting, and a reminder of their right to withdraw at any time without consequence. Informed Consent As previously described, once participants were recruited, they were sent an email with STUDENT CLINICAL REASONING 31 an attached study information sheet (see Appendix A) with key information about the study and the verbal consent process. The study information sheet was presented and reviewed verbally to each participant during the Zoom meeting prior to beginning the interview to verify their understanding and allow them to ask questions. Following this discussion, the participant chose whether to provide verbal consent to continue as a participant in the study. Data Collection Data was collected using individual semi-structured interviews until information power was achieved. The interviews were completed via Zoom, an online video conferencing platform (Zoom Video Communications, 2022). The meetings were audio recorded via 2 iPhones simultaneously with the participants verbal permission. Once the meeting began, the researcher reminded the participant about the purpose of the study, reviewed the definition of CR both verbally and visually by sharing the researchers screen with the definition provided, explained what to expect during the interview, and allowed time for questions. After the informed consent procedures noted above were complete, they were notified that the interview and audio recording were about to begin. At this point, the audio recording was initiated. Once audio recording began, the participant verbally affirmed that they understood the information presented in the study information sheet and that they consented to participate in the study and to be audio recorded during the interview. The researcher explained that a semistructured interview guide developed by the researcher would be used to conduct the interview (see Appendix E). The interviewer began with a broad question to allow the participant to begin sharing in an open-ended manner, specifically, As a therapist and a CI in the acute care environment, what does CR mean to you? Following this initial question, the interviewer STUDENT CLINICAL REASONING 32 progressed through a series of other open-ended questions as well as probing and follow-up questions to allow for detailed, in-depth responses. At the end of the interview, the researcher thanked them for their participation in and contribution to the study. They were informed that they would receive an email within approximately 3 months which would give them the opportunity to review the initial study themes and provide feedback on the initial themes. The interviewer offered the participant an additional opportunity to ask questions. Once all questions were addressed, the participant was asked to what email address they would like to have their Starbucks gift card delivered in appreciation for their participation. Finally, the audio recording and interview was terminated. Following each interview, the researcher sent a Starbucks gift card to the participant via email. The researcher used the reflexive process of memoing following the first interview and was continued after each subsequent interview in a continuous process of analysis throughout the study. Memos included a summary of the general concepts that emerged from the interview and noted any bias that was identified during the review of the interview, including assumptions, emotional responses, and the like (Henderson & Rheault, 2004; Stuckey, 2015). Each memo was then reviewed, thought processes regarding identification of codes were noted, and any potential emerging themes were recorded (Stuckey, 2015). With each additional interview, the same process was followed. Data Management and Analysis For each interview, a deidentified information cover sheet was created which stated the basic information about the participant including the age, gender, race, ethnicity, site, and years of experience as a clinician and as a CI. Audio recordings of the interviews were transcribed verbatim using the Temi speech-to-text transcription application. The researcher ensured STUDENT CLINICAL REASONING 33 accuracy of the information by reviewing and cleaning each transcript. All transcriptions were deidentified by assigning a unique identification number to each participants file to protect their confidentiality. The transcription was then downloaded to a password-protected Google Drive file that was accessible only to the research team to ensure the confidentiality of all participant information. The audio recording was then deleted. Dedoose Version 9.0.107, an encrypted qualitative data analysis software was used to assist researchers in data management, analysis, and presentation (Dedoose, 2021) and was used for data storage. The primary researcher, along with a secondary researcher with expertise in qualitative research methods, independently coded one transcript to begin the first round of analysis using in vivo coding and developed a framework for a codebook. The in vivo coding process used the participants words to uncover novel concepts using the verbiage relative to this subculture of PTs and PTAs (Saldana, 2016). By using the specific verbiage, the participants voices were expressed with specificity and emergent concepts were identified (Saldana, 2016). Code-recoding was accomplished by expanding, reassessing, and recategorizing the codes based on the emergent concepts from the data throughout the data analysis process (Henderson & Rheault, 2004). In the second round of coding, the researcher engaged in focused coding to identify codes with the highest frequency and detect major themes (Saldana, 2016). The primary and secondary researchers then reviewed all codes, merged similar codes to minimize redundancy, and eliminated any codes that were not relevant. Once complete, the primary and secondary researchers organized the codes into categories and identified overarching themes (Saldana, 2016). Following the completion of data analysis with the finalization of themes and codes, STUDENT CLINICAL REASONING 34 member checking was carried out. Specifically, the primary researcher sent the initial themes to the participants via email and asked for the participants to review the information and to respond within five business days if their experiences did not align with the content of the themes. None of the participants responded with any changes or concerns. Rigor/Trustworthiness Results were substantiated through techniques that ensured the study embodied both trustworthiness and rigor (Byrne, 2001; Henderson & Rheault, 2004). As described by these authors, methods were used to optimize credibility, confirmability, transferability, and dependability. Credibility, aligned with the truth or believability of the results (Henderson & Rheault, 2004), was optimized using reflexivity during the data collection and member checking during the data analysis. Reflexivity was accomplished through memoing and bias identification (Henderson & Rheault, 2004). Member checking was accomplished by sending the initial themes to the participants for feedback regarding the findings. The member checking ensured that the participants intent was accurately conveyed and reflected in the results to optimize the believability of the findings (Henderson & Rheault, 2004). Confirmability was supported by maintaining a solid audit trail (Byrne, 2001). During the data collection, memoing was utilized to support the audit trail by documenting general concepts, thought processes, and potential biases that were identified during data collection and analysis (Henderson & Rheault, 2004; Marshall & Rossman, 2011). Memoing was used for reflexive purposes to assist the researcher in keeping track of and reducing personal bias thereby providing greater objectivity and neutrality (Ryan-Nicholls & Will, 2009). Investigator triangulation was implemented through coding by both a primary and secondary researcher with collaborative analysis of the data (Byrne, 2001). STUDENT CLINICAL REASONING 35 Dependability provides a trackable trail for the decision processes and was implemented throughout the study (Henderson & Rheault, 2004). This was done throughout data collection via the development of a detailed method section providing a clear template for the reproducibility of the study (Henderson & Rheault, 2004). During the data analysis, a form of code-recoding was implemented to facilitate dependability (Henderson & Rheault, 2004). Transferability was facilitated during data collection by obtaining rich background information regarding the participants history as a clinician and CI allowing for comparison of information among the participants (Henderson & Rheault, 2004). The participant sample was intentionally representative of inpatient clinical populations within urban or rural-mixed communities across Indiana. All but one of the settings were at non-trauma centers, with only one being a level III trauma center. The incorporation of participants from a narrowly defined, focused community enhanced the understanding of the CIs expectations of the PTA student and CR needs prior to their final rotation in acute care and ensured the sample represented the perspective of a clearly defined clinical environment (Henderson & Rheault, 2004). Results This study used a basic interpretive approach to investigate the CIs expectation of the CR skills PTA students need prior to beginning their final acute care clinical rotation. Nine participants completed the study; their demographics and characteristics are in Table 1. All participants worked in acute care hospitals, with a mix of rural and urban communities and years of experience represented. Three major themes emerged from the data analysis, which included: A) Assimilation, B) Communication, and C) Safety. Subthemes were identified which further detailed the CIs perceptions within each theme. An overall concept of CIs definition of CR was formulated STUDENT CLINICAL REASONING 36 based on the collective responses, themes, and subthemes in the data. Overall, the CIs defined CR as the assimilation of a mental picture of the patient presentation based on the chart review, communication, and collaboration with the healthcare team. The CIs expected students to utilize this mental picture to develop a treatment plan with the ability to adapt the session based on the patient's response to treatment to maintain patient safety. Theme A: Assimilation Assimilation is a theme identified across all participant interviews. The CIs expect the PTA students to come to their final acute care clinical with the ability to know and look up diagnoses, a willingness to ask questions, and an understanding of the implications of the lab values, medications, and vital signs noted in the chart review. The student then should use this understanding to assimilate a mental picture of the patient and be able to plan and implement a physical therapy session successfully. Participant 4 stated: So they'll know how to do that as soon as they get herethey need to look at that PT note, they need to see the diagnosis. If they don't know what the diagnosis is, I expect them to look it up. Similarly, Participant 3 noted: they need to know diagnosesI would want them to be able to chart review, get the diagnosisbe able to look at the nursing notes and make sure there's nothing going on. Participant 7 described how student thoughts demonstrate CR stating: When I have a student who comes in and can look at a chart and review it and asks me good questions, to me that's demonstrating the CR to thinkI don't know maybe what this means, something's going offwhat could this be? Why am I looking at this one? Oh yeah, that's why I'm looking at this and why could that possibly show up in the presentationI love the students who ask questionsthey come in and they're not afraid STUDENT CLINICAL REASONING 37 to ask the questions. Two sub-themes emerged from the theme of Assimilation: Anticipate (A1) and Facilitators and Barriers (A2). Sub-theme A1: Anticipate Anticipating what the patient may feel and how they may respond to treatment when walking into the patients room based on their vital signs was frequently noted by participants. Participant 1 stated: vital signsblood pressure, oxygenhow's the heart rate and things like that. So being able to again, see what the trends are there andstart painting that picture in your mind of this is who I'm walking in to see. Participants expected that PTA students, at the beginning of their acute care clinical rotation, would also anticipate when a patient is at risk for pain, constipation, lightheadedness, dizziness, weakness, falling, or passing out. The student should assimilate information from lab values, vital signs, medications, and diagnoses to formulate an image of what to anticipate prior to walking into the patients room. For instance, with sodium and creatinine levels they could potentially be weak and fall noted Participant 5. Participant 9 expressed that if the hemoglobin's lowI would expect them to knowthey're probably gonna be maybe dizzy, lightheaded. The importance of student awareness was highlighted by Participant 7 who stated: I would likethem to know[the] critical level for like a potassium and why that's importantespeciallysomebody's there with cardiac issues and they have a critical potassium level. You know, it's not something you wanna push with a whole lot of activity. So that sort ofawareness I would say is important. STUDENT CLINICAL REASONING 38 Making the connection between medication and side effects was important to Participant 2 who expected the students to understand: pharmacology anddifferent dripssome medications, like oral medications are good to knowlike they're on a Lasik drip so they probably have to go to the bathroom a lotorpain medication and what could be causing some of their symptomsthey're constipated, they're on pain medicationthose sorts of things. Seven of the nine participants discussed hemoglobin (Hgb) as an important lab value for the PTA student to understand when beginning their final clinical. While potassium and sodium were discussed, and others were also noted, Hgb was the primary lab value that the participants wanted the student to understand in anticipation of the patients potential responses to treatment as well as knowledge of when to hold or adapt the treatment. Participant 4 stated: knowa low hemoglobin, what that means. Participant 1 specified: knowing a basic knowledge of why they're herestart to paint a picture in their mind of this is who I'm walking in to seethen just in generala basic knowledge ofdiagnosislab valueshow to interpret those a little bit too in terms ofhow hemoglobin is low. Participant 7 outlined that if hemoglobin is critically lowI want them to knowif a hemoglobin is below seven, we're not getting out of bed. If that hemoglobin's between seven and eight, we can kind of sit bedside, maybe monitor for symptoms. Participant 5 similarly mentioned that with low hemoglobinyou need to proceed cautiously and look for symptoms and probably not get 'em up. Understanding trends in vital signs and how that impacts patient care was also a consistent factor discussed by participants; they wanted the PTA student to begin their final STUDENT CLINICAL REASONING 39 clinical rotation in acute care with this knowledge. Participant 5 stated, their medical status vitalsif they're onoxygen. Participant 4 described that I'd like them to know what low oxygensaturation means. Similarly, Participant 6 expressed the importance of understanding the patients use of oxygen, stating that the student should have an idea ofthey're on oxygen, if they're trying to get them off of oxygen, what their oxygen is at baseline. Additional vitals sign knowledge is noted by Participant 1 who stated, obviously vital signsblood pressure, oxygenhow's the heart rate and things like thatbeing able tosee what the trends are. In another sense, Participant 9 expected the student to collaboratively communicate the findings stating so being able to comfortably like, you know, call the nurseand say, hey, is it okay to see this patient for PT? I sawtheir blood pressure was low; the blood pressure was high. Sub-theme A2: Facilitators and Barriers Clinical instructors presented concepts that were facilitators and barriers to CR related to the theme of assimilation and the subtheme of anticipate. The ability to assimilate information related to vital signs, lab values, diagnoses, and medications into a mental picture prior to going into the patients room were facilitators. Clinical instructors assert CR was facilitated by the ability to review the PT evaluation and utilize those findings in assimilation of the mental picture of how that patient may present. Whereas the lack of the ability to do so was a barrier. Participant 2 stated: taking the initial evaluation and then be able to apply in that a little bit in your head going into the sessionbased off of manual muscle testing results and coordination or balance, whatever is in the initial evaluation. So, kind of having that picture in mind. Assimilating information from observations of the patient during the session facilitated STUDENT CLINICAL REASONING 40 CR resulting in the ability to respond to the patient and modify the session to meet their need for either progressing or regressing activities for session tolerance. According to participant 1, a student did well with this, and she stated: He was very good at knowing what interventions to use during a treatment, and then kind of reading the patient in terms of this is way too easy, versus, maybe I'm pushing you a little too hard. So I thought he was very good at using those CR skills, just in terms of reading the patient, you know, during the session. Participant 1 also stated, a total hip or a total knee or back surgery, sometimes pain is a big factor in terms of being able to assess the patient on their pain level and how much you can push them versus not. Theme B: Communication Working as a healthcare team requires communication. The healthcare team represents a diverse set of professional fields all working individually to promote patient success. These individual efforts must then be communicated across disciplines to optimize collaborative care to meet the specific needs of each patient. The physical therapist assistant (PTA) is a cog in the wheel of care and there must be intentional interaction. Participant 4 stated: Our nurses are superheroesto be able to sayanything happened overnight that I need to know about after the chart review? this is a touch base, just so I know that I'm going intoa safe patient. Are there any issues with the blood pressure today? If there were then what were they? And, then at the endmy biggest thing is at the end of our session, what I do and what I want my students to do is the patient is safe. They're in their chair, they have an alarm onit was min assistto get them up. This represents an example of the communication that is crucial to implement in the acute STUDENT CLINICAL REASONING 41 care setting to keep the patient safe as the care is passed from one provider to the next. Within the theme of communication two sub-themes were evident: Collaborate (B1) and Anticipate (B2). Sub-theme B1: Collaborate Communicating through collaboration stood out as a sub-theme and key component of interprofessional collaboration between the PTA student and nursing staff, and intraprofessional collaboration between the PTA student and the physical therapist. Communication with the nurse prior to the PT session was seen as imperative for gathering patient information and then after the PT session to inform the nurse regarding patient care. Participant 5 discussed the importance of talking with the nurse and stated, communication as far as is it okay to get him up? Is there anything new going on? Reaching out to them before going into the room. Participant 7 expected that the student would be comfortable at the beginning of the final acute care clinical rotation with having this kind of conversation with the nurse in preparation for treating a patient and expressed: You know, check in, hey, I'm so and so PTA student, we're going in to see this patient. Are they okay for us to see, anything we need to be aware of? I think just that comfort level is what I would expect. Participant 6 expected the PTA student to follow through with the nurse after providing care and stated: If they leave them up in a chairbe able to callthe nurse and tell them they left them up in the chair. Ifthey did have an issue with blood pressure or something during the session to let the nurse know that. If the patient is asking questions about medicines or something, if they can inform the nurse that the patient is wanting pain medicine or if STUDENT CLINICAL REASONING 42 they're having nausea, vomiting. Intraprofessional collaboration between the PTA student and the PT was also an expectation for PTA students beginning their acute care clinical rotation. The participants want the PTA student to be able to discuss patient concerns and progress. They also expected the student to be prepared to discuss with the physical therapist when the patient had a status change. Participant 5 wants the PTA student to update the therapist, the evaluating therapist, on how the patient's doing, whether it be good or bad. Participant 4 stated: PTA goes to thePT and saysI see this with this patient that you seeis this new or I would like to try this with the patient, is that okay? I think you need to see them tomorrow. I saw this today. Those are thethings that I want thePTA to be able to do and not be afraid to go askthemgoing to them with a change of status is what I would like the PTA to know. Sub-theme B2: Anticipate Anticipate was a subtheme within the theme of communication. Providing the patient with quality care requires that the PTA student gather information not only from the chart but directly from the nurse and the physical therapist. These collaborative efforts are a key component that assists the PTA student in creating the mental picture of what they should anticipate prior to going into the patients room. Participant 2 stated, I like to ask the nursehow have they been getting up for you guys when you guys mobilize them when you get them to the bathroom? Like, what have they been doing, you know, since their last session? Participant 1 wanted to hear the PTA student communicate to both plan for and wrap up the patient care session as represented by this statement: STUDENT CLINICAL REASONING 43 Hey, I, I've gotthis patient or however many patients of yoursare they all appropriate to be seen? If they maybe have seen something in the chart that they're either wanting more clarification onI saw theirhemoglobin was a little bit low or arethey planning to have any blood transfusion, that type of thing. So I think just some basic communication skills there and then even following up after the session too and be able to kinda just educate or update them on howthe session went. Sub-theme B3: Facilitators and Barriers While interdisciplinary and intradisciplinary communication with nursing and the PT respectively were identified within the above subthemes, they were also presented as facilitators and barriers. Related to interdisciplinary communication with the nurse, participant 1 recommended the following facilitator of CR and stated, I think that could be a cool idea ifthey, maybe a nurse and a PTA student, go into the room together to treat a patient and that type of thing. Kind of collaborate. Student confidence was also noted as a facilitator and barrier to communication. Participant 2 stated, being able to be confident in what you're doing in order to talk to somebody about it. Participant 4 also highlighted confidence and mentioned: being confident that you know what you've learnedbe confident in the call you made, cuz that confidence, if you break that confidence with a patient or with a colleague, it, it is tough. Theme C: Safety Participants expressed the expectation that the PTA students should arrive at their final acute care clinical with the ability to implement safe patient care. Three sub-themes were identified as Anticipate (C1), Adapt (C2), and Facilitators and Barriers (C3). Participant 7 stated: If we have a patient who is in with a pneumonia and a respiratory failureknowing that STUDENT CLINICAL REASONING 44 oxygen is gonna be something that they're gonna wanna keep tabs on, or if we're seeing somebody who has had a stroke and we can look in the chart and see where their blood pressures have been running. Those sorts of things to know that they have been running high. Maybe we should keep this in here. You know, get that blood pressure machine in there to be able to checklooking atnot necessarily the complex things, but like certainly what disease processes or illnesses you're gonna want to be monitoring blood pressures, and signs and symptoms. Participant 8 discussed being ready to treat the patient safely and stated, I want them to be able to feel comfortable going in. Andjustkind of taking charge. Participant 1 expected students to provide safe patient care with the preparation for implementing basic clinical skills and interventions and stated, just like gait training, stairs, teaching them about assisted devices, being able to fit those devices and explain to patients, again, educate them on how to use them. Sub-theme C1: Anticipate Taking information from the chart and being able to anticipate what red flags and safety issues may arise was of critical importance to participants. PTA students are expected to recognize the indications of critical lab values, specific diagnoses, implement proper patient safety techniques, and plan for the appropriate equipment to monitor the patient and for the room set up. Participant 8 stated: lab values are hugeif you have a patient, let's just say something simple like their hemoglobin is six, nineat seven or below they will transfuse. So just knowing that, hey, we might wait until this patient gets a transfusion before we get them up because they're gonna be a little more perky. You know, they're gonna feel better. Right now they don't feel good. They're having trouble breathing. STUDENT CLINICAL REASONING 45 According to Participant 7, recognizing comorbidities assists the student in providing safe intervention expressed through the statement that: they're here with pneumonia and they have COPDknowing that they have bothmore than likely that patient hasa diminished oxygen capacity even before the pneumonia.And knowing thatwith COPD, we don't wanna crank oxygen because they're just gonna retain it, right? So that sort of thing, knowing that yes, they're here with pneumonia. Yes, their oxygen may be a little bit lower, but they have COPD, so I don't wanna overwhelm them with oxygen. Participants explained that understanding the patients diagnosis and their lines and leads assists the PTA student in anticipating how to plan and select the appropriate monitoring devices and room set up for the session to facilitate patient safety. Participant 1 stated, So it's just a matter ofslowing down and getting things organized first. Participant 8 emphasized that the student should: just pay attention, you know, really pay attention to where those lines are. Those NGs are a lot of times shorter than the other lines. So you really have to pay attention. A lot of times I just call the nurse and have 'em kind of put it on hold and have it unhooked. Participant 7 noted: If we have a patient who is in with a pneumonia and a respiratory failureknowing that oxygen is gonna be something that they're gonna wanna keep tabs on, or if we're seeing somebody who has had a stroke and we can look in the chartand see where their blood pressures have been runningthose sorts of things to know that, you know what, they have been running high. Maybe we should keep this in here. You know, get that blood pressure machinein there to be able to check. STUDENT CLINICAL REASONING 46 Sub-theme C2: Adapt There is an overlap between the sub-themes of anticipate and adapt. It is the initial anticipation of what may occur that then informs the responses that require adapting to provide safe patient care. Participants noted an expectation that the PTA students anticipate that a patient may fall and have the appropriate equipment and or assistance in place to prevent injury during an adverse event. Participant 5 stated: ortho patients their blood pressure might need to be monitored. They could pass outbucklecuz they're a new surgeryanticipate what might happen and be prepared before it happens and have things ready and in place. Participants emphasized that having the appropriate safeguards in place prior to patient care contributed to the patients protection from injury, enabling the therapist to quickly respond and adapt. For instance, Participant 8 stated: You're gonnaadjust accordingly. I had a lady who was 420 pounds yesterday. I grabbed a second person because I wasn't quite sure, and it's likeif that person goes down, they're gonna go down. There's nothing I'm gonna do about it. By having additional help, the therapist set the treatment up to optimize safety and expected the PTA students prior to their final acute care clinical rotation to be ready to do the same from the beginning of the clinical rotation. Participant 4 stated that by: using a gait belt andeducating the patient not only the patient, but the nursing staffthat this isone of the most important things that can save this patient from falling and hitting the ground. They may not realize, but it's notif the patient's gonna go down on you, it's when they go down on you, what you need to do. And so if you cancut that off and use the right safety equipment like gait belts, walkers, at the right STUDENT CLINICAL REASONING 47 height. Participant 7 discussed the importance of having a chair close to keep the patient safe and stated: post-op jointto know this person's had anesthesia, they've had pain medicine, maybe they haven't eaten when they get up, there's a good chance that they could pass out on me. And knowing that, you know, they need to be prepared with a chair close by and monitor for that loss of color in their face or the cold sweat'cause a lot of patients won't say anything. A lot of 'em will just be like, oh, I gotta power through this. The participants expected these anticipatory and adaptive skills to be present when the PTA students began their final acute care clinical rotation. There was the basic expectation that the PTA student could safely manage equipment while mobilizing patients. Participant 3 reported students should be able to manage a couple lines and get 'em organized andbe able to walk 'em down the hall with those lines with safety and being able to manage an IV pole and the patient. While the participants expected PTA students to safely manage a range of one to three pieces of equipment, the most frequent expectation was that the PTA student would be able to manage at least two pieces of equipment. The two pieces of equipment that participants universally expected the PTA student to manage prior to beginning their final acute care clinical rotation were an intravenous line (IV) and supplemental oxygen. Related to management of equipment while providing patient care, Participant 8 stated the PTA student should be able to manage an IV pole and perhaps an oxygen tankthe two together. Likewise, Participant 6 stated, the main thing would just be feeling more comfortable with the IV poles and [an] oxygen tank and Participant 9 noted an IV pole minimum and then maybelike oxygen STUDENT CLINICAL REASONING 48 lines. Sub-theme C3: Facilitators and Barriers The concept of hands-on activities emerged consistently in the CIs responses as a facilitator and barrier to CR among PTA students prior to beginning their final acute care clinical rotation. Participants expressed that having hands-on opportunities to practice, especially with actual patients, would help facilitate CR for the PTA student prior to beginning their final acute care clinical rotation. Incorporating students practicing hands-on activities was identified as developing greater comfort with equipment and the challenge of managing multiple lines and leads as well as the hospital beds. Additionally, by having actual patients with specific diagnoses the students develop a better understanding of how those conditions truly present. Participant 1 stated: In terms of like lines and leads and even the simple things of like how towork a hospital bed andjust different things like that they sometimes get into the acute care setting. They're focused on the patient. They haven't even thought of the other stuff to be able to get into those SIM labs and be able to just play around with the machines and the beds. Participant 4 noted, I'm sure you do scenario-based testing and class work and simulations. I think that'sprobably the best way to get CR. Gettinglive patients in there. Participant 4 also highlighted the importance of having a patient with a true deficit available in preparation for actual patient care and stated: I can pretend that I have hemiparesis on one side. I can pretend to have a broken leg and be non-weightbearing, but you know what, if I'm gonna fall, I'm gonna put my leg down. You know what I mean? And so that's the difference. I think getting that hands-on STUDENT CLINICAL REASONING 49 clinical stuff maybe, or as you're going through scenario-based testing or education that you actually have a patient that actually shows that to them. Participant 1 expressed the importance of having prior experience with hands on activities in preparation for the acute care clinical rotation and noted: I think as much of that as they can get, I thinkwould be great. Cause I think a lot of times students, they have the knowledge of how to treat the patient, but in the acute care setting, it's just a matter of you gotta juggle a lot of other things sometimes. Parallel to the concept of hands on, including complex patient simulations (SIM) was a recommendation to facilitate CR skills in PTA education. The participants discussed that exposure to complex patient SIM labs will make the acute care clinical rotation easier for the PTA student as it will better prepare them for managing medically complex patients in the acute care environment. Exposure to simulated bodily and medical fluids via medical devices and practicing interdisciplinary collaboration during complex patient SIM were all recommendations noted by participants as being facilitators for CR for the PTA student. Participant 2 noted I really liked the idea of them getting some actual like hands-on exposure. I mean, whether they come to here or they dolike mock stuff. A more specific recommendation was made by Participant 9 who stated, your IV comes outand it bleeds, or your Foley starts to leak or your Hemovac drain comes out. Participant 9 also recommended that the PTA program give them more complex scenarios than what they would probably see and get their juices flowing. Participant 2 recommended having the students actually call a doctor. Similarly, Participant 1 recommended having the PTA students collaborating interprofessionally in those simulations. Personal responsibility was noted as both a facilitator and barrier for students as they STUDENT CLINICAL REASONING 50 begin their final acute care clinical rotation. Students for whom this presented as a barrier for CR were noted as being challenging to teach. While personal responsibility is a facilitator when a student can accept constructive feedback and use that to facilitate further CR. Participant 3 discussed the challenge of instructing a student who does not demonstrate personal responsibility. Participant 3 reported: I would tell my other coworkersyou got any suggestions? Cuz I've tried everything. I do not know how to get through to this kid. You know? And it's not that she's mean and she's not listening. She looks at me and she's listening, but it's just likeno registering in there. Participant 8 made a recommendation for student behavior and stated: If they are doing things maybe not the way that it was instructed, you know, make sure that you pay attention to what's going on and how that person's trying to teach them. to correct their ways and know that there's gonna be constructive criticism and it's not a down thing on themthis is learning. Keeping the patient safe and providing quality patient care requires that the PTA student demonstrate the ability to take personal responsibility for their actions. This requires the ability to take ownership of ones mistakes, accept the full responsibility of the care, and be alert and pay attention to maintain patient safety. When this fails to happen it is a barrier for CR. Participant 3 reported student comments in which the student did not demonstrate personal responsibility or sound CR. Participant 3 stated: She was very unaware of what she did sometimesthe oxygen lines are around these people's feet. Are you not seeing that? She would be like, no, it's not. No, it's finethere were several things that she just, for whatever reason, she felt like she didn't STUDENT CLINICAL REASONING 51 do anything wrong. Regarding a separate student who struggled to take personal responsibility for their actions and the full scope of care that is provided by the PTA, participant 3 stated: At the beginning I said here in rehab occasionally we will have to wipe people's behindsthey're not able. She immediately sat back and she said, uh, no, they told us in school we weren't gonna have to do that. Or if she, she just misunderstood or whatever. But I'm like, no, that sometimes, and it's not all the time, but if we do take people to the restroom and if they can't reach their bottom, then we're not gonna leave 'em dirty. We're not gonna call the tech. We're gonna help them clean their bottom. You know? And she was just, no, they told us we wouldn't have to do that. Andwhat was astounding to me was that it was like she was clinging to that. Proactivity also emerged as a facilitator and barrier to CR among PTA students. Safe patient care requires that the PTA student think proactively regarding the room and equipment set up with lines and tubes closely monitored and organized to prevent pulling anything out and responding during the treatment session. Participant 7 noted the importance of preparation for the session and stated: being prepared going into the room. So knowing, equipment wise, whether it be adaptive equipment or monitoring equipment. Likewise, Participant 1 noted the importance of preparation as a facilitator for CR and stated, the hospital setting is just different in terms ofyou [have]lines and leads, IVs, catheters, whatever the case may be. Souse clinical reasoning there in terms ofI gotta get the room set up. Participant 3 suggested a way for PTA programs to facilitate CR by allowing students to fail and then subsequently incorporate that failure into learning how to think proactively in the moment once on the clinical rotation. Participant 3 provided an example of this and stated: STUDENT CLINICAL REASONING 52 We've all done it where you can't get through the doorway cuz you didn't take the leg rests offso just things like that in school, I think, letting them fail at those things and experiencing those things would be really beneficialand repetitionif you go through things, some of these basic things, especially, they don't seem basic until you actually get into the clinic. And then the basic things are what you're doing most of the time. So they're not really that complicated but getting a good routine so that you can do basic safety is really important. Especially for students. Cause that's 90% of what they're gonna do. Participant 1 discussed the importance of proactively thinking through the room set up and stated: Itwasn't like he was being unsafe with it, but it was just a matter of like getting the IV pole on the same sideon the same side of the IV, whatever the arm is in. It's just a matter of slowing down and getting things organized first. Participant 9 had a student situation in which the lack of proactivity was a barrier and stated: My student did not like bodily fluidsthe first patient we went to go seevomited and it was like, you're dry heaving, you're not doing well. The student was not doing well I obviously stepped in and it was fineand told her, get methe basin over there. And she just stood away so that afterwards I told heryou still gotta do this, you can't just walk away. Luckily, I was there. In this situation where lack of proactivity was a barrier, the CI secured patient safety. However, the lack of responding proactively leads to safety issues and is a barrier to CR. Discussion This study investigated clinical instructors expectations of the clinical reasoning (CR) STUDENT CLINICAL REASONING 53 skills physical therapist assistant (PTA) students need before beginning their final acute care clinical rotation. The results set the stage for defining and designing robust acute care preparation within the PTA curriculum. This basic interpretive qualitative approach broadens the scope of the available research through the introduction of a novel stakeholder, methodology, and population; this study included the clinical instructor (CI), a qualitative lens, and an acute care environment. Nine participants completed the study. The participants worked as physical therapists or physical therapist assistants in urban or rural mixed county acute care hospitals categorized as non-trauma or level III trauma centers for a minimum of 1 year. The participants served as a CI for a minimum of one PTA student who was in their final acute care clinical rotation during their final semester. The PTA Education Trends Task Force reported that PTA education is lacking supportive research and advocates for building this body of knowledge (APTA Academy of Education, 2020). This study pursued this effort through the investigation of the CIs expectations of the CR skills PTA students need prior to beginning their final acute care clinical rotation. This study explored four original questions. The findings are discussed as aligned with each question and the literature below. Question 1: Clinical Instructors Expectations The first and overarching question sought to determine what the CIs expectations were of the PTA student regarding CR skills prior to beginning their final acute care clinical rotation. Themes of assimilation, communication, and safety all contributed to the answers to this question. The CIs expected that students would arrive at their final acute care clinical rotation with the CR skills to glean information from the chart review including the physical therapy STUDENT CLINICAL REASONING 54 evaluation. This required knowledge of diagnoses, as well as an understanding of lab values, medications, and vital signs. There was an expectation for students to communicate collaboratively with the nursing staff prior to the session. Collaboration and communication are components of the CR process as defined and referenced in the literature (Christensen et al., 2017; Christensen et al., 2023; Greenwood, 2022; Huhn et al., 2019). Based on this collaboration and the knowledge from the chart review, students needed to assimilate a mental picture of the patient presentation. Once the mental picture was in place, CIs expected the students to anticipate how the patient would respond to treatment, including potential safety concerns which might arise during the session. This parallels a process described in the literature as pattern recognition (Abrandt Dalgren et al., 2022; Furze et al., 2015b; Kirk-Sanchez et al., 2022; Reilly et al., 2022). The use of pattern recognition with inductive reasoning uses a base understanding of a diagnosis to infer the typical presentation of that condition and assist the clinician in anticipating the patient presentation prior to implementing tests and measures (Furze et al., 2015). The findings emphasized that the student should be able to determine the safety concerns related to specific diagnoses which might result in issues such as blood pressure shifts, passing out, or buckling during a session. Based on these concepts the student PTA should be able to plan and implement both preparatory and adaptive techniques using safeguards while managing at least an intravenous pump and supplemental oxygen. Following the session, the CIs anticipate that the PTA student will engage in further collaborative communication with the nursing staff relaying patient information related to their response to treatment, end position, and any additional needs. This type of team approach was implemented by physical therapists in acute care who worked closely with nursing staff when STUDENT CLINICAL REASONING 55 treating critically ill patients (Amundadottir et al., 2018). The CIs denoted that the students should confidently communicate with the supervising PT when a patient demonstrates a status change. CAPTE (2024a) and Foster et al. (2017) require that PTA students should be prepared and competent in working as a PT/PTA team (CAPTE, 2024a; Foster et al., 2017). The summation of the findings indicate that CIs deemed that a PTA had sufficient preparation at the beginning of the final acute care clinical rotation if they were able to implement a physical therapy session by doing the following: assimilate relevant patient information envision a mental picture of the patient anticipate the patients response to treatment maintain patient safety communicate the patients treatment response with nursing and the supervising PT These basic concepts add a first glimpse into the competency expected by CIs for the PTA student prior to the final acute care clinical rotation. Question 2: Clinical Instructors Defining Clinical Reasoning A second question looked at how the CIs defined CR. The responses were representative of all three themes. Their definition was well aligned with the definition of CR presented in the core competencies for entry-level practice as a PTA and published through the APTA Acute Care Academy which was the deliberation about a course of action within a specific context with the ability to anticipate outcomes guided by a framework of previous experiences and knowledge of best evidence (Foster et al., 2017, p. 3). The definitions mention of anticipating outcomes aligns with the CIs definition of CR which includes anticipating the patient presentation through a mental picture. Additionally, anticipate was a subtheme emphasized by all STUDENT CLINICAL REASONING 56 participants. CR required students to assimilate information from multiple sources including communication. The assimilation of information first demanded conceptual understanding of both the presentation and impact of patient diagnoses, vital signs, lab values, and medications. The integration of the multiple sources of information into a mental picture assisted in the anticipation of how to set the session up to maintain patient safety. Question 3: Barriers and Facilitators to Clinical Reasoning A third question investigated what CIs perceived as the barriers and facilitators to CR among PTA students as they begin their final acute care clinical rotation. The answers to this question also represented all three themes. The discussion of CR facilitators is presented with incorporation of their antithesis as the barriers to CR. Facilitation of CR was represented by a student being able to review the initial PT evaluation and the chart and use their knowledge of diagnoses, medications, laboratory values, and vital sign trends to assimilate a mental picture. Having the ability to read the patient responses and proactively adapt the interventions appropriately was a CR facilitator. The CIs included identifying red flags as facilitating CR, specifically, the students understanding of the implication of various hemoglobin levelswhen to move forward with treatment, modify the treatment, or hold therapy altogether. This concept of assimilating a mental picture is consistent with research depicting the master adaptive learner who begins their journey to metacognitive CR by utilizing illness scripts (Reilly et al., 2022). Kirk-Sanchez et al. (2022) proposed using illness and movement scripts during didactic preparation to foster pattern recognition. It is in this pattern recognition that students begin to envision how a patient presents based on their given condition (Kirk-Sanchez et al., 2022; Reilly et al., 2022). Facilitators were identified specifically related to clinical skills, interventions, session STUDENT CLINICAL REASONING 57 preparation, taking personal responsibility, being proactive, and communication. These included taking goniometric measurements, utilizing the gait belt, performing heavy transfers, setting up and adjusting adaptive equipment, and the ability to instruct and educate the patients in gait, stair negotiation, and relative safety issues. Identifying potential problems, proactively preparing accordingly, and setting up the room for successful transfers and equipment management were included as well. A facilitator for CR was being receptive to constructive feedback followed by taking personal responsibility for that feedback by proactively adapting their approach to optimize their CR. Lastly, having confidence in communication with nursing and the supervising PT also facilitated CR. Question 4: Recommendations for Effective Student Preparation The fourth and final question sought to determine what CIs believe can successfully prepare students within the academic setting prior to beginning their final acute care clinical rotation. The CIs recommended that PTA students engage in acute care simulations as a means for honing their CR skills during their academic preparation. According to Furze et al. (2015b) and Greenwood (2022), student learning is facilitated in an environment where students felt safe to reveal their thoughts and to fail in the process of learning. Likewise, CIs conveyed the purpose of recommending the simulation activities was to allow students the opportunity to fail in a safe space and optimize the PTA students comfort with the acute care setting before entering the clinic. The CIs expected the students to benefit from the use of a simulation space where PTA students could learn how to manage and work hospital beds and equipment. One recommendation was to utilize graduate students as actors for scenario based, hands on simulations for PTA student preparation aligning with the concept of role playing presented by STUDENT CLINICAL REASONING 58 Reilly et al. (2022). These authors note that illness scripts assist students in understanding basic patient conditions and they are incorporated into low stakes role playing activities where these illness scripts begin to build a scaffolding for CR with a metacognitive approach. This process of learning leads to pattern recognition (Reilly et al., 2022). Cunningham and Cunningham (2020) found that DPT students had increased comfort with acute care skills after participating in a critical care patient simulation where they participated in suctioning a simulated tracheostomy and mucus. Their results are oriented with the current studys findings. The CIs recommended the integration of complex medical situations into the PTA training with the inclusion of an intravenous line (IV), closed wound drainage system, catheter, bloody wound, or nausea into the simulation activities then furthering the realistic nature of the simulation by exposing the students to simulated bodily fluids. The recommendation for advanced simulation labs where graduate assistants role play as a patient with increased complexity and exposure to simulated bodily fluids falls into the intermediate level of learning for master adaptive learning where there is a real time response to novel information (Reilly et al., 2022). The CIs perceived this type of activity as one which would assist in honing the CR skills of the PTA student prior to the acute care clinical rotation. There was also emphasis on providing the students with the opportunity to engage with patients to expose them to true deficits. Developing the PTA students understanding of how true medical conditions are present in a patient was a focus of the CIs recommendations. This is directly aligned to the intermediate level of learning for the master adaptive learner where students engage with people with real movement dysfunction (Reilly et al., 2022, p.19). The CIs recommendation to partner with organizations to have access to patients with deficits aligns with the master adaptive learner across the intermediate and competent levels. For the STUDENT CLINICAL REASONING 59 intermediate level, it aligns with practicing psychomotor skills on simulated patients at a basic level (Reilly et al., 2022). At the competent level, it aligns with treating patients while integrating more complex activities such as implementing a progressive treatment plan (Reilly et al., 2022). Incorporating interdisciplinary communication into the patient care simulations with nursing, occupational therapy, and physicians were all mentioned as activities which would be beneficial to incorporate into the PTA training during their academic preparation. The integration of the presented activities into the PTA education was anticipated to assist the PTA students in being better prepared and more comfortable managing patients prior to their final acute care clinical rotation. In alignment with the CIs expectations, educators have the responsibility to develop students who are competent in interprofessional communication that is patient centered, collaborative, and team based (Berg-Carramusa et al., 2023; CAPTE, 2024a). This study identifies CR skills that PTA students should have prior to beginning their final acute care clinical rotation. The findings also align with concepts related to the master adaptive learner. Based on these concepts, there is potential space for incorporating both the concepts of the master adaptive learner and competency-based education into PTA education in alignment with DPT education, but within the PTA skillset. One concept in the literature not incorporated into the interview guide nor identified throughout the participant interviews was incorporating the patients voice into the CR and treatment process. The literature discussed a relational process of CR using a collaborative patient and therapist model for decision making on the patients care and was in alignment with the care provided by more experienced physical therapists (Abrandt Dahlgren et al., 2022; BergCarramusa et al., 2023; Dahlgren et al., 2022; Deutsch et al., 2022; Kirk-Sanchez et al., 2022; STUDENT CLINICAL REASONING 60 Reilly et al., 2022). While this was not an emergent concept within the study; it is an emerging concept within the most recent literature. Study Limitations This study included limitations. While the researcher implemented multiple techniques to optimize credibility including the use of a field journal for bias identification, member checking, and triangulation (Byrne, 2001; Henderson & Rheault, 2004), a limitation is the primary researchers experience as a clinician in the acute care environment. The researcher had a 20year history as a clinician in the studys geographical region and 10-year history working as a clinician in the acute care setting in that region. While this assisted in recruitment of participants, it was a potential limitation as the researcher had a history of working with three of the nine participants at previous places of employment. Additionally, the researcher was the director of a PTA program from which the CIs take students. Implications and Future Research This study adds to the research related to PTA education for which the PTA Education Trends Task Force (APTA Academy of Education, 2020) reported a need. This is the first known qualitative study looking through the lens of the CI related to the PTA student and CR skills in the acute care setting. This study will add to the portfolio of new APTA evidence-based resources (APTA, 2022) which was set out as an objective for quality care in the APTA strategic plan for 2022-2025 (APTA, 2022). The results inform PTA faculty on how to better prepare the PTA students CR skills for acute care clinical rotation. Based on the themes of assimilation, communication, and safety and the CI expectations for the PTA student, there is a need for the concepts of the master adaptive learner to be applied to PTA education. The CIs expect that prior to the PTA students final acute STUDENT CLINICAL REASONING 61 care clinical rotation the student will have the CR skills assimilate information from the chart into a mental picture which is aligned with the concept of basic illness scripts and emergent pattern recognition along with collaborative interdisciplinary communication. From the assimilation of these components the student should have the basic skills for planning, implementing, and adapting the session to foster patient safety. These align with the concepts of reflection for action being in place and reflection on action being emergent as the student implements a session while adapting to the patient responses. Based on these findings, the PTA student is expected to arrive at their final acute clinical rotation with the ability to clinically reason with skills parallel to the intermediate level with emergent skills into the competent level of master adaptive learning (Reilly et al., 2022). CIs expect that the PTA student will arrive with strong didactic preparation for CR with the base understanding of diagnoses, vitals, medications, and lab values. This knowledge is used for scaffolding the deeper understanding with the mental picture of the patient presentation. Facilitating this deeper understanding was recommended through the implementation of simulation labs, actual patients, and hands-on practice where students develop CR skills in a safe, but challenging environment. These are components of education that PTA faculty can integrate into the PTA curriculum. While this study aligned with the concepts of the master adaptive learner, it did not specifically investigate master adaptive learning and the PTA student preparation for acute care clinical preparation. Further investigation of master adaptive learning could be investigated in relation to the PTA student. The master adaptive learner aligns with the movement within physical therapy education toward the acceptance of competency-based education (Abraham et al., 2022; Giffin & Levangie, 2022). This study sets the stage for further investigation into levels STUDENT CLINICAL REASONING 62 of competency expected for the PTA student in consideration of pursuing competency-based education across the spectrum of PTA and physical therapy education. Although CBE development is well underway in the entry to practice of the DPT student, there is no activity related to the PTA student at this time. Additionally, the researcher recommends further research through replication of this study with altered parameters. The alteration of parameters could include different regions such as rural counties and states outside of Indiana. Level II and level III acute care trauma centers could be investigated related to the PTA student and the expectation for CR skills prior to their final acute care clinical rotation. An additional adaptation could be to assess the CR skills expected by the CI in the acute care setting after one year of didactic preparation. Based on the literature, expansion of the interview guide could include questions related to the incorporation of the patients voice and needs into patient care. These potential concepts are all additional research opportunities that would expand upon this current study. Conclusions This study revealed CIs expectations in three themes of assimilation, communication, and safety related to the PTA student preparation for their acute care clinical rotation. The study findings identified specific activities to incorporate into the PTA curriculum recommended to better prepare the PTA student with successful CR skills for beginning their final acute care clinical rotation. Concepts emerged that aligned the PTA students CR skills expected by CIs prior to their acute care clinical rotation with the literature on master adaptive learning. The findings present the opportunity to investigate master adaptive learning and competency-based education models within PTA education. These are areas of research that align with current investigation and trends in physical therapy education research. This study provides a basis for STUDENT CLINICAL REASONING 63 further investigation into these topics as well as the definition of CR skills across the curriculum and settings for PTA student clinical preparation. STUDENT CLINICAL REASONING 64 References Abraham, K., Green-Wilson, J., Hartley, G. 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Zoom for you. https://zoom.us/ 73 STUDENT CLINICAL REASONING 74 Table 1 Participant Characteristics and Demographics ID Code Licensed Age Range Years of Experience PT/PTA Clinician 1 2 3 4 5 6 7 8 9 PT PT PTA PTA PTA PTA PT PTA PTA 31-40 31-40 41-50 41-50 41-50 41-50 41-50 51-60 31-40 1-10 1-10 31-40 21-30 21-30 21-30 21-30 21-30 11-20 Years of Experience Clinical Instructor 1-5 6-10 11-15 11-15 1-5 11-15 6-10 16-20 11-15 Acute Care Hospital Rural Urban Classification Urban Urban Urban Urban Rural Mixed Rural Mixed Urban Urban Rural Mixed STUDENT CLINICAL REASONING Figure 1 Visual Representation of Themes and Sub-Themes 75 STUDENT CLINICAL REASONING 76 Appendix A Study Information Sheet This document is provided beginning on the next page on the required UIndy IRB format on the appropriate letterhead. STUDENT CLINICAL REASONING 77 Department of Interprofessional Health and Aging Studies, University of Indianapolis KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS My name is Marjorie Britt. While I am the director of the Physical Therapist Assistant Program at the University of Indianapolis, I am reaching out today as a student in the Doctor of Health Science Program at the University of Indianapolis. I am conducting a qualitative study using a basic interpretive approach for which I am seeking the perspective of clinical instructors. You are invited to participate in a research project investigating clinical instructors expectations of the clinical reasoning skills PTA students need prior to beginning their final acute care clinical rotation. Consent is being sought for research and participation is study is 100% voluntary. Participants have the right to withdraw from the study at any time with no effect on their relationship with the University of Indianapolis Department of Interprofessional Health and Aging Studies or the Krannert School of Physical leadership, faculty, or staff. Purpose: The purpose of this basic interpretive qualitative study is to investigate the clinical instructors expectation of the CR skills PTA students need prior to beginning their final acute care clinical rotation. Procedure: This research will involve an interview via Zoom where Marjorie Britt will ask you questions related to your expectations what clinical reasoning skills are needed by the PTA student as they begin their final clinical rotation. Time Commitment: Approximately 10 minutes to complete the participant information sheet send it back via email. Approximately 5-to-10-minute preliminary phone call. Approximately 45 to 60-minute interview via Zoom. Approximately 30 minutes to review the initial themes. Potential risk/discomforts: 1. Loss of privacy could reveal basic demographic information linking the participant to the study results and transcription of the participant responses. To prevent any such event, all data will be stored in password protected and/or encrypted protection locations in a deidentified format. 2. Loss of time. The minimum loss of time will be 90 minutes and the maximal loss of time will be 110 minutes to complete all commitments related to the study. 3. Coercion. As previously noted, this study is 100% voluntary. Participants have the right to withdraw from the study at any time with no effect on their relationship with the University of Indianapolis Department of Interprofessional Health and Aging Studies or the Krannert School of Physical leadership, faculty, or staff. STUDENT CLINICAL REASONING 78 Potential Benefits: 1. No direct benefits. 2. This is an opportunity for the front-line members of the clinical education team to provide their perspectives and expertise. 3. Participating in this study is supporting and giving back to the profession. CONSENT TO PARTICIPATE IN RESEARCH STUDY Clinical Instructors Descriptions of Student Physical Therapist Assistants Clinical Reasoning Skills Study Principal Investigator (PI): Jessica Emlich Jochum PhD LAT, ATC UIndy Email: jochumj@uindy.edu UIndy Telephone: (800) 232-8634 x 3248 Study Student Investigator: Marjorie Britt PT, MHS UIndy Email: brittm@uindy.edu UIndy Telephone: (800) 232-8634 x 3426 Jessica Emlich Jochum PhD LAT, ATC from College of Health Sciences, Master of Science in Athletic Training at the University of Indianapolis (UIndy) and Marjorie Britt, PT, MHS from the College of Health Sciences, Department of Interprofessional Health and Aging Studies at UIndy are conducting a research study. You were selected as a possible participant in this study because you have served as a clinical instructor for a physical therapist assistant student in their final acute care clinical rotation in a non-trauma, urban, acute care hospital. Your participation in this research study is voluntary. The following are the criteria that each participant must meet to be eligible for participation: Must be either a Physical therapist (PT) or Physical therapist assistant (PTA) Worked as a PT or PTA for at least one year in an acute care hospital categorized as nontrauma or trauma level III which is in an urban or rural-mixed county Served as a clinical instructor for a minimum of one PTA student who was in their final acute care clinical rotation during the last semester of the program between 2019 and 2022 Your participation in this study is voluntary. Why is this study being done? Clinical instructors offer invaluable education to PTA students as they prepare to enter the workforce as entry level clinicians. As educators it is imperative that there is evidence of how STUDENT CLINICAL REASONING 79 best to prepare students through each phase of their education. This study is designed to investigate what clinical instructors identify as the clinical reasoning skills PTA students need to have when they begin their final acute care clinical rotation. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Notify Marjorie Britt regarding your interest in study participation via preferred mode of communication by: o Phone or text at 317-292-5473 o Email at brittm@uindy.edu Participate in a 1015-minute preliminary phone call ensuring participant eligibility and understanding of the: voluntary nature of the study o right to discontinue without consequence at any time o risks and benefits of study participation o time commitment o mechanisms in place to maintain confidentiality o timing of when the participant will receive a $20 Starbucks gift card with conclusion of the Zoom interview (this will be provided so long as the Zoom interview has been initiated which includes any potential participant that gets to the interview and decides to not move forward. Complete and return the personal information sheet to Marjorie Britt via email at brittm@uindy.edu prior to the Zoom interview. Participate in an approximately 4560-minute Zoom interview with the following important information: o The interview will be audio recorded o The questions will be based on a semi-structured interview guide developed for this study which includes an initial broad and open-ended question followed by a series of other open-ended questions as well as probing and follow-up questions to allow for detailed, in-depth responses. o Remind participant not to hesitate at any time to: ask questions or voice concerns request to terminate the interview and discontinue participation Each participant will be given the opportunity to review and provide feedback on the initial themes. How long will I be in the research study? Participation will take a total time commitment ranging from approximately 90 to 110 minutes over the course of about 3 months. The interviews will be held over a short period of time depend on the participants availability. The follow up opportunity for participants to review the initial themes is the portion that will increase the total time as these will be sent out for review after they are established across participant responses. STUDENT CLINICAL REASONING 80 Are there any potential risks or discomforts that I can expect from this study? Loss of privacy could reveal basic demographic information linking the participant to the study results and transcription of the participant responses. To prevent any such event, all data will be stored in password protected and/or encrypted protection locations in a deidentified format. Loss of time. The minimum loss of time will be 90 minutes and the maximal loss of time will be 110 minutes to complete all commitments related to the study. Coercion. This study is 100% voluntary. Participants have the right to withdraw from the study at any time with no effect on their relationship with the University of Indianapolis Department of Interprofessional Health and Aging Studies or the Krannert School of Physical leadership, faculty, or staff. The benefits include the opportunity to participate in a qualitative study that adds to the body of knowledge on physical therapist assistant education. Are there any potential benefits if I participate? You will not directly benefit from this research. Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences, or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation, or teaching materials. While the interview will be audio recorded, all transcriptions will be deidentified by assigning an identification number to each participant to protect their confidentiality. The transcription will be downloaded to a password-protected Google Drive file that will be accessible only to the research team to ensure the confidentiality of all participant information. The audio recording will then be deleted. Dedoose Version 9.0.54 is an online application used to assist researchers in data management, analysis, and presentation (Dedoose, 2021). It is a password-protected and encrypted data management system in which transcriptions will be stored ensuring that there is backup storage for the data. The transcriptions will be used by the researchers to identify codes and themes which will be analyzed and stored using Dedoose with deidentified data. Will the data from my study be used in the future for other studies? Your data will not be used or distributed for future research studies even if there is no way for your data to be linked with any information that could identify you. What are my rights if I take part in this study? STUDENT CLINICAL REASONING 81 You can choose whether or not you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you, and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and still remain in the study. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments, or concerns about the research, you can talk to the one of the researchers. Please contact: 1. Jessica Emlich Jochum PhD LAT, ATC at (800) 232-8634 x 3248 or jochumj@uindy.edu 2. Marjorie Britt, PT, MHS at 317-292-5473 or brittm@uindy.edu The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. How do I indicate my informed consent to participate in this study? If you consent to participate in this study, prior to beginning the official Zoom interview you will verbally affirm that you satisfy inclusion criteria, and your consent is voluntary. At that time you will indicate whether you voluntary consent and proceed with the interview by verbally selecting one of the following options: I voluntaryly consent to participate in this study and consent to having the interview audiotaped. I do NOT consent to participate in this study. Note: You do not need to sign this, or any other document to indicate your consent. The study student investigator will ask for verbal consent at the beginning of the interview in place of obtaining a participant signature. STUDENT CLINICAL REASONING 82 Name of STUDY PARTICIPANT Name of Participant SIGNATURE OF PERSON OBTAINING CONSENT Name of Person Obtaining Consent Signature of Person Obtaining Consent Date STUDENT CLINICAL REASONING 83 Appendix B Initial Participant Recruitment Email Hello, My name is Marjorie Britt. I am reaching out today as a student in the Doctor of Health Science Program at the University of Indianapolis. I am conducting a qualitative research study that seeks the invaluable perspective of the clinical instructor on the preparation of the physical therapist assistant students as they begin their final clinical rotation in the acute care setting. If you graciously decide to participate, the time commitment will include an approximately: 10 to 15 minutes for reviewing, filling out and returning a personal information back to me via email. 5 to 10-minute phone call discussing your interest in participation and scheduling an official interview. 45 to 60-minute interview via Zoom. 30-minute opportunity to review the initial themes and provide feedback. Participation in this study is voluntary and has no bearing on your relationship with the University of Indianapolis Department of Interprofessional Health and Aging Studies, the Krannert School of Physical Therapy, the primary or secondary researcher, nor with the University of Indianapolis faculty or staff. If you choose to volunteer as a participant, you can withdraw and discontinue your participation at any time with no consequence. Upon completion of the Zoom interview, you will be provided with a $20 gift card to Starbucks which will be sent to you via mail to the address of your choosing. If you are interested in participating, please read the attached study information sheet, recruitment flier, STUDENT CLINICAL REASONING and contact me via email or phone. My contact information is provided below and in the recruitment flier. I am looking forward to hearing from you! Sincerely, Marjorie Britt, PT, MHS 317-292-5473 (Cell) brittm@uindy.edu This research project has been approved by the University of Indianapolis Institutional Review Board (IRB). Approval Date: 2/3/2023 Approval Number: 01817 84 STUDENT CLINICAL REASONING 85 Appendix C Personal Information Sheet: ID# Participant Demographic Information Age at time of recruitment Years of experience: as a clinician as a clinical instructor (CI) Gender Identity Ethnicity: please place an x next to the correct choice Hispanic/Latino of any race American Indiana/Alaskan Native Asian Black or African American Native Hawaiian/other White Two or more races Unknown or prefer not to answer Worksite Location: Please note the name of the hospital at which you work and the number of years you have worked at that location. Hospital Name: Years worked at above location: Experience: please circle the correct answer to the questions: Have you True/False True/False Worked at the above location for at least 1 year? Served as a CI for 1 PTA student in the final clinical rotation @ the above location between 2019 and 2022 STUDENT CLINICAL REASONING 86 Appendix D Follow-up Participant Email and Definition Hello, I want to sincerely thank you for your willingness to participate in the study, Clinical Instructors Descriptions of Student Physical Therapist Assistants Clinical Reasoning Skills. This email verifies that you have been selected as a study participant. As discussed on the phone, your Zoom interview will be held on [Day, Date, Time] and the Zoom link is provided below. [Zoom link]. Prior to the interview, please print this email and take a few minutes prior to the interview to review the following definition for clinical reasoning: the deliberation about a course of action within a specific context with the ability to anticipate outcomes guided by a framework of previous experiences and knowledge of best evidence (Foster et al., 2017, p. 3). This interview will be held via Zoom with only the two of us present. Please complete and return the personal information sheet via email to me at brittm@uindy.edu prior to the Zoom interview. The document is attached below. I have also attached the study information sheet for you to review prior to the interview. Please let me know if you have any additional questions or concerns by replying to this email. Please remember that this study is voluntary and that you are free to discontinue your participation at any time with no consequence and no bearing on your relationship with the University of Indianapolis Department of Interprofessional Health and Aging Studies or the Krannert School of Physical Therapy leadership, faculty, or staff. If you wish to discontinue your participation at any time, please send me an email notifying me of your request and you STUDENT CLINICAL REASONING will be immediately removed from participation in the study. Thank you, Marjorie Britt, PT, MHS brittm@uindy.edu 87 STUDENT CLINICAL REASONING 88 Appendix E Interview Questions 1. As a therapist and a clinical instructor in the acute care environment, what does CR mean to you? 2. What does it look like to demonstrate CR within a PT setting? a. What about PTA students, what does it mean for them to demonstrate CR? b. Can you describe a situation in which CR skills would be needed by a PTA student? c. Can you share an example of a time when a PTA student demonstrated sufficient CR skills? i. Do you recall what type of impact this had on the patient? If so, can you share what that looked like? ii. Can you share an example of a time when a PTA student did not utilize sufficient clinical reasoning skills? iii. Did this have any deleterious effects on the patient? iv. How did you address it with the student? v. Was the student able to adapt and learn how to better implement CR after this? If so, what did success look like? 3. As a clinical instructor, what are the expectations of a PTA student regarding CR skills as they begin their final acute care clinical rotation? a. Can you describe a situation in which clinical reasoning skills would initially be needed by a PTA student at the beginning of their rotation? Can you describe a situation where a student implemented a sufficient level of CR STUDENT CLINICAL REASONING 89 during the initial portion of their clinical rotation? b. Can you describe a situation where a student was lacking a sufficient level of CR during the initial portion of their clinical rotation? c. Upon completion of a chart review, what clinical concepts would you expect the student to have in anticipation of the patients potential treatment response? d. Do you have any additional thoughts on how the PTA student would demonstrate a sufficient level of CR in patient care as they begin their clinical rotation? 4. How can a PTA program best prepare students to hone their CR skills for their final clinical rotation in the acute care environment? a. As a CI what do you perceive as barriers and facilitators to CR among PTA students as they begin their final acute care clinical rotation? b. As a clinical instructor what classroom experiences do you believe can successfully prepare students within the academic setting prior to beginning their final acute care clinical rotation? STUDENT CLINICAL REASONING Recruitment Flier 90 Appendix F This document is provided beginning on the next page. STUDENT CLINICAL REASONING 91 ...
- Creator:
- Britt, Marjorie
- Type:
- Dissertation
12. The Life Experiences of Adults Living with Head and Neck Lymphedema
- Keyword matches:
- ... The Life Experiences of Adults Living with Head and Neck Lymphedema Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Meg Kral, MS, OTR/L, CLT Copyright October 24th, 2024 By: Meg Kral, MS, OTR/L, CLT All rights reserved Approved by: Laura Santurri, PhD, MPH, CPH Committee Chair ______________________________ Katie Polo, DHS, OTR, CLT-LANA Committee Member ______________________________ Paula Jo Belice, PhD, OTR/L Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ PERSONS WITH HEAD AND NECK LYMPHEDEMA Lived Experiences of Persons with Head and Neck Lymphedema: A Qualitative Study Meg Kral Department of Interprofessional Health & Aging Studies, University of Indianapolis 1 PERSONS WITH HEAD AND NECK LYMPHEDEMA 2 Abstract Background: Adults with head and neck cancer are often burdened with numerous side effects after cancer treatment including lymphedema. There are no qualitative studies to date reviewing the life experiences of persons living with head and neck lymphedema. It is imperative that healthcare providers understand what head and neck survivors endure, living with head and neck lymphedema. Objective: This qualitative study used an interpretive phenomenological approach to explore what it means to live with head and neck lymphedema and gain a deeper understanding of quality of life and occupational performance. Method: A convenience sampling method was used to recruit eight participants that met the inclusion criteria from an outpatient clinic. A two-step semi-structured interview was conducted. Data was analyzed from both interviews to gain a deeper understanding of the participants experiences living with head and neck lymphedema. Results: Three main themes emerged, including side effects, disruption in activities of daily living, and occupational therapy. Unexpectedly, quality of life was not a significant factor in participants experiences living with head and neck lymphedema. Discussion: Results indicate that patients undergoing head and neck cancer therapies experience numerous side effects that affect daily activities. Additionally, data indicates that patients expressed experiencing benefits from occupational therapy. Therefore, healthcare providers need to screen for lymphedema and functional deficits and consider referring patients to occupational therapists certified in treatment of lymphedema. Keywords: head and neck cancer, head and neck lymphedema and or occupational and physical therapy. PERSONS WITH HEAD AND NECK LYMPHEDEMA 3 Acknowledgements I would like to thank everyone who supported and encouraged me through this journey. Id like to especially thank my husband Joel Baeza for standing by as I worked diligently towards my degree. I appreciate your patience and I love you dearly. I appreciate the support I received from my very good friends Adam Steuer and Steven Taylor. Your guidance and words of encouragement helped me through some dark times when I thought I would not achieve my career goals. Thank you to my parents for standing by my side and loving me. Your love, guidance, and generosity gave me the tenacity to overcome obstacles to pursue my dreams. Id like to thank my former director, Brenda Koverman, for pushing me out of my comfort zone and always advocating for my professional growth. Id like to thank my best friend and the rest of my family for their support. Thank you to my co-workers and manager at NorthShore University Health Systems for supporting me and allowing me to take time to finish my degree. In addition, Id like to thank my RUSH colleagues Kristie Trenkle, Elyse Holezer, Rachel Dratnol, Joshua Teitcher, Dr. Sameer Al-Khudari, Dr. Kerstin Stenson, Dr. Mary Jo Fidler, Dr. Michael Jelinek, Holly Scheltens, and Colleen Masters who supported and helped me implement this research. Without your referrals and therapeutic interventions, it would have been challenging to conduct a qualitative study alone. I would like to thank my committee members. Dr. Laura Santurri, Dr. Paula Jo Belice, and Dr. Katie Polo. Your support, words of encouragement, and belief that I could complete my doctoral project despite facing multiple obstacles gave me the drive and strength to finish. I am forever grateful to you all. Your support and expertise in guiding me through this process created such a positive experience. It has given me the courage and desire to continue to pursue research in the future. PERSONS WITH HEAD AND NECK LYMPHEDEMA 4 I am immensely grateful to all the adults living with head and neck lymphedema that agreed to participate in my doctoral project. Your experiences will hopefully increase awareness about head and neck lymphedema and encourage head and neck healthcare providers to implement appropriate screenings and referral processes for patients at risk for lymphedema or for those living with head and neck lymphedema. PERSONS WITH HEAD AND NECK LYMPHEDEMA 5 Table of Contents Title Page.1 Abstract2 Acknowledgement...3 Chapter 1: Introduction8 Research Problem9 Purpose Statement..10 Research Question.10 Significance of the Study...10 Definition of Terms10 Chapter 2: Literature Review.11 Incidence and Prevalence of Head and Neck Cancer-Related Lymphedema12 Assessment and Measurement of Head and Neck Lymphedema..13 Impact of Head and Neck Lymphedema...14 Symptom Burden...14 Quality of Life15 Psychosocial Health...16 Head and Neck Lymphedema Therapy.18 Occupational Performance and Head and Neck Lymphedema.19 Chapter 3: Method.20 Research Teams and Reflexivity...20 Study Design..21 Participants.21 PERSONS WITH HEAD AND NECK LYMPHEDEMA 6 Setting23 Procedures.23 Recruitment23 Informed Consent...26 Data Collection Process.27 Initial Semi-Structured Interview..27 Second Semi-Structured Interview29 Data Management..30 Data Analysis.31 Rigor & Trustworthiness34 Chapter 4: Results..36 Side Effects37 Swelling.38 Dry Mouth.39 Neck Mobility39 Disruption in Activities of Daily Living40 Eating.41 Personal Hygiene & Grooming..41 Sleep Participation.42 Occupational Therapy43 Home Program...45 Quality of Life47 Visual Representation of Findings.48 PERSONS WITH HEAD AND NECK LYMPHEDEMA 7 Chapter 5: Discussion & Conclusion.48 Implications57 Study Limitations...60 Conclusions61 References..62 Table 1 COREQ Checklist73 Table 2 Sociodemographic of Participants75 Table 3 Analysis of Primary Findings...76 Figure 1 Visual Representation of Findings..76 Appendices.....77 Appendix A: The Lived Experiences of Persons with Head and Neck Lymphedema..78 Appendix B: Screening Checklist for Head and Neck Lymphedema Research Study..79 Appendix C: Qualitative First Interview Guide & Data Collection..80 Appendix D: Qualitative Second Interview Guide & Data Collection..83 PERSONS WITH HEAD AND NECK LYMPHEDEMA 8 Lived Experiences of Persons with Head and Neck Lymphedema: A Qualitative Study Head and neck cancer survivors are often burdened with factors that interrupt survivorship. They report more psychosocial pain, depression, and thoughts of suicide than those surviving other cancer types (Park & Hashmi, 2018; Semple et al., 2013). Although multimodality treatment can improve survival, there is an increased risk of side effects that can impact function and quality of life (Deng et al., 2012a). Head and neck cancers account for approximately 4% of all new cancer cases, with a projected number of 68,000 new cases in 2021 (National Cancer Institute, 2021). Men are affected by these cancers more so than women (National Cancer Institute, 2021). Patients diagnosed with head and neck cancer undergo cancer therapies, which may include surgery, chemotherapy, and radiation (Deng et al., 2012c). Lymphedema is a common late side effect of head and neck cancer treatment that is often underrecognized (Deng et al., 2012a). The condition occurs when the lymphatic system becomes damaged by tumor or cancer treatment (Deng et al., 2016a). General burdens associated with head and neck lymphedema may include impaired musculoskeletal functioning, swallowing and chewing difficulties, breathing problems, and psychological dysfunction due to altered appearance (Deng et al., 2016b; McGarvey et al., 2014). With the increase in head and neck cancer survivors (Ringash, 2015), healthcare providers need to remain vigilant in identifying the long-term and late side effects of head and neck cancer treatment, including lymphedema. Throughout the last 15 years researchers have investigated head and neck lymphedema prevalence (Deng et al., 2012a); methods for assessment and measurement (Deng et al., 2015; Purcell et al., 2016); prevalence of external and internal lymphedema (Deng et al., 2012b; Smith et al., 2015); clinical outcomes and evaluation of various therapy programs (Pigott et al., 2017); patients perceived symptoms (Deng et al., PERSONS WITH HEAD AND NECK LYMPHEDEMA 9 2016b); and the psychosocial impact of head and neck lymphedema (Ridner, 2009). Despite efforts to develop a better understanding of head and neck lymphedema and how it can be treated, a paucity of literature remains exploring the impact head and neck lymphedema may have on day-to-day functioning. Given the long-term and late side effects patients may encounter in survivorship, healthcare providers need to develop a clearer understanding of how these side effects may impact the lives of patients living with head and neck lymphedema. Understanding how head and neck cancer survivors live with lymphedema may provide better insight into how healthcare providers and supportive care services can best meet the needs of their patients. Some phenomenological studies have investigated the lived experiences of head and neck cancer survivors and family members including caregivers caring for those with head and neck cancer (Dri et al., 2019), patients participating in a nutritional education program after head and neck surgery (Missel et al., 2018), patients receiving radiation treatment for head and neck cancer (Donovan & Glackin, 2012), and eating following esophagectomy (Jaromahum & Fowler, 2010). Despite the studies that investigated caregivers, patients and nutrition, patients and radiation treatment, and the lived experiences of eating following esophagectomy, no studies have explored the lived experiences of persons living with head and neck lymphedema thus far. Problem Statement Without a sound understanding of what it means to live with head and neck lymphedema, healthcare providers may not recognize the hardship patients face. Patients are often left to cope with the challenges of survivorship related to changes in activities of daily living, problems related to psychosocial wellness, issues in returning to work, and needs for supportive care (Brearley et al., 2011; Hwang et al., 2015; Park & Hashmi, 2018). Increasing awareness and understanding the impact of head and neck lymphedema on quality of life and occupational PERSONS WITH HEAD AND NECK LYMPHEDEMA 10 performance will allow healthcare providers to use a client-centered approach by making appropriate referrals to supportive care services, like occupational therapists. Purpose Statement The purpose of this phenomenological study was to explore the lived experiences of persons living with head and neck lymphedema, including an in-depth understanding of their quality of life and occupational performance. Research Question This study addressed the following research questions: What are the lived experiences of persons living with head and neck lymphedema? o How do participants describe their experience with occupational performance living with head and neck lymphedema? o How do participants describe their quality of life living with head and neck lymphedema? Significance of the Study Using a qualitative research approach to understand what it means to live with head and neck lymphedema facilitated the exploration of this specific phenomenon as lived by the participants themselves. Results from this study may provide healthcare providers with a deeper understanding of how to meet the needs of patients with this condition. Increasing awareness about the impact of head and neck lymphedema may warrant consideration for additional programming at facilities delivering head and neck cancer treatment or prompt early intervention for those struggling with symptoms of lymphedema. Definition of Terms PERSONS WITH HEAD AND NECK LYMPHEDEMA 11 Musculoskeletal functions: functions of the neck, jaw, shoulders, and chest (Murphy & Deng, 2015). External lymphedema: swelling affecting the face and neck (Deng et al., 2012b; Smith & Lewin, 2010). Internal lymphedema: swelling affecting the oral cavity, pharynx, and epiglottis (Deng et al., 2012b; Smith & Lewin, 2010). Occupational performance: the achievement of a desired occupation resulting from the interaction between the individual, context and environment, and occupation (American Occupational Therapy Association [AOTA], 2014). Quality of life: an individuals perception of his or her overall wellbeing (Ringash, 2015). Literature Review Strategies used to conduct a literature review consisted of searching several databases, including PubMed, Google Scholar, and Ovid through the Rush University library. Key terms used to obtain peer-reviewed journal articles included head and neck cancer, head and neck lymphedema, head and neck lymphedema and occupational and or physical therapy, and head and neck lymphedema and self-care. Surgery, radiation, and chemotherapy serve as the standard treatment methods for improving survival rates of individuals diagnosed with head and neck cancer (Ridner et al., 2016). Often times, side effects including lymphedema develop from multimodality cancer treatment leading to functional sequelae and secondary deficits related to the disease. Interrupted lymphatics from cancer treatment may cause swelling to accumulate in external tissues including the head and neck, and or internal tissues involving the oral cavity, pharynx, and larynx (Deng et al., 2016a). Lymphedema of the head and neck can lead to functional impairments and PERSONS WITH HEAD AND NECK LYMPHEDEMA 12 psychological dysfunction. Considering the abundance of research on breast cancer-related lymphedema, there is relatively minimal research concerning head and neck lymphedema (Shaitelman et al., 2015) Incidence and Prevalence of Head and Neck Cancer-Related Lymphedema Surgery and radiation are the primary treatments in the management of head and neck cancer, with chemotherapy serving as an additional treatment method to improve outcomes for advanced disease (Ridner et al., 2016). Unfortunately, these therapies can compromise the lymphatic system leading to a risk of the development of head and neck lymphedema (Deng et al., 2013). Until recently, data regarding prevalence rates in the United States for head and neck lymphedema remained scarce (Deng et al., 2012a). Deng et al. (2012a) conducted a study looking at head and neck lymphedema prevalence in a group of 81 participants. Of the 81 participants, 75.3% (n =61) developed some form of head and neck lymphedema (Deng et al, 2012a). European literature has reported similar findings, estimating the incidence of head and neck lymphedema to range between 12% and 54% (Buntzel et al., 2007; Deitz et al., 1998; Schiefke et al., 2009; Wolff et al., 2009). Researchers performed a prospective longitudinal descriptive study over a four-year period looking at the prevalence of internal, external, and combined lymphedema in a group of 83 participants (Ridner et al., 2016). Results revealed that prior to radiation treatment, 62% of patients had some form of external lymphedema, 41.7% of participants developed internal lymphedema, and 29.2% of participants presented with both internal and external lymphedema (Ridner et al., 2016). Following radiation treatment, rates of lymphedema were exacerbated, with 81.9-90.1% having external lymphedema, 80.4-89.4% having internal lymphedema, and 70.6-80.9% presenting with both internal and external PERSONS WITH HEAD AND NECK LYMPHEDEMA 13 lymphedema (Ridner et al., 2016). Results showed that the majority of participants experienced lymphedema as a late side effect of cancer treatment (Ridner et al., 2016). Findings from both studies suggested that head and neck lymphedema is a frequent late side effect for those undergoing head and neck cancer treatment (Deng et al., 2012a; Ridner et al., 2016). Late side effects, including lymphedema, may lead to functional deficits and or psychological distress (Deng et al., 2013). Therefore, patients should be frequently assessed for lymphedema and occupational deficits during and after cancer treatment, and referral for treatment of lymphedema is strongly recommended. Assessment and Measurement of Head and Neck Lymphedema Although limb lymphedema can be assessed using circumferential measurements, symptoms of head and neck lymphedema can be difficult to capture (Flores et al., 2015). There are few methods available to measure and characterize head and neck lymphedema (Flores et al., 2015). Objective measurements including tape measurements, identifying the stage of lymphedema using the M.D. Anderson Cancer Center Head and Neck Lymphedema Rating Scale, and ultrasound are some of the current ways to measure head and neck lymphedema (Flores et al., 2015). However, these methods lack evidence supporting good psychometric properties and clinical utility (Flores et al., 2015). Deng et al., (2012c) developed the Lymphedema Symptom Intensity and Distress Survey-Head and Neck (LSIDS-H&N). The LSIDS-H&N was pilot tested on 30 patients with head and neck cancer, and initial results showed that the assessment tool identified symptoms of external lymphedema (Deng et al., 2012c). Due to the lack of robust and validated assessments for measuring external lymphedema and tissue abnormalities, researchers identified a need to PERSONS WITH HEAD AND NECK LYMPHEDEMA 14 develop an assessment tool that measures external lymphedema and fibrosis (Deng et al., Ridner, 2015). Therefore, modifications to the LSIDS-H&N have been ongoing. Refinement and validation of the LSIDs-H&N have been recently completed. Deng et al., (2021) conducted a study looking at the usability and validation of the LSIDS-H&N. Due to the length of the LSIDS-H&N, as reported by 50 percent of participants, researchers reduced the patient reported outcome measure to 33 items and named the new assessment Head and Neck Lymphedema and Fibrosis Symptoms Inventory (HN-LEF Symptom Inventory) (Deng et al., 2021). Psychometric testing for strength and validity remains ongoing. A valid and reliable head and neck lymphedema assessment tool would be valuable to healthcare providers in assessing symptom burden and functional impairment related to head and neck lymphedema. Identifying deficits related to head and neck lymphedema would prompt referral to supportive services, like occupational therapy. The assessment tool could be used to measure patient progress and or response to therapeutic intervention. Impact of Head and Neck Lymphedema Symptom Burden Head and neck lymphedema can impact physical ability and psychosocial wellbeing, causing interruption and/or burden to ones life (Deng et al., 2016b). Symptom burden is a term used frequently to describe how symptoms may adversely affect patients going through cancer treatment (Gill et al., 2012), and has been defined as a patient reported outcome describing symptom severity and how symptoms may affect an individuals activities of daily living (Cleeland, 2007). Patients with head and neck lymphedema experience a significant amount of symptom burden. Deng et al. (2013) explored the severity of lymphedema, symptoms, and functional status in a group of 103 patients. Findings included an association between PERSONS WITH HEAD AND NECK LYMPHEDEMA 15 lymphedema severity and swallowing problems, lymphedema severity and dry mouth, lymphedema severity and decreased neck range of motion, and lymphedema severity and decreased hearing (Deng et al., 2013). In a qualitative descriptive study of 20 participants with head and neck lymphedema, patients reported experiencing a range of symptoms, including impaired sensation such as tightness, tingling, and numbness; neck and shoulder dysfunction impacting neck range of motion; altered physical functions related to swallowing, speaking, breathing, jaw tightness, and pain; and psychosocial symptoms including anxiety and poor body image (Deng et al., 2016b). Similarly, data taken from three cross-sectional studies of participants with head and neck cancer found patients with head and neck lymphedema reported symptoms of tightness, heaviness, warmth, swallowing problems, blurred vision, and swelling (Deng et al. 2016a). Jeans et al. (2019) conducted an interpretive descriptive qualitative study to explore participants perception of the impact of head and neck lymphedema on swallowing, voice and speech. Twelve participants participated in semi structured interviews that were transcribed and underwent thematic analysis. Four themes were discovered, with three of the themes relating to head and neck lymphedema and its impact on swallowing and speech (Jeans et al., 2019). Findings in the studies above suggest that lymphedema may negatively impact occupational performance including eating, driving, sleeping, exercise and psychosocial wellbeing (Deng et al., 2013; Deng et al., 2016a; Deng et al., 2016b; Jeans et al., 2019). Occupational therapists have the skills to address many of the occupational deficits reported in the literature. Early identification and treatment for lymphedema may lead to reduced long-term symptom burden. Quality of Life PERSONS WITH HEAD AND NECK LYMPHEDEMA 16 Quality of life (QOL) is a persons perception of his or her overall well-being, and consequently, QOL is often disrupted after receiving cancer treatment (Ringash, 2015). Head and neck lymphedema can have a negative impact on physical function, including difficulty operating a vehicle secondary to reduced neck range of motion, trouble eating meals, and difficulty communicating with others due to altered speech (Rhoten et al., 2018). Decreased engagement in these activities can often lead to social isolation (Rhoten et al., 2018). In a study involving 103 patients with head and neck lymphedema, there was a strong correlation between functional well-being and QOL (Deng et al., 2013). Those with increased levels of lymphedema severity had overall poorer functional well-being (Deng et al., 2013). Ridner (2009) reported similar findings among the breast cancer-related lymphedema population. When measured by three different quality of life assessment tools, patients with breast cancerrelated lymphedema reported overall reduced QOL after developing arm lymphedema (Ridner, 2009). Fu and Kang (2013) performed a systematic review focusing on the psychosocial impact of lymphedema. Most of the research gathered focused on patients with breast cancer-related lymphedema (Fu & Kang, 2013). Participants from the studies reported an overall reduced QOL as a result of developing lymphedema (Fu & Kang, 2013). Findings suggest patients at risk for developing head and neck lymphedema or those who develop head and neck lymphedema need to be referred to appropriate support services to prevent deterioration of QOL during survivorship (Deng et al., 2013; Fu & Kang, 2013; Ridner, 2009). Supportive care services, like occupational therapy, are uniquely positioned to help address concerns related to QOL (Park & Hashmi, 2018). Psychosocial Health PERSONS WITH HEAD AND NECK LYMPHEDEMA 17 Lymphedema is considered a chronic disease that requires daily maintenance to minimize complications (Fu & Kang, 2013). Although QOL among patients with lymphedema has been explored, there is a paucity of research examining whether lymphedema has an impact on psychological components, including body image and depression (Dominick et al., 2014). In a qualitative study exploring perceived symptom experience in patients with head and neck lymphedema, Deng et al. (2016b) found that 50% of participants (n = 10) reported having psychosocial symptoms, including altered cosmetic appearance, poor self-image, fear, anxiety, and difficulty accepting lymphedema as part of survival. In another qualitative study, McGarvey et al. (2014) reported variation in psychosocial issues between participants. Most male participants indicated no long-lasting psychological effects of head and neck lymphedema, while female participants expressed having body image problems related to swelling (McGarvey et al., 2014). Another study explored depressive symptoms, social anxiety, and perceived neck function in patients with head and neck cancer (Rhoten et al., 2018). Although participants did not have head and neck lymphedema, findings indicated that self-reported impaired neck function was associated with depression and anxiety leading to psychological distress (Rhoten et al., 2018). Dominick et al. (2014) performed a study looking at psychological distress in women with breast cancer-related lymphedema. Three hundred and thirty-five of the 2431 participants reported moderate to extreme distress due to breast cancer-related lymphedema (Dominick et al., 2014). Those who reported distress had higher odds of reduced physical and mental health as compared to women who did not have breast cancer-related lymphedema (Dominick et al., 2014). Psychosocial problems have been well documented among patients with breast cancerrelated lymphedema (Dominick et al., 2014; Fu & Kang, 2013; Ridner, 2005; Ridner, 2009). Research indicates that patients with head and neck lymphedema also experience similar PERSONS WITH HEAD AND NECK LYMPHEDEMA 18 symptoms (Deng et al., 2013). Symptoms of psychological impairments should be a part of routine screening among healthcare providers so patients can receive proper support as they move into survivorship. Head and Neck Lymphedema Therapy Despite the significant prevalence of head and neck lymphedema, the disease has continued to receive minimal attention. Researchers report a high symptom burden among this population, impacting function. Studies in recent years have discussed the need for therapy in addressing head and neck lymphedema. In a prospective observational pilot study of 10 participants with head and neck lymphedema, Pigott et al., (2017) found an overall significant reduction in neck circumference after participation in 13 lymphedema treatment sessions. Findings indicated that lymphedema treatment was beneficial in reducing swelling in the head and neck (Pigott et al., 2017). Doke et al. (2018) obtained similar findings in a retrospective study involving 34 participants with head and neck lymphedema. Neck circumference in all 34 patients reduced after one month of lymphedema treatment, cervical rotation improved more than 28% in each direction, and pain scores improved (Doke et al., 2018). Deng et al., (2019) conducted a qualitative study looking at patients experience of head and neck lymphedema therapy. Fifteen of 20 participants completed the study and reported an overall improvement in physical and psychological benefits, including reduced swelling and improved ability to swallow (Deng et al., 2019). The effectiveness of head and neck lymphedema treatment remains limited due the lack of sizable randomized controlled trials (Tyker et al., 2019). Despite the relatively small sample sizes in the studies previously identified, lymphedema treatment has proved to be beneficial in reducing symptom burden among patients with head and neck lymphedema. However, PERSONS WITH HEAD AND NECK LYMPHEDEMA 19 healthcare providers need to be aware of lymphedema therapy programs and be more proactive in identifying lymphedema and referring patients to lymphedema therapy. McGarvey et al. (2014) found that providers were likely to refer patients to therapy if head and neck lymphedema were thought to be severe. For those who developed mild lymphedema, health care providers did not refer patients to lymphedema therapy (McGarvey et al., 2014). They mostly provided patients with reassurance regarding lymphedema being a common late side effect and educated patients that it may or may not resolve (McGarvey et al., 2014). Healthcare providers need to be aware that lymphedema therapy is an option in reducing swelling and improving the overall quality of life. Occupational Performance and Head and Neck Lymphedema Symptom burden associated with head and neck lymphedema can have a profound impact on an individuals ability to carry out daily occupations like eating, social participation, driving a car, and several other daily activities (Deng et al., 2013; Deng et al., 2016b). Reports in the literature confirm that lymphedema remains a disease that affects quality of life, alters cosmetic appearance, and interferes with social and leisure participation, which ultimately affects occupational engagement (Pergolotti et al., 2016; Shigaki et al, 2013). As patients progress through head and neck cancer treatment and transition into survivorship, they remain at risk for developing head and neck lymphedema (Deng et al., 2012). Researchers have documented numerous functional limitations and psychosocial impairments patients experience after developing head and neck lymphedema (Deng et al., 2013; Deng et al., 2016b). However, no researchers have conducted studies on how lymphedema impacts engagement in life activities as patients transition into survivorship. Understanding how daily occupations are affected by lymphedema may elicit increased attention toward routine screening for those at risk for PERSONS WITH HEAD AND NECK LYMPHEDEMA 20 developing the disease. Early detection of head and neck lymphedema will prompt referral to appropriate rehabilitative services like occupational therapy to address deficits related to occupational performance. Occupational therapists help people across the lifespan to do the things they want and need to do through the use of daily activities (occupations). Occupational therapy practitioners enable people of all ages to live life to its fullest by helping them promote health, and prevent-or live better with-injury, illness, or disability (AOTA, 2019). Occupational therapists are experts in lifestyle management, routine management, and addressing psychosocial health (Park & Hashmi, 2018). They are skilled in addressing multiple obstacles patients with head and neck cancer face including physical disability, cancer-related fatigue, lymphedema, and psychosocial dysfunction (Park & Hashmi, 2018). A phenomenological study reviewing the lived experiences of persons living with head and neck lymphedema may provide healthcare providers with an increased understanding and insight into how occupational performance and quality of life are impacted. Methods Research Team and Reflexivity The Consolidated criteria for Reporting Qualitative research (COREQ) was used to improve the transparency of the primary researchers work (Table 1). The primary researcher who conducted this study is female and holds a Masters Degree of Science in Occupational Therapy. She is a practicing clinician certified in treatment of lymphedema and has been treating patients with lymphedema for more than 15 years. She was the sole researcher in conducting interviews. The primary researcher was the main recruiter for the study and met most participants while serving on the comprehensive head and neck team in in the cancer center prior PERSONS WITH HEAD AND NECK LYMPHEDEMA 21 to beginning the study. Participants who participated in the study had some knowledge of the primary researcher including her career goals and the research she was interested in pursuing. She noted her specific interest in head and neck lymphedema and desire to increase the unique role occupational therapists have in addressing head and neck cancer symptoms through applied skills in lifestyle management. A bias the primary researcher tried to overcome during the research process included research bias. Since the primary researcher is an occupational therapist who treats patients with lymphedema regularly, trustworthiness and rigor were implemented to reduce bias in this study. Study Design To gain the perspective of what it truly means to live with head and neck lymphedema, the primary researcher explored the phenomenon in depth. Therefore, an interpretative phenomenological study design was used to capture the unique experiences of persons living with head and neck lymphedema. This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research Guidelines (Tong et al., 2007). Approval to conduct the study was obtained from appropriate academic institutions. Participants A convenience sampling method was used to select participants. Cohen and Crabtree (2008) noted that a convenience sampling method includes recruiting participants from a convenient location to which the researcher has access. In this case, participants were recruited in person from the outpatient occupational therapy department and or the head and neck cancer clinic of the Cancer Center at Rush University Medical Center (RUSH) where the primary researcher worked. PERSONS WITH HEAD AND NECK LYMPHEDEMA 22 Individuals were eligible for the study if they met the following criteria: (1) at least 25 years of age; (2) diagnosed with head and neck lymphedema; (3) at least one month post head and neck cancer treatment; (4) no current evidence of cancer; (5) English speaking; and (6) the ability to provide informed consent. As head and neck cancer often affects middle-aged adults (American Head and Neck Society, 2016), individuals younger than 25 were not considered. Despite the Merriam-Webster Dictionary (2019) defining middle-aged adults as those between the ages of 45-60, some individuals diagnosed with head and neck cancer fall outside the parameters of what is considered middle age. Therefore, participants older than 25 were considered. Participants were excluded if they met any of the following criteria: (1) actively undergoing head and neck cancer treatment; (2) presently being treated for metastatic disease; and (3) currently receiving lymphedema treatment by the primary researcher. Participants with metastatic disease were not considered due to multiple variables that may or may not influence the experience of living with head and neck lymphedema. Since lymphedema is often a latent side effect (Deng et al., 2012), participants undergoing active treatment were not considered for the study until at least one month post treatment. To reduce bias, participants who received ongoing lymphedema treatment by the primary researcher other than the initial evaluation were not considered. In qualitative research, Creswell and Poth (2018) recommend collecting extensive data by studying a few participants. Smith et al. (2009) suggest three to six participants as being a sensible sample size for student projects. Given the detailed amount of information obtained in each individual experience, phenomenological studies only need a small number of participants PERSONS WITH HEAD AND NECK LYMPHEDEMA 23 (Smith et al., 2009). Therefore, to obtain a rich amount of data, recruitment included a range from three to ten participants or until saturation was reached. A total of eight participants were recruited for this study. All eight participants completed the first interview and five participants from the first interview completed the second interview. Three participants were lost to follow up. Setting Recruitment took place in Chicago, Illinois on the RUSH campus. RUSH is an academic medical center located on the west side of Chicago. Their mission is to serve the surrounding diverse communities by providing excellent patient care, performing research, and developing community partnerships (Rush, n.d.). RUSH has been ranked by U.S. News and World Report in five categories and has been recognized for high performance in a number of areas including cancer (Rush, n.d.). The cancer program is accredited by the Commission on Cancer of the American College of Surgeons. In addition, the Association for the Accreditation of Human Research Protection Programs accredited RUSH for their commitment to protecting the rights and welfare of individuals participating in research (Rush, n.d.). Procedures Recruitment Individuals were recruited over a period of nine months, April 2020 through December 2020. Screening procedures for recruitment took place in two locations on campus. Patients were recruited in person during follow-up outpatient visits in the head and neck clinic and or via scheduled therapy visits in the outpatient occupational therapy department using a screening tool containing the inclusion and exclusion criteria. Materials used to describe the study to the participants included fliers that were dispersed throughout the waiting areas of the cancer center PERSONS WITH HEAD AND NECK LYMPHEDEMA 24 and outpatient occupational therapy department (Appendix A). Information about the study, including an explanation of the purpose, where the study took place, and what was required of participants in the study, was disclosed on the flier. The primary researcher educated all healthcare providers and the primary researchers students assisting with the study on screening procedures, research criteria, and the informed consent process. Healthcare providers delivering patient care post-head and neck cancer treatment determined eligibility during scheduled outpatient office visits or therapy visits. Providers were given paper copies of a checklist serving as the screening tool to determine eligibility of participants interested in the study (Appendix B). The checklist contained space for the patients name, date, and medical record number. Patients scheduled for routine follow-up outpatient visits and who presented with head and neck lymphedema were screened by any one of the providers using the paper checklist. Providers included the oncologists, radiology oncologists, nurse practitioners, physicians assistants, a speech therapist, and the primary researcher. Patients who met the inclusion criteria were asked to participate in the research study. Those interested in participation were educated on the purpose of the study during the office visit or therapy visit by the healthcare provider. The healthcare provider read the informed consent form verbatim to each participant, and then each participant was asked to sign the informed consent disclosure. The provider gave each patient a flier they could refer to with information about the study. The provider then let each potential participant know they would be contacted within one week by the primary researcher. Due to the COVID-19 pandemic, not all informed consent was obtained in person. The primary researcher sought out additional approval by the institutional review board to obtain informed consent via Research Electronic Data Capture (REDCap). REDCap is a secure web PERSONS WITH HEAD AND NECK LYMPHEDEMA 25 platform that manages online surveys, informed consent, and databases. The primary researcher read the informed consent verbatim to one participant via telephone and used REDCap to secure the participants signature. There were instances in which providers did not have adequate time to engage in the screening of patients eligible for the study. In that case, providers asked the primary researcher or the researchers students to perform most of the screenings using the screening tool. Providers who did not have enough time to screen patients eligible for the study asked patients for their permission to allow the primary researcher or the researchers students to contact them. Providers were then instructed to provide the primary researcher with the patients contact information so that, the primary researcher or the primary researchers students could follow up with those who expressed interest in the study. Checklists of those interested in participating in the study and signed informed consent forms were given to the primary researcher. To ensure privacy and confidentiality, these forms were placed in a folder and stored in a locked cabinet in the primary researchers office. The primary researcher used patient de-identifiers such as participant A, participant B, and so on, and uploaded participants interested in the study into a Microsoft Excel spreadsheet. The spreadsheet contained each patient de-identifier, date of contact, date of initial interview, date of follow up interview or discussion, type of interview (in person or distance), and demographic information including diagnosis, stage of lymphedema, age, gender, race, education level, and contact information. The spreadsheet was saved in a secure location on the researchers computer until interviews were arranged. Information was password-protected so that only the primary researcher could open the document. Once the screening data was entered into the spreadsheet, PERSONS WITH HEAD AND NECK LYMPHEDEMA 26 the associated checklist remained in a locked cabinet. The primary researcher used the Excel spreadsheet of potential participants to schedule interviews. Informed Consent Informed consent was obtained during the screening process in the head and neck cancer clinic for patients who voiced interest. Consent forms contained the following: (1) the purpose of the study clearly stated; (2) an estimate of the expected duration of the study; (3) any risks associated with participation in the study; (4) the benefits for participation in the study which included a small gift card; (5) permission to access the patients medical chart; (6) a statement regarding confidentiality of records obtained by participants; (7) the researchers contact information if questions arose; (8) and a clause that stated participation is voluntary and participants would not be penalized if they decided to terminate participation. For those who voiced interest in the study, the primary researcher, providers, and or students involved in the screening process allowed ten minutes to review the study purpose to ensure each patient understood what is being asked of them. The teach back method was used to ensure patients understood what was expected of them in the study. The Agency for Healthcare Research and Quality (2015) stated that its important for patients to understand the information they have been educated on, and the teach back method requires participants to describe their understanding of the study back to either the primary researcher or other providers. Once patients verbalized understanding of the study, they were asked if there were any further questions. Signed informed consent forms included the date and time and were placed in a folder and given to the primary researcher. The primary researcher kept signed consent forms in the same locked cabinet that contained the checklists in the primary researchers office. Informed PERSONS WITH HEAD AND NECK LYMPHEDEMA 27 consent remained ongoing and was obtained verbally at the beginning of each interview, followup phone calls, or discussions. Steps taken to minimize the possibility of coercion or undue influence included respecting the patients need to take time to decide on whether to participate in the study. During recruitment, if a patient requested extra time to decide whether he or she wanted to participate in the study, recruiters respected this request. The researchers contact information was provided should a potential participant decide to participate in the study at a later time. Data Collection Process The primary researcher was responsible for conducting all data for this study. In some instances, the primary researcher was the participants initial provider in the treatment of lymphedema since the primary researcher was part of the interdisciplinary team in the head and neck clinic. To reduce bias, if the participant required further lymphedema treatment, the primary researcher scheduled follow-up treatment with other occupational therapists certified in treatment of lymphedema. Data were collected using a two-step interview process. Interviews were conducted in person or via distance using a semi-structured interview guide. Interviews were recorded via Zoom on a laptop. Furthermore, a voice recorder was used to record interviews to eliminate potential recording malfunctions and ensure that the entirety of the interview was recorded. In addition to using the interview guide for questioning, the primary researcher used the guide to take field notes on participants responses or if the primary researcher had any pertinent thoughts during interviews. In person took place in a private location on the RUSH campus. Distance interviews were conducted using a communications platform and also took place in a private location, such as the primary researchers office. PERSONS WITH HEAD AND NECK LYMPHEDEMA 28 Initial Semi-structured Interview. The initial semi-structured interview guide (Appendix C) was developed using information from Creswell and Poth (2018), a qualitative study reviewing symptom burden by Deng et al. (2016), and the Occupational Therapy Practice Framework (AOTA, 2014). The interview questions were mainly open-ended and incorporated laymans terms to ensure that participants understood the questions being asked. Open-ended questions allow for more information to be revealed including participants stories, feelings, attitudes, and behaviors (Turner, 2010). The semi-structured interview guide had five primary questions with several sub-questions to increase the likelihood for rich information to be obtained by participants. Additional questions were included for those who had begun lymphedema treatment. Prior to implementing use of the semi-structured interview guide, the primary researcher piloted the guide with one patient with head and neck lymphedema. Piloting the interview guide allowed the patient to provide the primary researcher with feedback regarding the flow of the interview guide, the interview questions written, and the need for additional questions. For the initial interviews, six participants were interviewed in person and two participants were interviewed via Zoom. For in person interviews, the primary researcher greeted each participant, invited them into a private room, and instructed them to take a seat. Interviews conducted via Zoom were also done in a private room. The primary researcher thanked each participant for agreeing to participate in the study and reviewed and re-confirmed informed consent. The primary researcher then, explained her research interests, reiterated the purpose of the study, provided information about the doctoral degree being pursued, and explained the process of the interview to each participant. She discussed how data collected from the participants were going to be reviewed to identify common themes and relationships with other PERSONS WITH HEAD AND NECK LYMPHEDEMA 29 individuals who have been diagnosed with head and neck lymphedema. The primary researcher discussed that all information and data collected would be kept confidential. She informed each participant that the interview would take approximately 45 minutes and could be stopped and terminated at any time upon request. Before beginning the interviews, the primary researcher identified each participants stage of lymphedema using the MD Anderson Cancer Center Head and Neck Lymphedema Rating Scale (American Head and Neck Society, 2016). The primary researcher then began the interview and asked participants a series of questions pertaining to the everyday life experiences living with head and neck lymphedema. Upon completion of the interview, the primary researcher thanked each participant and provided participants with a business card should questions arise after the interview. She informed each participant they would receive a follow up phone call, email, and or set up an additional follow-up interview approximately two to three months later. The primary researcher completed the same steps for participants participating in distance interviews. Participants were compensated with a small a gift card as a thank you for participating in the study. Participants who engaged in person interviews received the gift card in person. Participants who participated in distance interviews received an e-gift card sent to their email. Second Semi-structured Interview. The second semi-structured interview guide (Appendix D) was developed from the responses provided by participants from the first semistructured interview. Interview questions were primarily open-ended and incorporated plain language to ensure questions were understood by the participants. Interview questions were approved by the primary researchers research committee. A total of five participants participated in the second interview via Zoom. Interviews were conducted in a private space. The primary researcher greeted each participant and thanked PERSONS WITH HEAD AND NECK LYMPHEDEMA 30 participants for agreeing to participate in the follow up interview. She ensured participants that all information would remain confidential. In addition, the primary researcher informed participants that the interview would take approximately 30-45 minutes and could be stopped at any time upon request. She began by sharing a summary of the results from the first interview with each participant. Member checking was used to determine the credibility of the results found from the first interview. The primary researcher then asked each participant questions pertaining to the everyday life experiences living with head and neck lymphedema since completing treatment. Upon completion of the second interview, the primary researcher thanked each participant again. In addition, she assured participants they could reach out via phone or email should new questions arise. During the data collection and analysis process, the primary researcher engaged in bracketing by keeping a reflexive journal describing her own experience of the phenomenon. Bracketing is an attempt to set aside personal experiences and instead, focus on the participants experiences (Flipp, 2014). The reflexive journal also contained the researchers thoughts and reflections throughout the data collection and analysis process. Data Management Audio recordings obtained from both in person and distance interviews were stored on the primary researchers laptop. Each interview was labeled interview with participants deidentifiers and date of interview. The recordings were transcribed verbatim by the primary researcher using Zoom audio transcription. Once transcribed, each transcription was copied into individual Word documents, labeled participant transcription with each participants deidentifier, date of interview, and saved on the primary researchers laptop into a folder labeled PERSONS WITH HEAD AND NECK LYMPHEDEMA 31 data analysis. The primary researcher listened to each interview and reviewed each transcription to ensure accuracy of the Zoom transcriptions. Interview recordings and transcriptions were stored on the primary researchers laptop that was password-protected. Data were stored in a backup location on One Drive, an encrypted password protected cloud storage in case the data on the laptop was lost. Field notes taken on each interview guide containing field notes was labeled with each participants de-identifier, date of interview, and stored in a file in the locked cabinet with all other information obtained in the primary researchers office. Research files were shared with the primary researchers analysis expert via the encrypted One Drive. The analysis expert organized and stored electronic data including the interviews and transcriptions on a password-protected computer to protect participants privacy in similar fashion to how the primary researcher stored and organized data. Data will be kept until the research is published. After that time, data, computer files containing participant information will be deleted, and the informed consent forms and hard copies of field notes will be shredded. Participant transcriptions will not be returned to participants upon completion of the research, but rather, disposed of to ensure privacy. Data Analysis Once the first set of interviews were transcribed, the coding process began. The primary researchers analysis expert served as a consultant during the analysis process. In addition, the analysis expert served as both a consultant to guide the researcher in developing codes and assisted in establishing credibility through triangulation. Data analysis began with the researcher immersed in the data. This was accomplished through transcribing, listening, and spending time in reflection. Stuckey (2015) recommended reading through each transcript at least twice. The primary researcher read each transcript several PERSONS WITH HEAD AND NECK LYMPHEDEMA 32 times. In addition, repeated listening to the interviews while reading a transcript was performed to bring the researcher back into context and deepen the researchers relation with the written word. The primary researcher then described in detail her personal experiences with the phenomenon using her reflexive journal. Taking time to reflect on the data helped reveal participants experiences and improved the researchers reflexive acknowledgement for any potential biases. The reflexive journal provided a safe space for the primary researcher to detail her personal experiences with the phenomena in an attempt to suspend assumptions or epoche and allow for authentic data analysis. The primary researcher coded the transcriptions without the use of assistive qualitative data analysis software. Instead, different colored highlighters were used to extract important statements and powerful quotes noted by the participants. Using horizontalization, each participants statements was treated as providing equal value to analysis (Moustakas, 1994). Reading through each transcript, the primary researcher created memos in the margins. Memoing consists of short phrases or ideas that can lead the researcher to identify themes (Creswell & Poth, 2018). It can also serve as an audit trail to show the reader how decisions were made or how themes were formed (Stuckey, 2015). After extracting significant statements and quotes, codes were identified and defined in a code book using a Microsoft Excel spreadsheet. Once the code book was established the primary researcher shared the data with her analysis expert. The analysis expert reviewed interviews, transcripts, and the code book. This serves as a method for investigator triangulation. Once the analysis expert reviewed all interviews, transcripts, and the code book, the primary researcher and analysis expert met to review the documents together. The analysis expert provided the PERSONS WITH HEAD AND NECK LYMPHEDEMA 33 primary researcher with feedback on the findings as well as additional insights missed by the primary researcher. After the primary researcher and analysis expert agreed on codes from the first interviews, the next step included taking the statements and quotes and developing clusters of meaning into themes and subthemes. It is important to identify themes with a sense of coherency. Themes are extracted when they are supported by more than half of the participants narrative accounts (Smith et al., as cited in Finlay, 2011). This helped the researcher to create a rich, textural description of the phenomenon. The primary researcher identified statements and quotes from each transcription and the code book and placed them into initial themes and subthemes. The meaning of each theme and subtheme was explained in the code book. Initial themes were developed from the interview guide which were reflected from the primary researchers research questions and included activities of daily living, personal feelings, psychosocial wellbeing, and quality of life. Other themes emerged from the data, and the primary researcher remained open to adjusting themes and identifying new themes. Numeration was used as a method to determine themes. After the primary researcher and analysis expert agreed on themes and subthemes, a preliminary visual representation of findings was created in a word document by the primary researcher. Member checking was used to ensure accuracy in both the primary researcher and analysis experts findings and supported triangulation of data. Using results from the preliminary visual representation, findings from the first interview were shared with each participant at the beginning of the second interview. Second interviews were transcribed using the same procedures as the initial interview. The primary researcher extracted important statements and quotes from each interview, using the PERSONS WITH HEAD AND NECK LYMPHEDEMA 34 same procedures as the previous coding process by using colored highlighters. Additional memos in the margins or thoughts she had during the coding process were added. The primary researcher added any additional codes and the meanings of each code into the code book. The primary researcher reviewed the themes for modifications using data from the second interviews. The visual representation document was revised, incorporating any new findings from the second interview. Once this was complete, the primary researcher shared the revised code book of themes and visual representation again with her analysis expert to finalize the findings and the visual representation document. In addition, the final code book and visual representation were shared with the primary researchers content expert to ensure trustworthiness and rigor. The primary researcher used the code book and visual representation to draft a textural description of the phenomenon to describe what the participants experienced in the study. She also drafted a structural description of how participants experienced the phenomenon. This included the setting and context in which the phenomenon was experienced by the participants, as described by Creswell and Poth (2018). Once the primary researcher completed both a textural and structural description of the phenomenon, she concluded by developing a composite description describing the essence of the phenomenon to the reader. Rigor and Trustworthiness To establish trustworthiness and rigor, the researcher used several methods. First, the researcher established credibility by using member checking with participants to ensure the research represents participants realities (Henderson & Rheault, 2004). Once interpretations and conclusions were drawn, the primary researcher sent each participant the visual representation of themes and subthemes determined from their individual transcriptions, interview guides, and the PERSONS WITH HEAD AND NECK LYMPHEDEMA 35 researchers field notes via email or mail. Then, the primary researcher scheduled a second interview via Zoom, telephone, or in person to discuss the themes and subthemes that had been established. Second, investigator triangulation was implemented to establish credibility of the research. The analysis expert on the researchers committee served as a consultant. The analysis expert reviewed transcriptions, the codebook, and final themes and provided the primary researcher with feedback and additional insights into the research. Recruiting other researchers to review the primary researchers findings help confirm conclusions made by the researcher (Carter et al., 2014). Third, reflexive writing was performed to establish credibility of the research. The researcher kept a journal to record personal beliefs, views, and thoughts to avoid bias (Henderson & Rheault, 2004). Using a reflexive journal helped the primary researcher to take note of any personal biases and or preconceived notions about the research by bracketing these thoughts (Flipp, 2014). Once the research report was completed, the primary researcher shared bracketed information from the reflexive journal with the reader so that, the reader was aware of what the primary researchers interpretations were during the research process. A fourth method used to establish trustworthiness and rigor included duplication. Given the thoroughness of the study design, a study exploring the life experiences of adults living with lymphedema could be duplicated by another researcher. Dependability was yet another strategy that was used to establish trustworthiness and rigor. The researcher provided the reader with a comprehensive description of the research methods so that, if the study was repeated, other investigators could demonstrate similar findings (Henderson & Rheault, 2004). PERSONS WITH HEAD AND NECK LYMPHEDEMA 36 Lastly, external auditing was used to establish trustworthiness and rigor. External auditing was performed by another researcher familiar with the research topic to ensure the data reflects the findings of the primary researcher (Henderson & Rheault, 2004). Results Data were collected using a two-step semi-structured interview process. Eight participants, seven male and one female, between the ages of 44 and 77, were recruited and completed the first semi-structured interview. Table 2 describes the characteristics and demographics of the participants. Seven participants reported being White, and one participant reported being African American. The mean age of participants was 50 years of age. Most participants had a high school level education. All participants except for one held employment. Of the eight participants, four participants were diagnosed with tongue cancer, one participant was diagnosed with tongue and parotid gland cancer, two were diagnosed with tonsil cancer, and one participant was diagnosed with larynx cancer. The stage of lymphedema was determined by the primary researcher during the recruitment phase using the MD Anderson Head and Neck Lymphedema Staging Scale. Of the eight participants, seven participants were diagnosed with stage 1a lymphedema, and the other participant was diagnosed with stage 2 lymphedema. All participants received occupational therapy services. After multiple attempts to contact each of the eight participants via phone, text, and email over a five-month span, only five participants, all male, completed the second semi-structured interview. Three participants were lost to follow-up. One participant suffered a cardiac arrest resulting in an anoxic brain injury. The other two did not respond after multiple attempts. A total of 13 interviews were included in the data collection, eight from the first interview and five from the second interview. Themes were initially developed from the first PERSONS WITH HEAD AND NECK LYMPHEDEMA 37 interview guide which were reflective of the primary researchers research questions. However, throughout the coding process, participants responses deviated from the initial themes. For example, when asked about quality of life and psychosocial well-being, neither were an area of importance based on participants responses. Instead, participants focused on the side effects they experienced. Disruption of activities of daily living (ADL) was a recurring theme developed from the first interview guide and remained an initial theme since many questions centered around ADLs and how participants experienced engaging in ADLs living with lymphedema. Based on participants responses from the first and second interview guide questions, three main themes and supporting subthemes emerged from the data. (Table 3). The three main themes were side effects, disruption of ADLs, and occupational therapy. All participants experienced numerous side effects through their cancer treatment and elaborated on side effects including swelling, dry mouth, and impaired neck mobility during the interview process. In addition, when asked about their experiences in completing daily activities while living with lymphedema, eating, personal hygiene and grooming, and sleep participation were occupations frequently disrupted. When discussing their experiences being treated by occupational therapy for head and neck lymphedema, all participants shared positive experiences participating in occupational therapy. In addition, all participants interviewed commented on their home programs issued by occupational therapy. Therefore, the common experiences shared by participants led to the development of these specific themes and subthemes. Side Effects During the first interview all participants discussed their experiences with lymphedema and numerous other side effects from cancer treatment whether from surgery, chemotherapy, or PERSONS WITH HEAD AND NECK LYMPHEDEMA 38 radiation treatment. Common side effects among participants that developed into subthemes were swelling, dry mouth, and impaired neck mobility. Swelling All participants were diagnosed with and living with lymphedema or swelling. Many participants reported experiencing swelling either during or after multimodality treatment. Participant F stated, "I swelled after the very first treatment. The very first radiation treatment, I went home that night, and my face swelled." When asked what it was like to live with lymphedema in the first interview, participant A responded, I aint been eating too much because of the uh swelling. Participant E responded, "I swell pretty bad." Some participants described how the swelling impacted them cosmetically. Participant F stated, When I first had it, it was like, that was a, really bitter pill to swallow because my lymphedema was so bad that, like, I remember comparing myself to a male orangutan because, because I had a, like, you know a male orangutan's have that, like, extra, almost like quadrant to their cheeks. Participant G noted that swelling became progressively worse, stating, "My neck kept getting larger and larger and larger, larger. Like there was a, a balloon underneath my chin." In addition, participants described the swelling as being uncomfortable. Participant G said, "It was very uncomfortable." Participant F stated, "When I wake up in the morning my head is very tight." Participant H described how the swelling felt when the weather was cold outside. "If it's really, really cold out it feels like it's- I feel it more. Like it feels like a- like a lump. You know, like water freezing." The five participants participating in the second interview were asked again what it was like living with lymphedema. All participants reported experiencing improvements with their PERSONS WITH HEAD AND NECK LYMPHEDEMA 39 lymphedema. Participant A said, Yeah, it's a little, little, little ball-like thing. Like, it's big. It's not as big as it was. It's not as hard as it was. It's real tender now. Participant D described I don't feel like I got a bubble there. It just gets tender and stiff and it seems to be a lot better now since I've gotten the machine. Participant E said his swelling improved and felt that others should not worry about getting lymphedema. He stated I don't think they should worry about it. Because it... like, mine got better, you know? Dry Mouth Dry mouth was another side effect frequently mentioned in both the first and second interviews when asked what it was like living with lymphedema. Participant A stated, my throat is so dry in the morning." In addition, he described the dry mouth especially at night stating, like I said, the dry mouth, 'cause I got it dry so, like, like... I got to drink like two bottles of water a night just to, uh, I guess just to... 'cause my mouth is so dry, and I had to keep, keep, keep drinking little sips of water to keep it moist. Participant C noted, having dry mouth, I still have that. But that is not a cause of lymphedema. Participant D stated he still had more of an issue with dry mouth as opposed to any lingering lymphedema. He stated, I think the dry mouth is more of the issue than, you know ... Because it's trying to get down my throat and there's no salvia. I've gotta watch my teeth, so I fluoride regularly, you know, regularly every month. You know, so I do fluoride treatment. So, my teeth, the dry mouth I think are the lingering effects. Impaired Neck Mobility Lastly, impaired neck mobility was a recurring side effect voiced in the interviews. Participant F described having difficulty lifting her head during cancer treatment, stating, "I did PERSONS WITH HEAD AND NECK LYMPHEDEMA 40 not have the strength to lift my own head up off the table." Participant G explained, "it was uncomfortable and the mobility would be my big, my two biggest issues." In addition, he stated, when it swells up, two things happen: Y-your... Y-you can... Your limit on how far you can turn your head comes immediately. Participant C explained his experience in neck function since completing cancer treatment and said, every once in a while, if I'm looking at my phone wrong, or siting in my bed wrong, my neck jams up on me. Similar to participant C, participant D described his experience with his neck function and stated, Occasionally I'll get a, a severe, you know, spasm or something in that area, but that's usually after I've biked or after I've done, you know, more strenuous activity that I'll get, you know, an ache, you know, like, a tightness there that's pretty severe. It's almost like a cramp in my neck. Disruption in Activities of Daily Living In the first set of interviews, participants identified side effects as having a direct negative impact on ADL performance. The disruption in activities of daily living became a recurring dominant theme participants discussed. Subthemes identified were eating, personal hygiene and grooming, and sleep participation. Eating When asked about their experiences in being able to eat since being diagnosed with lymphedema, most participants said they struggled with eating. Participant A stated, when I do eat you know, it kind of chokes me." Participant E said, and then I just hadn't really realized until after he asked me that question. The next time I was eating, I was like, "You know, I am having a hard time swallowing." Participant G noted, "It's bigger than, you know, the opening and it gets caught in there and I cough it out." Similarly, participant H said, "caught because I PERSONS WITH HEAD AND NECK LYMPHEDEMA 41 don't chew it." Participant B noted problems with eating, but it was not necessarily due to the lymphedema, but from his surgery. He stated, "eating is a big problem for me. He explained that it was due to an impairment with his tongue. He said, they operated on the tongue and the tongue when, when they grafted it, it's not working properly." During the second interview, participant E explained he still had some difficulty with eating and said, my eating is still affected now. Um, I have to take pretty small bites. Participant G noted, for eating, there's a problem. [inaudible]. Even though I went to a guy that taught me how to swallow and everything. Personal Hygiene and Grooming Personal hygiene and grooming were common disruptions participants experienced in the interviews. Participants expressed concern about cutting themselves when shaving due to swelling concentrated in the submental region (front) of the neck or loss of sensation in the neck. Participant A explained, Im scared Im gonna cut myself or whatever because the- the- thebecause the lump right there. Participant D described having to be more careful with shaving stating, I got to be a little bit more careful when I shave. If I am not careful, I could cut myself sometimes. So, I just shave less. Participant G explained that he stopped shaving altogether because of the lack of sensation and because he cut himself on multiple occasions stating, I stopped. Cause its justForget that idea. Thats justYou knowAnd then its hard with the no feeling in the neck, the skin. You cant feel anything when you shave when you want. So you can cut yourself pretty good and not realize it. Somebodys like, what, what happened? Somebody shoot you [inaudible] and your shirts all bloody. Then you realize youve you realize youve hacked your neck. I just stopped shaving. Forget it. I just got one of those clippers, you know? PERSONS WITH HEAD AND NECK LYMPHEDEMA 42 Sleep Participation Disruption in sleep participation was frequently experienced by participants. Participants reported difficulty breathing when trying to sleep and an increase in lymphedema with sleep. Participant A explained, It was hard for me to sleep. Because it was choking. So, I was sleeping up a lot, sitting up. Participant F stated she felt like the lymphedema was worse when trying to sleep and said, Im still up and down because I have a trach. Because of the surgery that I had, and um the stiffness that I end up with, um, I-I feel that I end up with more lymphedema than I would because Im just laying on my back, and I cant move around. Yeah, so I end up more, um, limited my movements, and it definitely causes stiffness and fluid retention. Because its just pooling. Its been hard readjusting because I have never slept on my back before. Participant G, too, felt like the lymphedema was worse when trying to sleep explaining, The biggest problem, believe it or not, was me sleeping. I couldnt sleep on my stomach anymore. Youd wake up like youre laying on something. I started sleeping on my back. Not really good because I woke up a lot. My sleeping completely changed. Participant H said he had trouble finding a comfortable position to sleep in stating, "and sometimes when I am sleeping, I can never find a good spot to sleep." During the second round of interviews participant G described his experience with having to change his sleeping position because of the swelling. Prior to the lymphedema he said he slept mostly on his stomach. Since then, he sleeps on his back and describes feeling like a vampire. He said, but, yeah, I started to sleep in that, you know... I'm ready for somebody to come in with a wooden stake and a hammer. You know? PERSONS WITH HEAD AND NECK LYMPHEDEMA 43 Occupational Therapy All participants with head and neck lymphedema participated in occupational therapy and reported experiencing benefits in treatment. Occupational therapy treatment included learning manual techniques to enhance lymphatic circulation, wearing a compression garment around the head and neck, therapeutic exercise, and some participants were able to receive a pneumatic compression device. A pneumatic compression device is an inflatable garment that mimics lymphatic massage and is applied to the congested body part to help enhance lymphatic circulation. When asked about their experiences in participating in occupational therapy, all participants from the first round of interviews discussed their experiences in using the methods mentioned to alleviate symptoms of lymphedema. Participant B explained how his compression garment helped him. He said, It helped a lot because during the day you know, I was putting it on and I, I could feel the pressure, you know, pushing it away. Participant A and D discussed feeling mentally better by participating in occupational therapy. Participant A said, Uh, like I said, since I been starting this, and- and noticed that its been going down and- and Like I said, my spirits been getting, getting pretty up, pretty quick. Participant D explained, It was nice to see the measurements. I think it helped me mentally kind of wrap my head around my body, and how it was changing and I could see the changes after the treatment. There was one where we took pictures afterwards and it really made me feel kinda great about the process and just seeing how I looked after and before and there was significant change. That's why it made me feel better. It- it gave me positive reinforcement to use the garment. It gave me ah, the desire to do the, the machine and other things, so I think that the treatment process helped. PERSONS WITH HEAD AND NECK LYMPHEDEMA 44 Participant F not only reported the benefit of occupational therapy, but her experience with her care team recommending occupational therapy stating Im glad that I had someone that advocated for me early on. After having been intervened as early as I was made a big difference. Participant E was the only participant who received occupational therapy via telehealth and he shared his experience in participating via video. He said, It worked really well. I had a quick um, improvement once I started doing that. It wasId say a month I was getting way way better. For those who participated in the second interview, when asked about their experience in participating in occupational therapy, most continued to report therapy being beneficial. Participant G explained, For... I think it should be started immediately, actually. I think it should be, like, done at the same time. As soon as you get done with that stupid radiation crap. I was happy that she did it. You know what I mean? 'Cause it could have been another year and said nothing. And it'd be a year walking around like a frog and not being able to turn my head, have to turn my whole body to look around my shoulder. Participant D stated he felt as though occupational therapy offered much more than just helping him alleviate his physical symptoms. He explained, You know, you provided as much, like, emotional support as you did physical. So, I think if I were to design the best strategy for helping people with this, it would be that they'd have to come to, you know, for months of the occupational or physical therapy, whichever it's called. Participant E said, Yeah, all the things they taught me to do to push it down, get it out o-... you know, of my, you know, kidneys or whatever or bladder. Yeah, i- it definitely worked. PERSONS WITH HEAD AND NECK LYMPHEDEMA 45 Home Program A home program was one major subtheme that emerged from participants attending occupational therapy. All participants in the first round of interviews commented on completing their home programs. Participant C described how he did his self-lymph massage, "And I pull it back to the back of my neck as similar to the way the therapist was moving the lymph fluid in my neck." In addition, he described putting on his compression mask before bed, "I got to wear my thing at night." Similar to participant C, participant D described completing his self-lymph massage, "I've also created a habit where I, I try and push it down a lot." Participant E reported seeing improvements in implementing his home program stating, "I had a quick um, improvement once I started doing that. It was...I'd say a month I was getting way way better." Like participant E, participant F described the effectiveness of her home program. She said, "Between the manual movements (inaudible) and with the OT appointments that I had, the compression garment, and, and that type of thing, um for the most part, I look normal." When asked about his experience completing the home program participant G commented on using the compression mask that was dispensed from the occupational therapy clinic. He said, "The one that you made worked better than the one you got from that place. That thing that looks like you're the Three Stooges you gave me." When asked about his experience with doing his home program participant H stated, You know, like shoveling or doing whatever, then, uh, it does, you know, then you feel it. And then, I do my mask and all that stuff when I get home and stuff. And- and- and it seems like it goes away. During participant Hs interview his wife interjected a comment and stated how the pneumatic compression pump helped since she was not able to do the lymph massage on participant H as PERSONS WITH HEAD AND NECK LYMPHEDEMA 46 well as his therapist did. She said, "I don't quite have that pressure thing down. So, the machine you guys had...phenomenal because they knew what to do with those machines." When asked about their daily life experiences since participating in occupational therapy, participants who participated in the second interview continued to discuss completing their home programs. Participant A discussed his experience with continuing to use his pneumatic compression device. He stated, Like I said, a lot of times I just constantly keep squeezing the, squeezing the fluids out of there. And but I used the machine to get it all. It seemed like when I'm using it, it gets it out even better. In addition, he explained continuing to do his manual massage and said when I'm sitting, like just... I'm just constantly just massaging it and massaging it. Similar to participant A, participant C described his experience continuing with the self-lymph massage. He stated, I just push it like 20 times from the center all the way around to the back of the neck, 20 times. He also stated that he does not want to look a certain way stating, I don't want to be, you know, elephant man. Participant C explained he tries to do his home program as often as he can remember. I do it whenever I remember. I know its effective. I stay on top of it. I got to put on my pump vest. I got to wear my thing at night. When asked what it was like doing his home program, participant D explained his experience wearing his compression garment and said I'm starting to not like the, uh, the compression garment, but it's been a habit for so long now that I have a harder time sleeping without it. When asked about his experience completing his home program, participant G described what he does when the swelling returns. He stated, Whenever... If it comes back, I just get rid of it. Specifically, participant G described his experience using the pneumatic compression device stating, PERSONS WITH HEAD AND NECK LYMPHEDEMA 47 I put that thing on for like three days and it goes away immediately. So, if it swells up, then I, you know, I go and put that think on and its got a thing in and its got a thing for 32 minutes. And then theres the one for 13 minutes for just the neck and I do that like three or four nights and it usually goes away. Quality of Life Impact on quality of life and psychosocial well-being was a motivating force in conducting a study on the lived experiences of persons living with head and neck lymphedema, yet, when asked about quality of life and psychosocial well-being, most participants did not feel quality of life or psychosocial well-being had been affected. For example, Participant C stated, "I think my quality of life is pretty damn good." Participant H felt that his quality of life had not been affected and said, "It' hasn't changed." When asked what his quality of life was like having gone through cancer treatment and developing lymphedema, participant D also felt his quality of life was better due to the weight he lost. He said, "Again part of that is the weight loss that my quality of life has gotten better." Quality of life was revisited again in the second round of interviews, however participants continued to endorse experiencing little to no interruptions in quality of life. Participant C stated, my quality of life has not reduced. Participant D continued to endorse feeling like his quality of life was better and said, I think it's better than it was pre cancer. When asked about what his quality of life was like now, participant E stated, oh, it's good. Similar to other participants, participant G did not feel his quality of life had been affected stating, nothing really bothers me, to be honest with you. 'Cause, long as I'm still breathing, I'm completely good. Visual Representation of Findings PERSONS WITH HEAD AND NECK LYMPHEDEMA 48 A visual representation was constructed to illustrate findings from both the first and second interviews. Figure 1 emphasizes the three main themes and illustrates the relationship between the three themes. As shown in the diagram, side effects had a direct negative impact on ADL function. Nevertheless, occupational therapy services had a direct positive impact on both side effects experienced and ADL function. Quality of life was positioned on the outer borders of the diagram as quality of life was not a factor in participants experienced in living with head and neck lymphedema. Discussion Patients entering survivorship following head and neck cancer treatment often face challenges that impact activities of daily living, psychosocial well-being, and quality of life (Park & Hashmi, 2018; Semple et al., 2013; Deng et al., 2012a). The purpose of this phenomenological study was to explore the lived experiences of persons living with head and neck lymphedema, including an in-depth understanding of their quality of life and occupational performance. This is the first qualitative study to explore the life experiences of persons living with head and neck lymphedema. Participants experiences provide healthcare practitioners with insight of what it means to live with head and neck lymphedema. Three themes, including side effects, disruption in activities of daily living, and occupational therapy, emerged from this study, shedding light on what it means to live with head and neck lymphedema. First, side effects were a recurring theme among participants in this study. They emphasized experiencing side effects like lymphedema, dry mouth, and impaired neck mobility. Previous literature has confirmed that patients experience negative side effects following head and neck cancer treatment (Deng et al, 2016b). PERSONS WITH HEAD AND NECK LYMPHEDEMA 49 All participants interviewed in this study were diagnosed and living with lymphedema. It has been well documented that head and neck lymphedema is a common late side effect of head and neck cancer treatment. Previous research demonstrates that head and neck lymphedema develops in 12 to 90 percent of patients undergoing head and neck cancer therapies (Ridner et al., 2016; Deng et al., 2012). In exploring the life experiences of adults living with head and neck lymphedema, most participants discussed lymphedema as having some sort of impact on daily functioning like eating, swallowing, breathing, decreased neck mobility, personal hygiene and grooming, dressing, work performance, sleep participation, driving, and altered appearance, among other complaints. In addition to having lymphedema, dry mouth was an ongoing side effect. The impact of dry mouth, known as xerostomia can be significant. Researchers who developed an oral health outcome measure for patients undergoing head and neck cancer therapies identified multiple xerostomia-related functional deficits, including chewing and swallowing, difficulty sleeping, and impaired speech (Cooperstein et al., 2012). Similar to findings from Cooperstein et al., (2012), participants in this study reported complications with eating and swallowing due to dry mouth. Impaired neck mobility was another main side effect participants openly discussed. One participant described having a crook in his neck. Another participant experienced difficulty turning and lifting his head when engaging in work or leisure-related tasks. Similar to findings from this study, Deng and researchers (2013) reviewed 103 head and neck cancer survivors and found 40% of the participants to have a cervical range of motion deficit in at least one direction when measured with a cervical range of motion device. PERSONS WITH HEAD AND NECK LYMPHEDEMA 50 Data regarding the side effects participants experienced from this study confirm findings from previous head and neck cancer research studies and clearly indicate the need for healthcare providers to perform routine screening for such complications. Proactive, early identification and treatment of side effects from head and neck cancer treatment may help ease the reduction of long-term symptom burden and or functional deficits so that, patients can enter survivorship with less adversity. The second theme to emerge was disruption in ADLs. Side effects discussed in this study had a direct negative impact on ADLs, especially occupations like eating, personal hygiene and grooming, and sleep participation. Many participants struggled with eating and described food getting stuck in their throats during mealtime. One participant, in particular, complained that their lymphedema directly affected their eating ability. Previous research has shown that head and neck lymphedema can interfere with eating and swallowing (Ridner et al., 2017). In conducting a four-year study, Deng and associates (2015) concluded that the majority of their patients had internal, external, or a combination of both internal and external lymphedema. In reviewing internal imaging of the throat, researchers concluded that lymphedema in the throat may be a contributing factor to swallow dysfunction (Deng et al, 2015). Personal hygiene and grooming were reported as another recurring occupation affected by lymphedema. Due to neck lymphedema and impaired neck sensation, participants described difficulty with shaving. There is no research to date discussing the impact of head and neck lymphedema on shaving. However, Deng and associates (2016b) studied head and neck cancer patients experiences of lymphedema with an emphasis on physical findings and symptom burden. A common symptom discussed throughout the qualitative study included altered PERSONS WITH HEAD AND NECK LYMPHEDEMA 51 sensations like numbness. This research provides insight into why participants with impaired sensation may have had difficulty shaving. One participant shared his experience with shaving and described sustaining multiple lacerations to his neck. As a result, he stopped shaving completely. In addition to eating and personal hygiene and grooming, disruption in sleep participation was frequently reported among participants. Previous research has shown that sleep disturbances are common in patients with head and neck cancer (Murphy & Deng, 2015). Several participants experienced a disruption in sleep due to having head and neck lymphedema. Although previous literature has identified causes of sleep disruption among head and neck cancer patients including underlying sleep disorders, pain, mucus production, and dry mouth, little research has noted the effects of head and neck lymphedema on sleep participation. Findings from this research suggest that head and neck lymphedema may be a contributing factor to poor sleep participation in addition to other side effects. Results from this study clearly indicate that patients undergoing head and neck cancer therapies will likely develop functional deficits from treatment. Previous research and findings from this study indicate that lymphedema is a delayed side effect that can interfere with occupational performance. Therefore, healthcare practitioners should consider referring patients undergoing head and neck cancer treatment to occupational therapy since occupational therapists are skilled in providing services to achieve independence with ADLs. For example, some occupational therapists have advanced training in feeding, eating, and swallowing and can help improve the functions necessary to participate in eating. Additionally, occupational therapists are skilled in identifying sensory deficits. Given that patients expressed concerns about shaving in this study, occupational therapists are skilled in providing education and modifications to daily PERSONS WITH HEAD AND NECK LYMPHEDEMA 52 routines that can promote safety with shaving. Despite oral hygiene being unaffected in this study, good oral hygiene is important, especially for patients undergoing head and neck cancer therapies. Patients are at risk for dental caries due to the demineralization of the enamel (Murphy & Deng, 2015). Additionally, lack of saliva can have a negative effect on oral hygiene leading to cavities (Samim et al., 2016). Occupational therapists are skilled in assessing for and educating patients on good oral hygiene to reduce dry mouth and prevent cavities. Furthermore, occupational therapists can play a unique role in helping patients with head and neck impairments and or lymphedema improve sleep participation. They are trained in providing patients with strategies to improve the sleep environment and or recommend ideal positioning to minimize an increase in lymphedema. Additionally, this study indicates that occupational therapists certified in treatment of lymphedema should not only be assessing for and treating patients with head and neck lymphedema, but they need to assess for and address the occupational deficits these patients may encounter. Hashmi and Park (2018) note that new models of care for patients diagnosed with head and neck cancer include occupational therapy from diagnosis through treatment (Silver et al., 2013). Occupational therapists have the expertise to educate patients with head and neck cancer on coping strategies, exercise, nutrition, sleep hygiene, and energy conservation, to maximize participation in life activities while undergoing head and neck cancer therapies (Hashmi & Park, 2018). Additionally, they are skilled in assessing for and treating neck and shoulder impairments (Hashmi & Park, 2018). With all the skilled services occupational therapy can provide, they have a strong role in the survivorship of patients with head and neck cancer. Therefore, occupational therapists certified in lymphedema treatment, should not only be PERSONS WITH HEAD AND NECK LYMPHEDEMA 53 addressing lymphedema management, they should be addressing the many functional impairments patients with head and neck cancer experience. Lastly, the third theme to emerge was occupational therapy treatment. Literature suggests that patients with lymphedema be referred to therapy services prematurely to control symptoms of lymphedema by preventing/reducing the fibrotic changes that can occur and obstruct lymphatic circulation (Deng et al., 2019). All participants in this study participated in occupational therapy services. Occupational therapists delivered a combination of treatments, including manual lymph drainage, compression, exercise, education on skin care, and education and training on self-manual lymphatic drainage. In addition, some participants were approved for and received a pneumatic compression device as an additional tool to help enhance lymphatic circulation. Although participants experienced improvement in lymphedema management, this study showed they had additional occupational needs. Occupational therapists certified in lymphedema treatment need to address occupational deficits in addition to lymphedema management. Results showed that occupational therapy had a direct positive impact on side effects and occupational performance. All eight participants described having a positive experience in occupational therapy. Several emphasized this during the second interview. Most reported improvements in physical appearance, occupational performance like eating, job performance, sleep participation, and some reported improvements in psychosocial wellbeing. These results complement previous research in which investigators conducted a qualitative study reviewing the experiences in participating in head and neck lymphedema treatment (Deng et al., 2019). Ninety percent of participants reported physical improvements, and 70 percent reported psychological improvements (Deng et al., 2019). In addition, participants interviewed a second time PERSONS WITH HEAD AND NECK LYMPHEDEMA 54 emphasized the benefits of participating in occupational therapy and stated they believe it should be recommended when symptoms of head and neck lymphedema develop. Those who participated in the second interview also reported having little to no current deficits with the occupational performance activities discussed in the first interview. Current findings imply and support the benefits of receiving treatment from occupational therapists certified in treating lymphedema. Not only did lymphedema improve, but participants also reported little to no difficulty with completing ADLs. In addition, they utilized the skills taught by occupational therapy to alleviate their symptoms. Therefore, providers may want to encourage participation in occupational therapy or include an occupational therapist as part of the comprehensive cancer team. Of note, this study took place right before and during the COVID-19 pandemic. As a result, one participant received occupational therapy services via telehealth. Telehealth is a form of treatment in which healthcare services are delivered via communication technologies to promote and improve the health and well-being of individuals who are not able to access care easily (Brick et al., 2022). The participant who received occupational therapy via telehealth was sent a compression garment for his face and neck via mail and participated in several video visits where the occupational therapist taught the participant how to do self-manual lymphatic drainage and basic neck exercises. The therapist was unable to take measurements, however, the participants swelling visibly reduced, and improvements in occupational performance were reported by the participant in both the first and second interviews. The participant shared their experience in going through lymphedema treatment via telehealth as being effective. They were able to control and alleviate their symptoms despite not being able to participate in an in person visit. PERSONS WITH HEAD AND NECK LYMPHEDEMA 55 Given the success of this participants treatment via telehealth, telehealth may have a powerful role in the future for patients requiring healthcare services or patients with limited access to healthcare. Researchers conducted a systematic review exploring the effectiveness of telehealth-based cancer rehabilitation for adult cancer survivors and found a small effect on telehealth cancer-based interventions (Brick et al., 2022). They concluded that telehealth cancerbased interventions have potential, however further investigation is required to advance telehealth (Brick et al., 2022). Despite the minimal evidence on the delivery of telehealth services, telehealth was advantageous for the participant who was unable to participate in therapy due the COVID-19 pandemic. In addition to sharing experiences in participation of occupational therapy, all participants described their experiences following their home programs issued by occupational therapy. The entire group reported improvements in symptoms of head and neck lymphedema. Their perceived improvements in lymphedema validate the importance of an individualized home program for alleviating symptoms of lymphedema. This research supports previous literature in which investigators piloted a study comparing the outcomes of a head and neck lymphedema home therapy program with a hybrid program consisting of clinic visits in addition to home therapy (Yao et al., 2020). Results showed no statistically significant difference between the two groups, except for patients with facial swelling suggesting a home program may be appropriate should patients not be able to attend clinic therapy (Yao et al., 2020). Interestingly, participants who were interviewed a second time were still following their home programs after two years post-treatment. Home programs consisted primarily of selfmanual lymph drainage, neck exercises, wearing a compression garment, and using the pneumatic compression pump for those who were approved for a pump. It was expressed that PERSONS WITH HEAD AND NECK LYMPHEDEMA 56 home programs were not completed daily, but when needed or when participants felt swelling beginning to accumulate again. In addition, participants described having minimal to no current lingering lymphedema. Current findings from this study not only demonstrate the benefits in prescribing a home program to mitigate head and neck lymphedema, but all participants were compliant, they reported a reduction in symptoms of lymphedema, and expressed having little to no occupational deficits. Impact on QOL was a driving force in conducting a study on the lived experiences of persons living with head and neck lymphedema, yet, when asked, participants did not feel QOL had been affected. This finding was unexpected. Previous research has identified a correlation between head and neck lymphedema and decreased QOL (Deng et al., 2013). In addition, there is an abundance of research on breast cancer related-lymphedema and its impact on QOL. Investigators conducted a study examining women with breast cancer-related lymphedema and their perspectives on QOL and found QOL to be affected not only shortly after diagnosis but over the seven-year period they were followed (Anbari et al., 2021). Findings on QOL from this study are not consistent with previous literature. One rationale for this finding may be due to the researcher not defining QOL during the interviews. Understanding what QOL means can be complex. Perhaps QOL meant something different for each participant. Another consideration for the current finding is the disproportion between male and female participants. Seven males and one female participated in this qualitative study. In a study looking at males and females with heart failure, investigators found that women reported worse health-related QOL than men (Dewan et al., 2019). Since this study demographic was predominantly male, most participants did not feel that QOL had been interrupted, but instead described feeling grateful for being able to recover and resume most daily activities. Current PERSONS WITH HEAD AND NECK LYMPHEDEMA 57 findings, and other research suggest that males and females may perceive QOL differently and respond to QOL dissimilarly. Implications Data from this study inspire new opportunities for future research studying patients diagnosed with head and neck lymphedema. First, all participants endorsed the benefits of occupational therapy. Occupational therapists have the ability to look at a patient holistically. Not only do they help their clients achieve physical independence, they help improve mental well-being and quality of life for their patients. Participants in this study reported improvement in lymphedema as well as improvement in ability to engage in ADL tasks. These results reinforce a previous study in which Deng et al., (2019) explored patients experiences participating in head and neck lymphedema therapy. Findings noted an improvement in physical functioning and psychological benefits from participation in a lymphedema therapy program (Deng et al., 2019). Given the improvements in lymphedema and occupational performance, this study suggests that occupational therapists certified in lymphedema are well equipped not only to address head and neck lymphedema, but they have the skills to address functional impairments that may develop as a result of head and neck cancer treatment. Therefore, researchers may want to consider further exploring the efficacy of an occupational therapy driven lymphedema therapy program for head and neck cancer patients. The functional deficits head and neck cancer patients face are within the scope and amendable to occupational therapy. For example, occupational therapists can provide education on potential side effects and coping strategies to reduce the impact it can have on daily functioning (Park & Hashmi, 2018). They have the ability to assess and treat for body image, PERSONS WITH HEAD AND NECK LYMPHEDEMA 58 scarring, lymphedema, fascial weakness, oral functioning, pain, fatigue, neurological impairments, range of motion deficits, sleep hygiene, and psychological distress (Park & Hashmi, 2018). Findings from this study showed that participants experienced occupational deficits with the most discussed occupational deficits being eating, personal hygiene and grooming, and sleep participation. In the future, occupational therapists especially those trained in treatment of lymphedema, need to assess for lymphedema and various functional deficits head and neck cancer survivors may encounter. Perhaps this would make occupational therapy more distinct from other disciplines and demonstrate occupational therapys value in treating patients with head and neck lymphedema. Therefore, future investigation on OTs role with patients with head and neck cancer outside of traditional lymphedema care is warranted. Numerous adult cancer survivors have reported a decline in functional status after completing cancer treatment (Pergolotti et al., 2016). However, there is little research emphasizing occupational therapys role in cancer survivorship care. Hwang et al., 2015 conducted a study exploring functional deficits and perceived QOL among cancer survivors and found that participants reported multiple functional deficits within the first year of survivorship. Additionally, perceived QOL was significantly low with in the first year (Hwang et al., 2015). Given the reported functional deficits participants experienced, very few received occupational therapy (Hwang et al., 2015). Similar to Hwang and associates, Pergolotti et al., (2014) conducted a study and found that of the 87% elderly cancer survivors, only 32% of them participated in occupational therapy in the first two years after being diagnosed with cancer. Future research exploring the significance of occupational therapy as part of multidisciplinary cancer care or the outcomes of occupational therapy treatment for cancer survivors should be considered. PERSONS WITH HEAD AND NECK LYMPHEDEMA 59 In addition to lymphedema care, occupational therapists need to advocate their unique skill set and utilize their full scope of practice including evaluating and providing interventions for cancer survivors with occupational performance limitations. Despite the value of occupational therapy services, previous research notes that occupational therapy is underutilized in cancer care. Advocating the need for occupational therapy services in cancer care may help healthcare providers gain a better understanding of occupational therapys important role in cancer survivorship. Second, providers may want to explore the use of telehealth services as an alternate method in providing treatment to patients with head and neck lymphedema who have limited access to healthcare. To date, there are no studies exploring the effectiveness of telehealth and patients with head and neck lymphedema. Telehealth is not appropriate for every patient requiring supportive care services, however, in this study one participant shared having a positive experience receiving lymphedema treatment via telehealth. Researchers interested in learning more about the effects of treatment for persons with head and neck lymphedema may want to consider exploring the use of telehealth with this population. Third, QOL was unexpectedly not emphasized in this study. Most participants did not feel that QOL had been affected despite experiencing multiple side effects and disruptions in activities of daily living. Perhaps participant experiences may have been different had a clear definition on QOL been provided to the participant during the interview. Many studies have noted reduced QOL in cancer survivors. Firkins et al., 2020 conducted a meta-analysis looking at QOL among cancer survivors and found QOL to be significantly impacted following cancer diagnosis. Future investigation on QOL and patients living with head and neck lymphedema may help provide healthcare practitioners with a clearer understanding of what patients with head and PERSONS WITH HEAD AND NECK LYMPHEDEMA 60 neck lymphedema experience and how it impacts daily functioning. In addition, further exploration of how occupational therapy can impact QOL in patients with head and neck lymphedema may increase the justification for referral. Study Limitations Although some of the findings were unique and implications for future research open new opportunities for investigation on patients with head and neck lymphedema, there were limitations to this study. First, recruitment for this study was halted due to the restructuring of the primary researchers position within the institution. Because of this change, the primary researcher was no longer able to conveniently recruit for this study. As a result, the study was limited to eight participants. Second, due to the abrupt end of recruitment, the sample size of this study was small. Although there is no specific requirement for the number of participants in a phenomenological research study, perhaps additional significant findings may have emerged with more participants. Furthermore, three participants were lost to the second set of interviews, leaving only five participants to complete the second interview. A third limitation of this study was the disproportion of males to females recruited. Seven of the eight participants were male. Perhaps recruiting more females would have enhanced the current findings. Females may have a different perspective on body image, occupational performance, quality of life, and psychosocial well-being. The study findings may not be representative of females. A fourth limitation of this study includes research bias. Although the primary researcher used a reflexive journal and triangulation to reduce bias, the primary researcher is an occupational therapist certified in the treatment of lymphedema. PERSONS WITH HEAD AND NECK LYMPHEDEMA 61 Conclusion Lymphedema is a common late side effect that is often overlooked in patients with head and neck cancer. Participants in this study were interviewed on their experiences living with head and neck lymphedema. Not only did they describe their experiences in living with lymphedema, but they also they expressed being challenged with multiple other side effects as a result of cancer treatment. Unfortunately, side effects had a direct negative impact on engagement in ADLs. Participants reported struggling with eating, personal hygiene and grooming, and sleep participation. On the other hand, participants described having a favorable experience participating in occupational therapy. In addition, participants interviewed a second time described their experiences in continuing to follow their prescribed home programs issued by their occupational therapist. Findings suggest that side effects including lymphedema can have a damaging impact on daily functioning in adults receiving head and neck cancer therapies. Despite the side effects of cancer treatment and disruptions it may cause in ADLs, rehabilitative services like occupational therapy are available and should be considered for all patients with head and neck lymphedema. Occupational therapists and occupational therapists certified in treatment of lymphedema can offer skilled therapy services to meet the needs of patients with head and neck lymphedema and improve daily functioning. Moving forward, healthcare providers may want to establish a standard of care by performing routine screenings for lymphedema and functional deficits, and make appropriate referrals to an occupational therapist so that deficits in ADLs and or lymphedema can be addressed. PERSONS WITH HEAD AND NECK LYMPHEDEMA 62 References Agency for Healthcare Research and Quality (2015). Health literacy universal precautions toolkit, 2nd edition. 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The Laryngoscope, 130(12), E858-E862. https://doi.org/10.1002/lary.28549 PERSONS WITH HEAD AND NECK LYMPHEDEMA 73 Table 1 COREQ (Consolidated criteria for Reporting Qualitative Research) Checklist Topic Item No. Domain 1: Research team and reflexivity Personal characteristics Interviewer/facilitator 1 Credentials Occupation 2 3 Gender Experience and training 4 5 Relationship established 6 Participant knowledge of the interviewer 7 Interviewer characteristics 8 Methodological orientation and Theory 9 Sampling 10 Method of approach 11 Sample size 12 Non-participation 13 Setting of data collection 14 Presence of non-participants 15 Description of sample 16 Interview guide 17 Repeat interviews 18 Audio/visual recording 19 Field notes 20 Guide Questions/Description Which author/s conducted the interview or focus group? What were the researchers credentials? What was their occupation at the time of the study? Was the researcher male or female? What experience or training did the researcher have? Relationship with participants Was a relationship established prior to study commencement? What did the participants know about the researcher? e. g. personal goals, reasons for doing the research What characteristics were reported about the interviewer/facilitator? e. g. Bias, assumptions, reasons, and interests in the research topic Domain 2: Study design Theoretical framework What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis Participant selection How were participants selected? e. g. purposive, convenience, consecutive, snowball How were participants approached? e. g. face-to-face, telephone, mail, email How many participants were in the study? How many people refused to participate or dropped out? Reasons? Setting Where was the data collected? e. g. home, clinic, workplace Was anyone else present besides the participants and researchers? What are the important characteristics of the sample? e. g. demographic data, date Data collection Were questions, prompts, guides provided by the authors? Was it pilot tested? Were repeat interviews carried out? If yes, how many? Did the researcher use audio or visual recording to collect the data? Were field notes made during and/or after the interview or focus group? Reported on Page No. 20 20 20 20 20 20 20-21 21 21 21 21 23 23 27 36, 75 28 29 27 27 PERSONS WITH HEAD AND NECK LYMPHEDEMA Duration 21 Data saturation Transcripts returned 22 23 Domain 3: analysis and findings Data analysis Number of data coders Description of the coding tree Derivation of themes 24 25 26 Software 27 Participant checking 28 Reporting Quotations presented 29 Data and findings consistent 30 Clarity of major themes 31 Clarity of minor themes 32 74 What was the duration of the interviews or focus group? Was data saturation discussed? Were transcripts returned to participants for comment and/or correction? 29, 30 How many data coders coded the data? Did authors provide a description of the coding tree? Were themes identified in advance or derived from the data? What software, if applicable, was used to manage the data? Did participants provide feedback on the findings? 31 Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e. g. participant number Was there consistency between the data presented and the findings? Were major themes clearly presented in the findings? Is there a description of diverse cases or discussion of minor themes? 33 33 32 30, 33 38-48 48-57 37, 48-57 37, 48-57 Note: Developed from: Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349357. https://doi.org/10.1093/intqhc/mzm042 PERSONS WITH HEAD AND NECK LYMPHEDEMA 75 Table 2 Sociodemographic Characteristics of Participants Basic Characteristics Gender Male 7 Female 1 Age (mean) 50 Race Caucasian 7 African-American 1 Education Bachelors Degree 1 High School Diploma 7 Type of Cancer Tongue 4 Tongue & parotid gland 1 Tonsil 1 Larynx 1 Type of Cancer Treatment Chemoradiation 5 Hemi-glossectomy & Bilateral Neck Dissection 1 Hemi-glossectomy & Sentinel Node Dissection 1 Parotidectomy & Bilateral Neck Dissection with 1 Radiation Stage of Lymphedema Stage 1a 7 Stage 2 1 Occupational Therapy Interventions 8 PERSONS WITH HEAD AND NECK LYMPHEDEMA Table 3 Analysis of Primary Findings Themes Subthemes Side Effects Swelling Dry Mouth Neck Mobility Interruptions in Activities of Daily Living Eating Personal Hygiene & Grooming Sleep participation Occupational Therapy Home Program 76 PERSONS WITH HEAD AND NECK LYMPHEDEMA 77 Figure 1 Visual Representation of Findings What are the Lived Experiences of Persons with Head and Neck Lymphedema? Positive Impact Reduction in lymphedema Quality of Life Negative Impact Quality of Life Positive Impact Eating Personal hygiene & grooming Sleep participation PERSONS WITH HEAD AND NECK LYMPHEDEMA 78 Appendix A The Lived Experiences of Persons with Head and Neck Lymphedema Lead researcher: Meg Kral Meg Kral and associates from the outpatient occupational therapy department at Rush University Medical Center are recruiting participants for a research study to explore the lived experiences of persons with head and neck lymphedema including an understanding of their quality of life and occupational performance after developing lymphedema. Eligibility: At least 25 years of age At least 1-month post head and neck cancer treatment No current evidence of cancer Diagnosed with head and neck lymphedema English speaking Can provide informed consent Are not currently undergoing treatment by Meg Kral. The study will take place at Rush University Medical Center, virtually, or via phone. Participation includes semi-structured interviews with one to two follow interviews and or discussions virtually, via phone, or in person. Interviews should last no more than 45 minutes. As part of the participation, you will be asked to provide information about your experience living with lymphedema. Upon completing the second interview, follow up phone call, or discussion you will be compensated with a $10 gift card to the Rush Au Bon Pain restaurant. If you are interested in participating in this study please contact Meg Kral at megan_kral@rush.edu or 312-942-6836 PERSONS WITH HEAD AND NECK LYMPHEDEMA 79 Appendix B Screening Checklist for Head and Neck Lymphedema Research Study Medical Record Number_______________ Date:_______________ Eligible if the following criteria are met: 1. At least 25 years old Y N 2. At least 1-month post cancer treatment Y N 3. No evidence of current disease Y N 4. Head and neck lymphedema Y N 5. English speaking Y N 6. Can provide informed consent Y N 7. Is not currently being treated for Y lymphedema by the primary investigator N PERSONS WITH HEAD AND NECK LYMPHEDEMA 80 Appendix C Qualitative Interview Guide and Data Collection Introductory Paragraph Thank you for agreeing to participate in the interview today. I am an occupational therapist at Rush working towards a doctoral degree with a research interest in head and neck lymphedema. The purpose of our meeting today is to better understand what it is like to live with head and neck lymphedema. Ill ask questions pertaining to your everyday life experiences living with lymphedema. These experiences will be analyzed to identify common themes and relationships with other individuals who have been diagnosed with head and neck lymphedema. The interview will take approximately 45 minutes and I will ask you a series of questions. If any of the questions make you feel uncomfortable you do not have to answer them, and you may terminate the interview at any time. Everything you share will be kept confidential. I plan to share this information primarily with my research team and then eventually publish our findings in a peer reviewed journal. To keep things confidential, I will provide you with a pseudonym so that no one can identify you. If at any point after the interview you have questions, please feel free to contact me. I will give you a business card with my contact information or provide you with my information over the phone. Are there any questions before we get started? To ensure I understand all of your responses, I would like to audio record our interview. Is that okay with you? (Assuming the participant said yes), Thank you, I have begun recording. 1. Tell me about your day to day life living with lymphedema? How are you managing each day? PERSONS WITH HEAD AND NECK LYMPHEDEMA 81 How has it been for you and your family? 2. Tell me a little bit about the activities in your daily life including day-to-day activities and hobbies. Whats it been like to do those things since developing lymphedema? How has it been for you to carry out everyday activities like swallowing or eating, grooming, or getting dressed? How has it been for you to participate in other activities like driving, physical fitness, or grocery shopping? How are you sleeping? Whats it been like to engage socially with your friends? Tell me what its been like to participate in your work activities since developing lymphedema. 3. How do you feel about yourself? How do you feel about your appearance? 4. How would you describe your quality of life? How has developing lymphedema affected you as a person? How is your quality of life? 5. Is there anything else that you would like to shed light on regarding this topic? For those who have participated in previous lymphedema treatment: 6. What was your experience in going through lymphedema treatment? How did you feel afterwards? How was it carrying out day to day activities after completing therapy? How is your quality of life since participating in therapy? PERSONS WITH HEAD AND NECK LYMPHEDEMA How does it feel to live with head and neck lymphedema since completing therapy? For those just beginning lymphedema treatment: 1) What is it like going to lymphedema therapy? What has it been like to be diagnosed with head and neck lymphedema? How do you feel now that you just started therapy? How is carrying out daily activities since beginning therapy? How do you describe your quality of life? 82 PERSONS WITH HEAD AND NECK LYMPHEDEMA 83 Appendix D Qualitative Second Interview Guide and Data Collection Introductory Paragraph Thank you for agreeing to participate in the interview today. As you are aware, I am an occupational therapist at Rush working towards a doctoral degree with a research interest in head and neck lymphedema. The purpose of our meeting today is to share some of my findings with you from the first interview and ask you some additional questions to better understand what it is like to live with head and neck lymphedema. Ill ask questions pertaining to your everyday life experiences living with lymphedema. These experiences will be analyzed to identify common themes and relationships with other individuals who have been diagnosed with head and neck lymphedema. The interview will take approximately 30 minutes and I will ask you a series of questions. If any of the questions make you feel uncomfortable you do not have to answer them, and you may terminate the interview at any time. Everything you share will be kept confidential. I plan to share this information primarily with my research team and then eventually publish our findings in a peer reviewed journal. To keep things confidential, I will provide you with a pseudonym so that no one can identify you. If at any point after the interview you have questions, please feel free to contact me. I will give you a business card with my contact information or provide you with my information over the phone. Are there any questions before we get started? To ensure I understand all of your responses, I would like to audio record our interview. Is that okay with you? (Assuming the participant said yes), Thank you, I have begun recording. 1. How has it been this past year living with lymphedema? PERSONS WITH HEAD AND NECK LYMPHEDEMA How do you know the swelling is still there? How does being aware of the swelling affect you or impact you? Some of the participants mentioned having trouble with activities like eating and 84 swallowing, sleeping, neck mobility, and participating in social activities. What are your experiences with eating, swallowing, sleeping, turning the neck, and or engaging socially with friends or family now living with the swelling? Why do you think you had difficulty with eating and or swallowing? 2. How do you feel about your appearance now since completing cancer treatment and the therapy you participated in? How do you feel others view you having lymphedema? How do you feel about dating or being in a relationship with your spouse/significant other living with lymphedema? Some participants discussed experiencing weight loss. How did losing weight affect you? 3. How do you think the chemo and or radiation has affected you or impacted your life? How do the current side effects affect your life now? What effects has the radiation had on you? How do you think the radiation impacted you physically? How do you think those side effects affect day to day activities? 4. How would you describe your quality of life now? How has developing lymphedema affected you as a person? 5. Many participants I interviewed talked about the benefits of therapy to address the swelling. How did you feel about participating in therapy to address your swelling? How do you think the therapy helped you? PERSONS WITH HEAD AND NECK LYMPHEDEMA 85 What is your opinion on referring all adults with head and neck lymphedema to therapy? Some participants discussed using the compression mask. How has it been using the compression mask since completing therapy? How do you find time in your day to do your home exercises like the massage, stretching, and wearing the compression mask? What improvements do you see when you do your exercises like the massage, stretching and or wearing the compression mask? 6. Some participants were not able to get a pneumatic compression device to help massage the swelling. How do you think the compression pump helped you or would have helped you if you could have been given one? 7. Is there anything else you would like to share on your life experience living with head and neck lymphedema? ...
- Creator:
- Kral, Meg
- Type:
- Dissertation
13. The Role of Movement in Clinical Decision Making: Exploring the Practice of Expert Clinicians in Orthopedic Physical Therapy
- Keyword matches:
- ... The Role of Movement in Clinical Decision Making: Exploring the Practice of Expert Clinicians in Orthopedic Physical Therapy Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Melanie Lambert, PT, DPT, OCS Copyright December 5, 2023 By: Melanie Lambert, PT, DPT, OCS All rights reserved Approved by: Lisa Borrero, PhD, FAGHE Committee Chair ______________________________ Emily J Slaven, PT, PhD, MS Committee Member ______________________________ Susan Wainwright, PT, PhD Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ MOVEMENT IN CLINICAL DECISION MAKING The Role of Movement in Clinical Decision Making: Exploring the Practice of Expert Clinicians in Orthopedic Physical Therapy Melanie D. Lambert Department of Interprofessional Health & Aging Studies, University of Indianapolis 1 MOVEMENT IN CLINICAL DECISION MAKING 2 Abstract Background: Recognition of a physical therapists expertise in movement is reflected within the identity and vision of the profession. Through a unique skill set, physical therapists frequently use movement as a critical data source to inform their clinical practice. The relationship between movement and physical therapists clinical decision making (CDM) has yet to be clarified with little empirical evidence supporting best practice in the use of this critical data source. Objective: The purpose of this qualitative study was to investigate how expert orthopedic physical therapists use movement within clinical practice to inform their CDM. Method: A grounded theory study using a systematic approach was conducted using interviews with expert clinicians in orthopedic physical therapy. Constant comparative analysis was used through an iterative process of open, axial, and selective coding to identify themes that emerged. Results: The central theory of Movement: An implicit medium, emerged describing the relationship of 5 themes in collection, reasoning, application, patient centricity, and professional lens. The relationship between these themes upholds an implicit communication channel of movement, frequently accessed throughout patient management to drive clinical decisions. Conclusion: The developed theory enhances the understanding of movement in key steps of patient management and as a unifying construct within orthopedic physical therapy. Future research should examine the application of this theory in orthopedic clinical practice, to further refine best practice and educational pathways toward the use and application of movement within CDM. Keywords: movement, clinical decision making, orthopedic physical therapy, movement analysis, education MOVEMENT IN CLINICAL DECISION MAKING 3 Acknowledgments Many individuals should be credited for the successful completion of this project. Their unfailing support, encouragement, and guidance was instrumental in grounding my focus throughout this study. First and foremost, I am grateful for a committee that with welcome curiosity supported me in exploring a novel topic. Their presence and discerning questions proved instrumental in shaping the design and driving the successful completion of this project. Within my committee, I am incredibly grateful to Dr. Lisa Borrero, for consistently providing positive encouragement and putting my mind at ease for every logistical step. As my content expert, I feel fortunate to have borrowed the expertise of Dr. Emily Slaven who kept me one step ahead in sound reasoning and routinely helped me consider a wider perspective. As my analysis expert, I would like to thank Dr. Susan Wainwright who made a vast amount of data feel small and always managed to ask the perfect question to help me consider developing narratives. To my entire committee, I am humbled to have been the recipient of your time and effort and for that, I am eternally grateful. The participants in this study deserve recognition as it is their energy, perspectives, and gracious time investment that invigorated my passion for this topic. Their willingness to share their personal lens of clinical practice only strengthened my resolve to investigate this topic both here and in the future. Thank you all for energizing my love for orthopedic physical therapy and fueling greater curiosity in orthopedic practice. Last but certainly not least, I would like to thank my husband for reminding me every day that I can accomplish what I set my mind to and never hesitating to pick up the scattered pieces of life in progress. You keep me grounded in the definition of success and I am blessed to share accomplishments big and small with you by my side. MOVEMENT IN CLINICAL DECISION MAKING 4 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgments........................................................................................................................... 3 List of Tables .................................................................................................................................. 7 List of Figures ................................................................................................................................. 7 The Role of Movement in Clinical Decision Making: Exploring the Practice of Expert Clinicians in Orthopedic Physical Therapy...................................................................................................... 8 Problem Statement .................................................................................................................... 10 Purpose Statement..................................................................................................................... 10 Significance of the Study .......................................................................................................... 11 Definition of Terms................................................................................................................... 11 Literature Review.......................................................................................................................... 11 Movement in Physical Therapy ................................................................................................ 11 National Organizational Changes ............................................................................................. 14 Embracing the Movement System ............................................................................................ 15 Neurological Applications .................................................................................................... 15 Orthopedic Applications ....................................................................................................... 15 Orthopedic Assessment of Movement ...................................................................................... 17 Embodiment of Movement ....................................................................................................... 19 Expert Clinical Decision Making.............................................................................................. 20 Movement in Clinical Reasoning.............................................................................................. 22 Method .......................................................................................................................................... 23 Study Design ............................................................................................................................. 23 MOVEMENT IN CLINICAL DECISION MAKING 5 Participants................................................................................................................................ 23 Procedures ................................................................................................................................. 24 Sampling and Recruitment.................................................................................................... 24 Informed Consent.................................................................................................................. 25 Data Collection ..................................................................................................................... 27 Data Management and Analysis ........................................................................................... 28 Rigor and Trustworthiness ........................................................................................................ 31 Results ........................................................................................................................................... 32 Central Theory .......................................................................................................................... 33 Overview of Themes ................................................................................................................. 33 Collection .................................................................................................................................. 34 Reasoning.................................................................................................................................. 39 Application................................................................................................................................ 43 Patient Centricity ...................................................................................................................... 46 Professional Lens ...................................................................................................................... 48 Discussion ..................................................................................................................................... 51 Limitations ................................................................................................................................ 66 Future Directions ...................................................................................................................... 67 Conclusion ................................................................................................................................ 68 References ..................................................................................................................................... 69 Table 1. Demographic Characteristics .......................................................................................... 86 Table 2. Aggregate Demographics ............................................................................................... 87 Table 3. Emergent themes and corresponding categories ............................................................. 88 MOVEMENT IN CLINICAL DECISION MAKING 6 Figure 1. Visual Representation of Steps Taken Throughout Study ............................................ 91 Figure 2. Conceptual Model ......................................................................................................... 92 Appendix A. Interview Guide ....................................................................................................... 93 Appendix B. Qualtrics Study Information Sheet & Reflective Case Vignette ............................. 97 MOVEMENT IN CLINICAL DECISION MAKING List of Tables Table 1. Demographic Characteristics Table 2. Aggregate Demographics Table 3. Emergent Themes & Corresponding Categories List of Figures Figure 1. Visual Representation of Steps Taken Throughout the Study Figure 2. Conceptual Model 7 MOVEMENT IN CLINICAL DECISION MAKING 8 The Role of Movement in Clinical Decision Making: Exploring the Practice of Expert Clinicians in Orthopedic Physical Therapy Movement has been a hallmark of the physical therapy profession since the time of its inception. Initial development of the profession focused on movement as a health promoting cure, while later advancements expanded on the clinical science behind the therapeutic evaluation and use of movement to address human disorders (Wikstrom-Grotell & Eriksson, 2012). Within clinical practice, movement is widely used to evaluate a patients impairments and functional abilities, integrating with a therapists diverse skill set to establish diagnoses and tailor effective patient management plans. Physical therapy literature supports a focus on movement as an attribute of expert practice, and despite a struggle to define the identity of the profession, the recognition of movement as a central data source is commonly accepted (Jensen et al., 2000). The use of this movement data source works to distinguish the profession from other healthrelated fields, such as medicine or nursing, in the unique use and application of a patients movement (Huhn et al., 2018). Synthesis of movement data occurs within a therapists clinical reasoning and subsequent clinical decision making (CDM), supported as requisite components of successful practice (Christensen et al., 2017). Clinical reasoning represents a therapists overall thinking and decision making process by which wise action is taken, whereas CDM is evidenced by the application of this reasoning to the patient (Higgs et al., 2019). These terms are often used interchangeably yet represent separate concepts, with CDM carrying a distinction as an end product of clinical reasoning (Higgs et al., 2019). In recent years the breadth of literature surrounding CDM has grown in attempts to standardize educational pathways for the advancement of best practices. Development towards expert proficiency in CDM is thought to MOVEMENT IN CLINICAL DECISION MAKING 9 occur over time, with novice practitioners relying on hypothetico-deductive methods driven by initial cues and hypothesis generation, and expert clinicians utilizing metacognitive approaches in pattern recognition and knowledge organization (Edwards et al., 2004; Macauley et al., 2018; Wainwright et al., 2011). Movement is frequently represented in studies utilizing these models as a critical data source to gain information, educate ones patient, and foster greater body awareness (Oberg et al., 2015; Sebelski et al., 2019). Despite this observed presence of movement within existing CDM literature, no identified studies have investigated the extent to which movement drives the clinical decisions of physical therapists. Explicit means by which movement and CDM are interrelated have yet to be explored with no specific literature illustrating this process in practice. Application of CDM to patient management is central to driving positive clinical outcomes, with increased accountability of successful performance required in autonomous practice (Higgs & Jones, 2008). As physical therapists uphold roles as autonomous practitioners, CDM built from foundational elements of the profession, such as movement, are essential (Sahrmann, 2022). In 2013 the American Physical Therapy Association (APTA) adopted a new vision statement reflecting the identity of physical therapists as movement system experts Transforming society by optimizing movement to improve the human experience (American Physical Therapy Association, 2015). Considering the profession grounds itself in the APTA driven identity as movement system experts, a greater understanding is warranted in how the concept of movement intersects with a therapists CDM. A lack of clear guidelines and best practice standards endorses a wide variation in practice and assessment of a fundamental concept (Saladin & Voight, 2017). MOVEMENT IN CLINICAL DECISION MAKING 10 Problem Statement Responses to the call towards an identity in the movement system are evidenced by the efforts of the Academy of Neurologic Physical Therapy with a white paper endorsing the use of movement system diagnoses as well as recent movement system models to guide functional task analysis (Hedman et al., 2018; Quinn et al., 2021). These advances support therapists in their development of task specific movement analysis, yet the identification of key components within skilled observation beyond a specific task remains ill defined. Furthermore, the implicit use of movement within the patient management process and a therapists CDM lacks clarity. Within the realm of orthopedics, limited scholarly advances are evident leaving gaps in research affecting orthopedic physical therapists ability to embrace their role as movement system experts. Purpose Statement The primary purpose of this study was to investigate how movement informs the CDM of expert clinicians of orthopedic physical therapy and secondarily what specific components are integral to this decision making process. This study sought to answer the following research questions. How does movement inform the CDM of expert clinicians of orthopedic physical therapy? a. What components of movement are identified within the evaluative process? b. How are movement components prioritized within their reasoning process? c. What role does embodiment of movement play within their decision making? d. How does prior experience influence their CDM? MOVEMENT IN CLINICAL DECISION MAKING 11 Significance of the Study The proposed study provides valuable insight into the relationship between movement and CDM in orthopedic physical therapy. As a result, educational programs and clinical pathways may intentionally target curricular methodologies to foster this skill set. With a greater understanding of the use and application of skilled movement, orthopedic physical therapists may better drive best practices, upholding their identity as movement system experts and meeting the vision set forth by the APTA. Definition of Terms Clinical decision making: The decisions a healthcare practitioner makes towards the care of a patient, resulting from their reasoning and thinking process and applied to the patient (Higgs et al., 2019). Literature Review Movement in Physical Therapy The recognition of movement within physical therapy treatment models spans centuries with evidence of this data source seen as early as 1813 (Moffat, 2012). These early roots recognized the natural continuum of movement in healing within a treatment model recognized as medical gymnastics, focusing on restoring an individuals strength, stamina, and flexibility (Moffat, 2012). With evolution of the profession across the globe, calls within the United States to ground the identity of the profession in the fundamental concept of movement were made in 1975. This included the development of conceptual models highlighting an individuals communication in all things through an expression of movement (Hislop, 1975). This expression as defined by Hislop expanded on the concept of movement across six levels of being, all interacting through a flow of hierarchical systems. Hislops model provided the earliest MOVEMENT IN CLINICAL DECISION MAKING 12 theoretical conceptualization of physical therapy yet faced criticism in its ability to reflect an individuals interaction with society and their environment (Cott et al., 1995). Later theories expanded on existing models seeking to better define a grand theory for the profession and drive empirical efforts towards assessment and research (Cott et al., 1995). This Movement Continuum Theory (MCT) further defined the construct of movement and offered a grounding conceptual framework through the key concept of movement. The MCT consists of eight principles of movement with three of these speaking to paramount principles of movement shared with other disciplines, and the remaining five defining principles unique to the practice of physical therapy (Cott et al., 1995). Despite these attempts to provide a grand theory of the profession, the MCT failed to produce significant contributions to research and evidence-based practice due to a generic realization of movement (Allen, 2007). Proposed solutions to this scholarly inactivity included further defining the construct of movement within six dimensions to better allow identification and treatment of current and preferred patterns. These six dimensions included flexibility, strength, accuracy, speed, adaptability, and endurance (Allen, 2007). Irrespective of an enduring recognition of movement and attempts to develop a grand theory within physical therapy, a unifying construct to guide best practice remains elusive. Multiple treatment paradigms have presented from both pathokinesiologic and kinesiopathologic models offering competing priorities in the evaluation and use of movement (Sahrmann, 2017). From a historical perspective, predominance of a pathokinesiologic approach in medicine has been used, defined by a diagnostic process that emphasizes structure or tissue pathology that is generating pain or limitations, with treatment often directed towards these identified impairments (Dingenen et al., 2018; Ludewig et al., 2017). In contrast kinesiopathologic models focus on the identification of repeated or biomechanically altered movement patterns that may contribute to MOVEMENT IN CLINICAL DECISION MAKING 13 symptom behavior, with prioritization in treatment of the underlying phenomenon itself that is viewed as the cause of pathology (Dingenen et al., 2018; Ludewig et al., 2017). Continued research has led to various recommendations to adopt a kinesiopathologic approach due to reported limitations of pathoanatomic labels to direct physical therapists CDM, align with patient symptoms, and manage patient expectations in the severity of treatment required (Barreto et al., 2019; Cools & Michener, 2017; Friedman et al., 2021; Ludewig et al., 2022; Zadro et al., 2021). No consensus has been established with continued diversity in diagnostic process used by practicing physical therapists. This variation in approach has led to a lack of standardization within orthopedic physical therapy to direct education and best practice, with a subsequent lack of understanding in the critical use of a patients movement within a therapists CDM (Ludewig et al., 2022; Sebelski et al., 2019). Additional conceptual frameworks widely recognized within physical therapy include the International Classification of Functioning adopted by the World Health Organization in 2001, and the Patient Management Model as illustrated in the Guide to Physical Therapist Practice (American Physical Therapy Association, 2023; World Health Organization, 2001). The International Classification of Functioning has been widely adopted to guide a therapists organization of patient variables, in addition to the patient management model developed to optimize outcomes by synthesizing key components of the evaluation process including examination, evaluation, diagnosis, prognosis, intervention, and outcomes (American Physical Therapy Association, 2001; Escorpizo & Bemis-Dougherty, 2015). While these models represent broad frameworks, they lack specific guiding constructs in the use and value of movement within CDM (Rundell et al., 2009; Steiner et al., 2002). MOVEMENT IN CLINICAL DECISION MAKING 14 National Organizational Changes Recently, calls within the physical therapy profession have charged practitioners to embrace their role as movement system experts and focus themselves on the central concept of movement as their identity (American Physical Therapy Association, 2015). This has included adoption of a new vision in 2013 focusing on maximizing movement to transform society, as well as the Movement System Summit in 2016 formulated to develop an integrative plan for the movement system within practice, education, and research (American Physical Therapy Association, 2019). From an educational perspective, the accrediting body of physical therapy educational programs recognizes the utility of movement evaluation within entry-level curricula through required elements and standards for accreditation (Commission on Accreditation in Physical Therapy Education, 2020). In addition, the American Council of Academic Physical Therapy has expressed supporting statements in the guidance of practice, education, and research in the movement system (American Council of Academic Physical Therapy, 2017). Further advancements include the release of a movement screen by APTA to assist clinicians in the detection of movement impairments, and ongoing solicitation of movement system diagnoses from the membership to continue progress toward the standardization of movement system diagnoses (American Physical Therapy Association, n.d.). Despite these measures, integration of the movement system within educational curricula remains poorly focused as seen through national studies investigating programs of excellence (Jensen et al., 2017). Widespread variation is evident in practice and education towards the adoption and delivery of movement system concepts with little empirical evidence in grounding concepts, terminology, and exemplar practice to build from (Jensen et al., 2017; McClure et al., 2021; Sebelski et al., 2019). MOVEMENT IN CLINICAL DECISION MAKING 15 Embracing the Movement System Neurological Applications Within the APTA, the Academy of Neurologic Physical Therapy has embraced the movement system through the development of clinical tools and educational constructs to guide best practice. Recognizing the lack of a broad unifying framework, a Movement System Task Force was developed following adoption of the new vision to identify diagnostic classifications and evaluative guidelines to accurately capture a patients movement system impairments (Hedman et al., 2018). Outcomes of this work included the development of diagnostic classifications and identification of key tasks for movement analysis every physical therapist should be able to use in assessing a patients functional movement (Hedman et al., 2018; Quinn et al., 2021). This includes identification of observable constructs in symmetry, speed, amplitude, alignment, postural control, coordination, and symptom provocation (Quinn et al., 2021). Principles of motor control are integrated within recommendations from the Academy of Neurologic Physical Therapy utilizing an extensive base of motor control research. It is relevant to note these tools were developed regarding neurologic populations, presenting limitations in application to a broad population of pathological conditions and diagnoses. Orthopedic Applications Within orthopedic populations, a lack of frameworks exists capturing the use of movement within a therapists patient management process. Approaches within orthopedic physical therapy include classification-based models, driven by algorithms into various treatment categories, as well as specific movement approaches based on precise examination of patient movement and tissue length (Alrwaily et al., 2016; Lam et al., 2018; Sahrmann, 2001; Sahrmann & Associates, 2010). In 2006, the Academy of Orthopaedic Physical Therapy began MOVEMENT IN CLINICAL DECISION MAKING 16 development of clinical practice guidelines to guide evidence based practice of common musculoskeletal conditions (Cibulka et al., 2017). These guidelines provide a tool for physical therapists to classify their patients based on presentation and direct their treatment in providing an evidence-based approach (Enseki et al., 2023). Categories represented within various clinical practice guidelines speak to movement patterns and movement coordination deficits, yet little guidance in the integration of these components within a physical therapists reasoning process is provided. The clinical practice guidelines are implemented at a varying frequency and recent studies report limitations in the association between the use of these tools and patient outcomes (Baumann et al., 2023; Laderia et al., 2017). In recent attempts to embrace the movement system, the 4-Element Movement Model was proposed as a model to guide evaluation of essential movement components across a wide variety of patient populations, showing promise for orthopedic applications (McClure et al., 2021). This model includes focus on key variables of movement in motion, force, energy, and control, along with identification of observational targets in control, amount, speed, symmetry, and symptoms (McClure et al., 2021). Recent authors have demonstrated the utility of the model in sports orthopedic populations, using the framework to support the evaluation of specific movement tasks and components within entry-level and post-graduate residency programs (Zarzycki et al., 2022). From a cohesive viewpoint, literature supports the utility of movement within orthopedic practice in multiple capacities, yet an understanding of what components are prioritized and how this is used to guide clinical decisions lacks substantive support. Evidence demonstrates that as the profession adopted a new vision and unifying identity in the movement system, many developments were spurred from the Academy of Neurologic Physical Therapy, yet similar achievements within orthopedic physical therapy have yet to be seen. MOVEMENT IN CLINICAL DECISION MAKING 17 Orthopedic Assessment of Movement Clinical assessment of movement is performed through all senses including auditory, visual, and kinesthetic or tactile means (Jensen et al., 2017). Beyond these senses empirical evidence describes expert practitioners utilizing movement in almost an unconscious way through a fluid process of palpation, observation, and guidance throughout evaluation and dialogue with the patient (Jensen et al., 2000). These skills are further integrated within orthopedic practice through clinical applications including video-based motion analysis, used by roughly 50% of orthopedic physical therapists, and movement-based screening measures utilized to prevent injury and assess return to sport benchmarks (Bonazza et al., 2017; Hensley et al., 2020). This widespread use of movement within patient management emphasizes foundational practices in the collection and use of a critical data source, a patients movement. Skilled Observation Educators recognize skilled observation as a vital skill for best practice in movement evaluation, however, limited educational pathways to foster this skill set are evident (Dekkers et al., 2022). Radan et al. (2020) demonstrated differences between expert and novice practitioners in the performance of observational movement analysis with increased visual spatial abilities observed from expert practitioners. McDuff et al. (2021) further expanded on skilled observation by demonstrating an increased prioritization of visual information within eye gaze behaviors from expert therapists suggesting the ability to broadly assess and prioritize visual information for accurate interpretation. The use of skilled observation through assessment tools is widely evidenced in orthopedic practice with common use of visual assessments. These include assessment of an individuals postural orientation, observation of dynamic tasks such as a single leg squat or forward lunge, and comprehensive movement screens such as the Functional MOVEMENT IN CLINICAL DECISION MAKING 18 Movement Screen (FMS) and Athletic Ability Assessment. A review of the literature indicates good to excellent reliability for many of these measures supporting the application of visual observation in clinical practice (Bonazza et al., 2017; McKeown et al., 2014; Nae et al., 2017; Ressman et al., 2021). Such evidence illustrates the integral role of movement in expert orthopedic practice and the significance of developing skilled observation. Within the medical community, health professions such as medicine and nursing have integrated curricular tools to foster skilled observation by using a humanities approach. A widely investigated strategy in this realm is Visual Thinking Strategies (VTS) where the visual arts are used to develop student skills of visual literacy, critical thinking, ambiguity, and compassion (Chisolm et al., 2021; Cerqueira et al., 2023). In a recent systematic review by Mehta and Agius (2023), overwhelmingly positive results were reported with the use of VTS, noting increased skill in student's visual observation, yet reported limitations in evidence toward improved diagnostic abilities. Similarly, Cerqueira et al. (2023) demonstrated the ability of VTS to develop skills of in-depth visual analysis supporting greater integration within medical school curriculum. Despite this growth of literature, no studies exist investigating VTS within physical therapy. Conversations within the profession have supported greater use of a humanities approach, speaking directly to the ability of visual arts to foster students observational skills (Blanton et al., 2020), yet empirical evidence investigating these strategies is yet to be seen. The significance of movement assessment is further evidenced by the signature pedagogy of the profession established as the human body as teacher by a previous study of excellence (Jensen et al., 2017). In this Carnegie-type study, authors noted a clear focus on the body to concentrate students on what they could feel, hear, and touch in developing a keen observation of movement. Exploration into developing these skill sets can be seen in a novel study by Judd et MOVEMENT IN CLINICAL DECISION MAKING 19 al. (2021) who investigated virtual reality as an intervention to direct skills of movement analysis, reporting positive student attitudes in the use of virtual reality and promise in further integration for skill development. Embodiment of Movement Further understanding of movement in clinical practice is reflected by a practitioner and patients embodiment of movement. Movement provides a mechanical means to function and participate in daily activities, yet movement has also been conceptualized as an emotional expression and means of communication between a patient and therapist (Wikstrom-Grotell & Eriksson, 2012). Oberg et al. (2015) describes how embodied action occurs when a therapist recognizes their own objective body as well as their patients body, detailing the importance of integrating both first and second-person perspectives for an embodied interaction with ones patient and towards their CDM. Covington and Barcinas (2017) explored how clinical instructors facilitate embodiment of movement with physical therapy students, demonstrating key behaviors towards skill development including prioritized direction, enhancing students understanding of movement, and connecting the use of movement with patient care. Mechanisms such as mimicking the instructors hands and reflecting on their own use of movement were found to support student growth (Covington & Barcinas, 2017). Further scholarly works make a direct link between a therapists own body and movement awareness and their ability to promote movement quality (Ahola et al., 2022; Skjaerven et al., 2010). Key steps toward building greater movement awareness include recognizing ones individual movement experiences and an intentional learning cycle of contact, explore, experience, integrate, create meaning, master, and reflect (Ahola et al., 2022; Skjaerven et al., 2010). Within literature descriptions are found into how expert practitioners perceive MOVEMENT IN CLINICAL DECISION MAKING 20 movement quality as a multi-interactive process encompassing biomechanical, physiological, psycho-social-cultural, and existential domains (Skjaerven et al., 2008). The embodiment of movement presents as a holistic expression of these factors demonstrating promising evidence in supporting physical therapists as collaborative movement educators with their patients. These studies demonstrate a connection between a physical therapists personal movement experiences and their ability to promote movement quality with their patients yet little research has expanded on this phenomenon in the context of a therapists reasoning process. Expert Clinical Decision Making Over the last few decades, multiple health professions have contributed a large body of research on CDM, finding the complex skill integral to successful clinical practice (Young et al., 2020). Within the physical therapy profession, CDM has gained increased focus, establishing precedence as a key component in producing optimal outcomes (Christensen et al., 2017). The term CDM has been used interchangeably with diagnostic reasoning, clinical reasoning, and clinical judgments describing the cognitive process through which a practitioner makes decisions and solves clinical situations (Huhn et al., 2018). Despite the wide breadth of literature across disciplines, a shared definition of CDM remains elusive (Durning et al., 2018; Young et al., 2020). The skill of CDM remains a recognized component of professional education and practice, yet wide variability is seen in the integration within program curricula (Jensen et al., 2017). Christensen et al. (2017) define the complex nature of this non-linear skill, revealing a wide variability in explicit teaching methods, definitions, and assessments. Medical literature has described CDM models as both hypothetico-deductive where a clinician creates tentative hypothesis and seeks to confirm or reject various hypotheses through continued patient evaluation, as well as forward thinking, focused on a therapists use of knowledge organization MOVEMENT IN CLINICAL DECISION MAKING 21 and pattern recognition (Edwards et al., 2004). Both novice practitioners and students demonstrate greater use of hypothetico-deductive models, with research supporting the progression to forward thinking models within expert CDM, often continually developed through post-professional programs and clinical practice (Baker et al., 2017; Wainwright et al., 2010). Continued use of hypothetico-deductive reasoning may be utilized by expert practitioners within history taking and evaluative pieces yet is often scaffolded with higher-level CDM processes such as pattern recognition and narrative reasoning (May et al., 2008). Edwards et al. (2004) examined CDM amongst expert therapists and identified six reasoning strategies that may be utilized interchangeably throughout patient interactions highlighting the underlying complexity of CDM. These six reasoning strategies include interaction, procedure, teaching, collaboration, prediction, and ethics. High level reasoning processes are further reflected in a therapists use of illness scripts, originally described in medical literature as a practitioners ability to quickly retrieve relevant networks of information based on patient presentation (Schmidt et al., 1990). Kumar et al. (2021) note that expert clinicians demonstrate greater proficiency in these scripts with the ability to sort through fewer pieces of information for diagnostic reasoning. Only recently have movement scripts been proposed within physical therapy, serving as a similar model to guide expertise in the integration of movement and clinical reasoning (Kirk-Sanchez et al., 2022). Movement scripts appear to directly reflect APTAs vision statement and may offer tools for organizational structure of educational practices. Gilliland and Wainwright (2017) previously supported calls for the use of movement scripts to drive expert CDM, demonstrating the variability in which students develop CDM skill sets through a qualitative case study approach. Furthermore, embodiment of movement has yet to be integrated within clinical reasoning MOVEMENT IN CLINICAL DECISION MAKING 22 frameworks with limited tools bridging movement into a therapists clinical decisions (berg et al., 2015). Challenges to establishing consistency in CDM concepts and models have included the context dependent nature of the process, as well as the individuality of expertise, directly speaking to gaps in CDM research towards a physical therapists expertise in movement (Higgs & Jones, 2008). Movement in Clinical Reasoning Movement is seen within CDM literature through multiple studies highlighting expert use of movement as a data source. Seminal literature has supported the use of movement by expert physical therapists (Jensen et al., 2000), and various concepts of movement are found within CDM studies (Baeske et al., 2020; Edwards et al., 2004; Gilliland & Wainwright, 2017). Wainwright et al. (2011) revealed that while both novice and experienced therapists observe movement, the degree to which this is integrated within their CDM is greater amongst experienced clinicians. In pursuit of fostering this skill development, broad curricular mapping has been proposed to integrate the movement system within educational practice, suggesting ideal placement for students development of knowledge (Hoogenboom & Sulavik, 2017). Outcomes and developmental benchmarks are needed for the purposeful integration of these curricular threads requiring further investigation into how a physical therapist collects, prioritizes, and adapts their reasoning based on individualized patient movement. Efforts to standardize language and unify an understanding of concepts surrounding CDM can be seen in a recent concept analysis aimed to conceptualize a description of clinical reasoning in physical therapy (Huhn et al., 2018). Authors define clinical reasoning as an adaptive, iterative, and collaborative approach to patient management (Huhn et al., 2018). Salient themes within the study described a cyclical process that includes observation and embodiment MOVEMENT IN CLINICAL DECISION MAKING 23 of movement, yet explicitly identifies the gaps in research toward movement within CDM (Huhn et al., 2018). Additional literature highlights this need by recognizing gaps from a theoretical basis and a need to align the signature pedagogy of body as teacher with CDM to further guide research, education, and practice (Sebelski et al., 2019). Method Study Design A grounded theory approach was used to understand how expert clinical orthopedic physical therapists use movement to inform their CDM. Using a systematic grounded theory approach, the primary researcher aimed to generate a theory elucidating this decision making process as demonstrated in orthopedic clinical practice (Corbin & Strauss, 2008). Grounded theory allows exploration into a process or action that consequently leads to a theoretical explanation built from participant experience (Corbin & Strauss, 2008). This approach allowed optimal insight into the sparsely researched topic of movement and CDM. The study was approved by the University of Indianapolis Institutional Review Board and took place from January to August of 2023. Participants Purposive sampling was used to identify qualifying expert orthopedic physical therapists. Purposive sampling is frequently used in qualitative research to deliberately identify participants with characteristics and experiences relevant to the research (Etikan et al., 2016). Homogenous purposive sampling was used to identify candidates who shared similar traits in the following inclusion criteria. Individuals were eligible to participate if they, 1) had advanced certification in one of the following: Orthopaedic Certified Specialist (OCS), Sports Certified Specialist (SCS), Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT), MOVEMENT IN CLINICAL DECISION MAKING 24 manual therapy certified (MTC), 2) had at least three years of clinical practice, 3) engaged in teaching students and/or colleagues within the profession, and 4) currently practiced for at least 20 direct patient care hours weekly in an orthopedic practice. Teaching criteria was satisfied by formal mentorship within the profession, regular acceptance of student clinical rotations, or engagement in teaching through workshops, seminars, or long-term courses within the last year. Consistent with grounded theory methodology, the number of participants was not determined in advance of the study but in response to data analysis. Standard grounded theory sample sizes are noted to range from twenty to thirty participants, yet nonetheless, recruitment was concluded when saturation was reached and no new concepts were emerging from the data (Gentles et al., 2015). Procedures Sampling and Recruitment The initial round of participants was identified by the primary researcher through personal contacts. With fourteen years of experience in the field of orthopedic physical therapy, the primary researcher was positioned efficiently to identify peers and colleagues that satisfied the established inclusion criteria. Separation between the researcher and participants was ensured in the sample by excluding participants that the researcher had directly supervised from a managerial position in clinical practice. Following the initial round of participant interviews, ongoing sampling and recruitment occurred through snowball sampling techniques. Snowball sampling allowed selected participants to identify peers that meet the studys inclusion criteria, maximizing the expert orthopedic physical therapists personal and social networks (Portney & Watkins, 2015). At the conclusion of each participant interview, individuals were asked to nominate peers satisfying the inclusion criteria of the study. Participants were asked to verbally MOVEMENT IN CLINICAL DECISION MAKING 25 provide the name and email address of the identified individuals. Theoretical sampling was used for ongoing participant recruitment following the initial round of interviews. This method provided an open and flexible approach toward emerging concepts, allowing the researcher to select the next round of participants based on relevant concepts emerging at each step of data collection (Corbin & Strauss, 2008). By using this sampling approach, an in-depth discovery into new areas was supported (Corbin & Strauss, 2008). All eligible participants were invited to participate in the study by direct email communication from the primary researcher. Emails to individuals identified through snowball sampling included information on the purpose of the study, anticipated time commitment, and methods by which their confidentiality was protected. An explanation of potential risks and benefits was also included, in addition to researcher contact information and instructions asking the individual to reply with a statement of interest and their preferred phone number for contact. Following email receipt of interest, the primary researcher communicated with individuals through email or phone to screen them for inclusion criteria, review key information surrounding the study to verify continued interest, and lastly schedule the interview at a convenient day and time for the participant. Consistent with grounded theory methodology, the recruitment measures described continued until no new data or concepts were emerging, thus reaching saturation (Aldiabat & Le Navenec, 2018). Informed Consent When an interview was scheduled, the primary researcher emailed the participant a link to an electronic study information sheet through Qualtrics, which is a secured online survey platform. The purpose of this document was threefold; to provide information for the process of informed consent; to serve as a collection point for demographic data, and to serve as a data MOVEMENT IN CLINICAL DECISION MAKING 26 collection point for a reflective case vignette. Informed consent information within the electronic form included a review of the study purpose, confirmation of IRB approval, what confidentiality measures would be taken, voluntary participation expectations including the freedom to withdraw at any point in time, contact information for the primary researcher, and potential risks and benefits to the participant. There were no known risks for participation in the study, with benefits including contribution to the scientific community surrounding orthopedic physical therapy practice and education. What the participant was expected to do during the study was detailed within this section of the study information sheet listing submission of the study information sheet, completion of the interview, and follow-up email communication for member checking. Demographic information obtained within the second section of the study information sheet included the participants age, state they practice within, years of clinical practice, graduate degree institution, allocation of teaching commitments, and program of attendance for advanced certification if applicable. The final section of the electronic form included six questions for the participant to reflectively describe a unique patient case they have experienced within clinical practice, serving to provide an additional artifact for data collection and contextualized prompts for interview questions. The participants name was obtained on this electronic form to provide a means for matching reflective case answers to their individual virtual interview guide. No identifiable information was utilized past this point. Prior to conducting the virtual interview, the researcher reviewed the study information sheet with the participant allowing an opportunity for dialogue surrounding the purpose of the study and any questions that the participant may have. With the verbal assurance that no questions remain from the participant, the researcher collected verbal informed consent for study participation and initiated the interview. The process of informed consent continued, with each MOVEMENT IN CLINICAL DECISION MAKING 27 interview beginning with verbal scripted information providing statements to give the individual the ability to stop the interview at any point in time, obtain permission to record, and provide contact information for further questions upon interview completion. Data Collection Data collection occurred at two points in time with each participant, through the transmission of their completed study information sheet described above, and during the virtual semi-structured interview. Virtual interviews were conducted via Zoom. Use of these platforms has been shown to serve as a viable tool for collecting qualitative data (Archibald et al., 2019), allowing the researcher the ability to conduct multiple interviews from various geographic locations. Audio recordings were captured through Zoom as well as a secondary backup recorder on the primary researchers smartphone, placed next to the speaker during interviews. The primary researcher, educated in qualitative methodology, performed all data collection. Both the participant and the primary researcher engaged in interviews within a quiet private office, free from distractions, and conducive for quality audio recording. They were conducted using a semi-structured interview guide (see Appendix A) with a flexible approach to questions, prompts, and dialogue. The interview guide was developed following the completion of a literature review identifying supporting research in CDM and movement-based principles within the patient management process. The interview process began with broad questions related to the participants professional role and their perceptions of the use of movement within patient evaluation and treatment to assist in building rapport. More detailed questions followed addressing movement-based concepts and principles, probing into how they experience and integrate this information within their CDM. Reflective questions completed within the participants study information sheet were used to guide questions requiring the participant to MOVEMENT IN CLINICAL DECISION MAKING 28 think aloud. Think-aloud techniques were used because they have been described as effective research methods to understand individuals thought processes (Gss, 2018). Prompts and follow-up questions were used to ensure adequate depth of detail in topics discussed. Additional data collection included field notes and memos completed by the primary researcher. Field notes were completed during the interview, serving to provide observational data from the social interaction with the participant (Montgomery & Bailey, 2007). Memos were completed following each interview as the researcher begins the analysis process. These statements were written and dated by the researcher reflecting their thoughts and thinking process as they read through the participant transcript. Memos served to support the initial conceptual process directing initial coding steps and to support the overall theory development (Montgomery & Bailey, 2007). Data Management and Analysis Each participant was assigned an ID code to allow the de-identification of all data collected. The hardcopy master list of participant IDs was stored separate from other electronic data, securely in a locked cabinet in the primary researchers office. Multiple measures were taken to ensure the privacy and security of virtual interview data. All virtual links were created by the primary researcher through a password-protected Zoom account. On the morning of the interview, the secure link was emailed to the participant only. A waiting room feature ensured all participants were screened prior to entering the virtual interview space, with encrypted communication throughout using 256-bit advanced encryption standard (Zoom, 2022). Audio recordings were downloaded to the primary researchers passwordprotected computer following each interview. All interviews were transcribed verbatim within one week of conducting the interview and categorized with their participant ID code for MOVEMENT IN CLINICAL DECISION MAKING 29 transcript de-identification. Temi, a transcription service app, was used for this transcription process. Each interview transcript was reviewed for accuracy following transcription and stored within folders on the researchers password protected computer. Audio recordings were deleted from the primary researchers computer and smartphone following transcription completion. Further data sources including researcher memos and field notes were stored electronically on the same computer. An iterative process of coding using constant comparative analysis occurred throughout data collection following steps as described by Strauss and Corbin (1990). This analysis process was completed as described for both the participants reflective case vignette obtained within their study information sheet and their interview transcript. Open coding was used at each step of data collection attempting to prescribe meaning to information presented (Vollstedt & Rezat, 2019). Initial identified codes contributed to the generation of a codebook and were continuously compared to new codes at each step of data collection serving to refine existing coding schematics. Consistent with grounded theory, axial and selective coding were utilized as categories were revealed and relationships between codes became evident. As conceptual lines developed, refining questions drove continued data collection through theoretical sampling (Corbin & Strauss, 2008). An overall coding schematic led to theme representation and identification of the underlying theory present. Dedoose, a computer assisted qualitative data analysis software, was used to assist in data analysis and representation of coding schematics (SocioCultural Research Consultants, 2021). Access to this private Dedoose account was restricted to the primary researcher, with software installation occurring on the primary researchers password protected computer. Within Dedoose, data in the form of audio recordings, transcripts, and memos and field notes were stored. Output and schematics created MOVEMENT IN CLINICAL DECISION MAKING 30 within this software were shared with a secondary researcher through a private Google folder to aid in confirming the accuracy of data output. The secondary researcher, with expertise in qualitative methodology, assisted with data analysis during the initial round of interviews to contribute to the development of the codebook. De-identified transcripts were shared through a private Google folder, following which each researcher completed memos and open coding. The primary and secondary researcher then met to discuss identified codes, coming to a mutual agreement on terminology and concepts for the codebook. Following development of the codebook, the secondary researcher served as a peer expert, auditing coding schematics developed by the primary researcher checking for areas of concern or need for further information throughout the analysis process. Member checking was utilized once themes emerged, allowing the participant an opportunity to review analyzed data and reflect on the accuracy of information presented in representation of their individual experience (Birt et al., 2016). Specifically, participants were emailed the primary researchers initial themes and asked to provide response towards analysis made by emailing the primary researcher. The primary researcher cross referenced the participants interview data with overall frameworks present as responses were received, checking for inconsistencies or further exploration as needed. Participants provided clarifying questions during this process but no edits or suggestions that were inconsistent with presented themes. While one participant voiced surprise in the lack of a shared systematic approach to movement evaluation, all comments obtained agreed the themes were representative of their perspectives. No significant theme revisions were completed following member checking. MOVEMENT IN CLINICAL DECISION MAKING 31 Rigor and Trustworthiness Rigor and trustworthiness are essential within qualitative research and include four main concepts: credibility, transferability, dependability, and confirmability (Henderson & Rheault, 2004). Throughout the study, multiple steps were taken to address these components. Credibility, or the truth value of presented information (Henderson & Rheault, 2004), was upheld by multiple methods. These included member checking following completion of participant data analysis, and triangulation of data through multiple sources of data and the use of a secondary researcher. Credibility was also supported through the background of the researcher in outpatient orthopedics, giving the researcher and participant a common knowledge base to communicate from and assist in establishing researcher competence in study concepts. An additional component of trustworthiness includes transferability, or the ability to apply findings to similar populations. Transferability was addressed through measures taken to build a representative sample. Intentional steps in the design of the study provided recruitment from a varied orthopedic background and region, reflecting the larger population of practicing outpatient orthopedic physical therapists. Other methods included the collection of detailed dense background information of the participants using the study information sheet and background data gained through virtual interviews. This information helped to greater illustrate the sample achieved and thus the transferability to appropriate populations. A third component of trustworthiness is found in dependability. Dependability ensures the results of the study would be consistent if repeated and were addressed through detailed descriptions as well as transparency in steps throughout the research process (Henderson & Rheault, 2004). These audit trails of researcher and participant steps and sources of data collected allowed other researchers to understand the decision making process of the primary MOVEMENT IN CLINICAL DECISION MAKING 32 researcher throughout. Collected data and audit trails were reviewed by the secondary researcher, and explicit research and analysis steps are reflected in a visual representation as seen in Figure 1 to further uphold principles of dependability. Lastly, confirmability reflects that bias was controlled within the study and results were objectively achieved by the researcher (Henderson & Rheault, 2004). This was addressed by taking measures to reveal researcher bias and utilize peer expert checking throughout data analysis. Researcher memos and field notes allowed reflection into decisions made, and a peer expert audit into coding schematics helped to identify unwarranted influence in analysis and results. Together these strategies served to increase the overall rigor of the study. Results A total of 21 participants met the inclusion criteria and were interviewed for this study. Demographic and professional practice characteristics can be found in Tables 1 and 2, illustrating the diversity in post-professional certification, wide geographic representation, years in practice, and current weekly practice hours of participants. The age of participants interviewed ranged from 26 years of age to 55 years of age. All interviews were conducted via Zoom with durations spanning 31 minutes to an hour and 20 minutes, with a mean interview duration of 46 minutes. Findings from the study are organized in two ways: (1) in explanation of the central theory developed, and (2) in description of the primary themes within this theory. Five primary themes emerged from the data that explored how expert clinical orthopedic physical therapists utilized movement to inform their CDM. Three of these themes, collection, reasoning, and application explicitly speak to steps within the patient management process. The other two themes, patient centricity, and professional lens are represented as broadly integrated themes across the spectrum of patient management. These relationships are conceptualized in Figure 2. MOVEMENT IN CLINICAL DECISION MAKING 33 Central Theory The central theory developed by the study has been titled Movement: An implicit medium describing the central tenet of the theory. The identified themes support the overarching theory that establishes movement as a medium, or channel through which something is accomplished. Merriam-Webster defines a medium as a means of effecting or conveying something. This is understood here as a communication channel, providing a way to engage a speaker and their audience. In the context of movement, the speaker exists as the human body, and the audience is represented as the external participant, or physical therapist. This channel carries through all steps of the patient management cycle with communication occurring in a natural and implied manner, not always outwardly expressed. The use of this implicit medium is identified by the themes of collection, reasoning, and application, as physical therapists fluidly gather and assimilate movement data in a cyclical nature. Categories within these themes reveal how physical therapists engage in this implicit medium and prioritize information within their reasoning process. A physical therapists use of this communication channel is influenced by ones intentions toward a patient-centric approach and variables individual to their education and experience in their professional lens. Overview of Themes Five major themes emerged that illustrate the use of movement throughout each participants patient management process: collection, reasoning, application, patient centricity, and professional lens. Table 3 provides descriptive content for each theme including subcategories within each theme and example participant quotes supporting the identified category. The theme of collection integrates two elements, 1) Participants use of movement within data collection stages, and 2) Strategies used to gain information from their patient from a MOVEMENT IN CLINICAL DECISION MAKING 34 movement context. The theme of reasoning speaks to, 1) Participants thinking process in finding meaning behind collected data, and 2) The connection of this data to understood patterns, diagnoses, or impairments. Following reasoning, the theme of application represents participants treatment or interventions that are often directed by decisions produced from the reasoning theme. This application results in the acquisition of further knowledge and greater understanding of their patient. Thus, the participant has an ability to refine their thinking process, often returning to the cyclical process of collection, reasoning, and application. The theme of patient centricity is broadly applied across this cycle, serving to illustrate participants intention toward collaboration with their patient in understanding their unique preferences, as well as the use of movement to provide assurance, build confidence and empower their patients in effective self-management strategies. The final theme, professional lens, reflects influencing factors of ones professional identity and perspectives on movement in orthopedic physical therapy that integrate within their treatment approach and overarching patient management. Collection Participants spoke about the use of movement to gather data from their patients in multiple ways. A prevailing use of observation was evident across all participants, and while multisensory contributions were revealed with involvement from auditory and kinesthetic senses, a dominance from visual observation was apparent. Many participants commented on the use of this skill from the earliest point of examination, in providing the ability to gain a greater understanding of their patients movement preferences and in collecting data that signals relevant tissue demands. Describing the integral use of observation, participant 10 shares: My observation actually starts in the waiting roomI'm kind of observing, always kind of watching, judging, watching, judging. As I bring them back, as I take my subjective, MOVEMENT IN CLINICAL DECISION MAKING 35 I'm looking at how they make themselves comfortable before I even offer them a position of comfortThats kind of the best look into what the system does. (Participant 10) It became evident participants regularly relied on visual observation to collect critical data points. They carried this forward into educational practice by speaking to the value of training the eye in clinic mentorship of students, residents, or fellows in training. I usually try to observe with them and ask them, what are you seeing? What would you think is the desired movement or the desired pattern for this situation? ..I think its a challenge sometimes because it makes them think. And I think as a student you dont have the background of what does a normal pattern look like.So maybe we need to look at more people squat and maybe something like, hey, lets look at more people. Do a pattern. Or maybe we, in between people we can go to the side and say, hey do some squats. What does that look like? What is, what is a good movement pattern? (Participant 9) Within the context of this skill, roughly a quarter of participants voiced a consistent approach with a top down or bottom-up sequence, yet no widespread agreement was found between participants on a standardized approach to visual observation. Despite this lack of standardization, the prevailing use of visual observation was clear. In addition to static posture, skills of visual observation were frequently applied within the context of a functional task movement analysis. Participants demonstrated wide variability in the chosen functional task with examples such as gait, squat, sit to stand, workplace patterns, and sport specific movements reported. The selection of this task was consistently driven by patient considerations, as participants weighed individual factors to determine the appropriate task. MOVEMENT IN CLINICAL DECISION MAKING 36 So part of that is gonna be in my subjective, getting an idea of, you know, what do you do for work? What are the movements that are bothering you at work? What do you do recreationally? What are the movements that are bothering you recreationally?...and then I try to break down those movements. So like if its knee pain, Im gonna break it down into like, all right, lets try squatting. Lets try maybe a stork stance, kneeling, stairs, put em onto a treadmill. (Participant 17) Comments reflected intention in choosing movement patterns that replicated their day to day activity, workplace demands, or symptom aggravation, to construct a movement analysis relevant to the patient for optimal data collection. So I guess for me, function means like for a lot my, like the patients that I work with, its like putting them into the positions that theyre doing often. So like for running, like having them doing like weigh bearing tests that are then more likely going to replicate what theyre dealing with as opposed to non-weightbearing strength testing. (Participant 11) While a functional task analysis was consistently applied by participants, a small sample utilized a more formal movement screen such as the Functional Movement Screen (FMS) or Selective Functional Movement Assessment (SFMA). Whether a task analysis or formal assessment was chosen, participants consistently applied these data collection tools as an early component of examination to allow the direction of further tests and measures. An early use of a movement screen gave them the ability to identify and pare down appropriate follow up tests and measures. These comments supported the category of movement as an indicator in providing a wide perspective that supported the value of movement evaluation in further direction of the patient examination. MOVEMENT IN CLINICAL DECISION MAKING 37 And so if I see a movement that I need to look at on a table I already have kind of that hypothesis of what structure might be impaired based on the movement. So then I go to the table to test it manually. So like if I see a limited shoulder flexion, for example, it might be lats. So I would go test lats, but it also might be a glenohumeral joint or an AC joint problem. So then I go to the table to test those three things. But its been the movement thats dictated that. (Participant 19) The theme of movement as an indicator encompassed direction to participants data collection as they used patients movement to guide their thinking process. The majority of participants spoke to subsequent testing in range of motion, manual muscle testing, joint mobility assessments, and occasional special tests following movement evaluation. It was evident the expert orthopedic physical therapists were selective in their use of tests and measures, with occasional remarks on the contrast to student populations in the amount of testing believed appropriate. Movement served as an indicator to narrow their focus on specific body regions, isolate areas of vulnerability, and establish tentative hypotheses. Supportive comments mention movement as a vehicle to identify what tissue or structure may be impaired. In the cyclical nature of this theme, participants frequently revisited this area for ongoing data collection. They used movement to gauge their patients awareness and understanding, determine readiness for progression, and overall effectiveness of treatment. I guess in terms of making an exercise harder, I think it has to do with the success of movement. (Participant 11) Participant 5 elaborated on gauging this success in movement as follows. Your also kind of looking at their ability to, like when you are trying to retrain them or perform a certain test what is their, how well can they respond to, you know, the corrections or if you try to change their movement pattern or perform a certain test, how MOVEMENT IN CLINICAL DECISION MAKING 38 well can they guide that movement?...how well can they understand what it is that youre asking them to do and how much control they have over it. (Participant 5) Statements made by participants when speaking about their use of movement in data collection spoke to principles of treatment efficiency. The use of movement analysis early in the examination process provided participants with the ability to gather a large amount of information quickly. Supportive statements spoke to efficiency at multiple points of the patient management process including efficiency in actual patient treatment time, overall treatment duration, and the amount of data gained in comparison to standard tests and measures. Participant 18 summarized this as follows. But like I think as you grow with experience, just looking at the big picture and like the functional stuff has definitely been much more like a focus of mine versus like, oh Im gonna do this little test and this little test and kinda put all of that together. Like obviously special tests have a, a place and are important, but I think you just realize like they only give you like a little bit of information. (Participant 18) Participant 9 further expanded on this as follows. I think it gives us a lot of information just on how people, you know, I mean were squatting up and down from stairs and doing that. So whether its a squat or a stairstep or something like that, just kinda looking at, they give us a lot of information more so I think than resisted motions of you know, how people are moving and what impairments they may have. (Participant 9) Participants preference towards the use of movement was often expressed through the ability to accelerate the speed of recovery and efficiently collect a larger amount of meaningful data. MOVEMENT IN CLINICAL DECISION MAKING 39 Reasoning The theme of reasoning focused on participants thinking processes and cognitive steps taken to arrive at a clinical decision. Resonating clearly within this theme was the category of problem identification in participants' use of movement to clearly identify the treatment area and underlying factors driving the impairment. Identifying the problem, considered the nature of symptoms, irritability levels, structures involved, and similar items that were contemplated while the patient was performing a movement. It was evident that watching their patient move served to narrow their hypothesis and contextualize the information to a central impairment or problem. If something doesnt look right, why does it not look right? And so youre constantly breaking that down. And then when youre constantly breaking it down then it reveals other things. And well, maybe its weakness in a certain musculature, maybe its you know, a restriction within the joint itself and then we can, we can break that down (Participant 2) Often this was an iterative process as participants modified or challenged certain movements to direct their thinking process and evaluate the congruency of potential hypothesis. She also had some femoral internal rotation. And so working through that I would change like one variable at a time to try to gauge which of those are more of a driving factor compared to anotherif you push with both hands so that you take away the rotation side bend component did that help? It helped somewhat with regards to low back pain alone and then I cued her to kind of keep her chin down or look toward the floor in order to reduce the extensor pattern throughout her spine. And that eliminated her low back component of things, but it didnt change her hip problem. Controlling her femoral MOVEMENT IN CLINICAL DECISION MAKING 40 medical rotation immediately reduced her lateral hip pain, but it was much harder for her to understand what I was asking her to do. (Participant 5) A few participants spoke to the value of movement in identifying what they do to control their symptoms, explicitly seeking information to understand how the patient corrects or adapts when symptoms present and how this might be contributing to the central problem. So I go into a functional task and then Im kind of looking at, you know, how they do it. You know, are they compensating?...and then Ill ask them can you make it not hurt? Because I wanna see what they do to get around the discomfort that theyre having or the pain that theyre having. A lot times they kind of know the key, right. But its more of just seeing what they do. So that gives me a lot of information on how they compensate or dont compensate for the discomfort that theyre having. (Participant 10) Within the theme of reasoning, all participants frequently spoke to concepts of pattern recognition, complimenting steps taken in problem identification. It was evident movement helped organize their knowledge into familiar categories, as some explicitly discussed pattern recognition while others implicitly supported this theme through descriptive comments. Participants regularly voiced expectations they held in anatomical and biomechanical principles when identifying normal movement, as well as bringing their experience and knowledge into identified patterns. And so kind of combining what I would expect normal movement to be. And as I take someone through you know, your basic functional patterns of movement, bending, flexing, squatting, raising arms overhead, you knowcluster. I guess movement presentations into a pattern and treating that pattern with corrective exercise. (Participant 14) MOVEMENT IN CLINICAL DECISION MAKING 41 Participant 8 described this pattern recognition as follows. I think more or less the diagnosis starts out as who, who are the team players? You know, is it joint related? Is this muscle related?...Does that hurt and offloading takes it away?...but based on those symptoms and you know, the practice of seeing other people who do it I can kind of tell, okay, well we can rule out nerve, we can rule out joint, we can rule out, you know something else soft tissueso it seems more spine related, you have more consistency with your pain pattern when we have loading and unloading. (Participant 8) Motor control issues, neurological patterns, or common lumbar diagnoses were frequent examples of familiar patterns participants spoke to in the context of their reasoning process. Additional comments were gained on establishing pattern recognition when mentoring students with the use of their patient population to explore exaggerated examples of movement patterns and contrasting presentations to identify patterns along both ends of the spectrum. Within these descriptions, participants frequently used wording such as normal movement and identifying patterns outside of this normal yet struggled to define what normal or quality movement entails. It's just you have those, those movements that, you know, in your brain movements that youre accustomed to treating and helping people do. And some of them are, are pretty glaring. You can tell if someones a quad dominant squat or not. (Participant 19) Employing pattern recognition entailed a keen sense of optimal movement in using this knowledge as a benchmark to observed patient patterns. Identification of appropriate patterns entailed a process of data alignment as objective and subjective information was repeatedly paralleled with movement data to corroborate the overall agreement of findings. Similar to pattern recognition, some participants explicitly used terms of data alignment while others MOVEMENT IN CLINICAL DECISION MAKING 42 provided implicit support through descriptive comments. Participants frequently spoke about the alignment of data gained from movement evaluation to other pieces of information collected throughout the examination. These included quantitative measurements, patient report of symptoms, or standardized tests and measures. It was evident consistent attempts were made to confirm their hypothesis by this data alignment of objective measures while also identifying any possible gaps in knowledge. ..I think it better encompassed looking at how the patient moves and then aligning that with the objective data that youre seeing and hopefully those two things should match up. And if they dont, then kind of coming up with a different hypothesis. So its a little bit of a blend of kinda using the data and the numbers andalso kinda making sure youre looking at the patient and seeing kind of that stuff is matching up or if theres something else that you might be missing. (Participant 6) Participants reflective practices emerged when elaborating on their reasoning describing a process of continual re-assessment in both their treatment efficacy and understanding of the patient. Cognitive processes of reflection in action and on action allowed participants to make sense of collected data, evaluate their treatment approach, and identify any modifications needed. Participants frequently spoke to reflective practices when re-evaluating movement patterns following a treatment technique in an effort to understand the effectiveness of the approach and to identify lingering deficits or gaps in understanding. ..everything you do should have a purpose, like youre targeting something with it. And then you should be able to remeasure that something at some point, whether its that session or after the intended effects should normally take place with..and then you should MOVEMENT IN CLINICAL DECISION MAKING 43 be able to remeasure it and show progress and determine if that was the needed thing to do. I guess not necessarily the right thing, but the necessary thing to do. (Participant 7) Beyond their own meta-cognition, participants encouraged their students and patients to engage in a process of reflection in an attempt to foster student clinical reasoning and facilitate greater patient body awareness. Application The theme of application focused on participants treatment and interventions directed toward their patients as the application of their clinical decisions. Treatment and patient education were typically interconnected with evident preferences towards interventions that facilitated patient awareness of their body, movement patterns, and a mindful connection for greater patient understanding. Participants prioritized the ability of their patients to feel the desired activity, whether that be a more effective movement pattern or sensations of negative tissue stress, to accomplish therapeutic goals. Other examples of embodiment included patients feeling weakness from side to side, using kinesthetic or visual cues to provide greater patient self-awareness of movement, and helping patients understand their position in space. Its like, okay well lets compare like your left firing to your right firingAnd then having them focus on, okay, now we can identify. And typically they can feel like wow, thats a lot harder on my left side than my right side. All right, lets practice that. And as youre practicing that, lets start incorporating that into a strengthening exercise, like a bridge. I want you to ladder up going through feeling that glut engage and then lift off into that, maintain that control, and then come back down and ladder back down. (Participant 17) MOVEMENT IN CLINICAL DECISION MAKING 44 I feel like sometimes people struggle with knowing where they are in space, you know, what different body parts are doing through an activity. So sometimes it's drawing attention to that, those things and letting them kind of work through that and figure it out, you know with the cuing weve talked aboutis just trying to put them in situations where they have to think about it and draw attention to it. (Participant 9) Participants frequently spoke to the importance of patient education within their treatment applications in efforts to achieve their desired goals and gain a better understanding of how to mitigate their individual deficits going forward. And so when youre able to have them feel and see what you are looking at, then that gives them a much better understanding of whats going on from their own personal movement perspective and then when they do it again, theyre much more cognizant of how theyre doing it and what theyre doing versus just going from point A to point B. (Participant 8) The use of feedback took many forms in the application theme with participants using tactile, verbal, auditory, and kinesthetic cues to facilitate optimal movement patterns. Participants chose to have their patients exaggerate the desired movement pattern, perform movements with external cues from bands and equipment, or provide demonstration and modeling to translate optimal performance and provide feedback. Some participants voiced a preference to avoid excessive tactile cues and chose to rely on visual means through mirrors or video analysis, while others strongly held to a hands-on preference with the ability to feel the joint or tissue and guide movement with their patient. A common tool for feedback was a mirror, and a small number of participants spoke to the value of using their patients phone to record a video for patient feedback. MOVEMENT IN CLINICAL DECISION MAKING 45 Other application approaches spoke to breaking movement down through segmented practice or similarly using trial practice within the clinic to gauge effective performance, determine readiness for progression, and provide an opportunity for patient feedback. Performing partial movements or practicing individualized patterns served as many participants applied approaches to achieve set goals. ..and so I try to get a lot of feedback from the patients through, well how do you do this at work? And then try to create something in there as well. And if they cant do the full activity, which a lot of times they cant right away, well lets break it down to pieces of the activity and then do that part of it. (Participant 1) The application theme further recognized the connection between movement and pain and spoke to early treatment approaches in recognition of this relationship. At times this was in the context of patient irritability and the need to address early limiting factors, while others spoke to the value of movement in reducing pain. Its very powerful to be able to take a functional movement that theyre doing and be able to reduce their symptoms and immediately show them a way that they can better have control over their symptoms. So if I can teach them how to actively self-modulate their own pain, I will always start that route first. (Participant 5) Participants recognized movement as an integral pain mediator and often prioritized this in the timing of their treatment interventions to address fear avoidance patterns of movement early within the patient management process. the biggest thing with practice and movement now that I find myself doing is just trying to reduce fear of movement with pain.So I think thats the biggest thing MOVEMENT IN CLINICAL DECISION MAKING 46 nowadays is knowing about tissue resilience and the fact that most often that you should be able to move the way you think you should, even if its causing pain. (Participant 7) Patient Centricity The theme of patient centricity is integrated across the spectrum of patient management as participants described foundational principles of their patient care perspective. A central focus on adapting their approach to the patient in front of them and ensuring the patient was a key partner throughout the management process emerged. Efforts to understand their patient's experience included questioning what is important to their patient, how they perceived their injury, and for others identifying their readiness for change and psychosocial factors needing consideration. A clear focus on connecting their treatment to patient needs and ensuring relevance to their world was evident as Participant 14 describes. I mean clearly Im trying to involve them with, with everything. So I mean, our typical exam is that patient response to movementI try to think the most important thing is drawing relevance to what Im finding to what they need. (Participant 14) Participant 2 described the importance of this relationship and understanding their patients perspectives as follows. I think we gotta give people a little bit more credit for knowing their bodies than what we do. Even us being specialists, we really dont know what theyre feeling. Everybody perceives pain in a different way. And so if we can get a better understanding of their perception of their injury and kind of work with that, that goes a long way because the mind is very powerful. (Participant 2) MOVEMENT IN CLINICAL DECISION MAKING 47 Through efforts to relate to their patient, it was evident a strong rapport was prioritized by many participants, with rich descriptions into how they build this relationship and the value provided in increasing patient buy-in. I do try to pick up on what the most honest description of whats going on, you know to allow them to not just give me the brass tacks of what theyre feeling, but a lot of the, like, let them describe their emotional connection to whats going on, the physical part of it, the environmental part of it, you know, the spiritual or psychological part of itI dont want you to pretend this is some sort of like primary care meeting where youre trying to give me those top 10 questions you just filled out in the waiting room, talk to me as a person. (Participant 8) Categories within patient centricity focused on cognitive aspects of care in participants use of movement to build confidence, provide assurance, and empower their patients for greater self-management. Participants spoke to empowerment of their patients through examples such as allowing them to independently manage pain and symptoms with movement and using movement as a means to build confidence to return to preferred movement patterns or activities. Empowering their patients to understand healthy or adaptive ways to continue activities they may have believed harmful was a focus of many participants. I find thats incredibly important to provide patients with any self-pain modulatory techniques that they have and giving them empowerment over being able to control their own pain and symptoms. And as something that if you can change their movement pattern, theres a higher compliance rate long-term anyway compared to doing an exercise program alone. So its more meaningful to the patient to take away their symptoms right then and there. (Participant 5) MOVEMENT IN CLINICAL DECISION MAKING 48 Keeping a patient centric perspective included recognition of patients activities for enjoyment in life, personal priorities, and even coping with a clear attempt to find common ground for continued performance. I kind of take the approach of, all right, prove to me why you shouldnt do it. Lets find out if we can do it. And then, if not whats the closest thing to it we can do that youll be happy doing. (Participant 13) Comments supporting the theme of patient centricity spanned the course of treatment, with some participants describing ways they communicate with patients outside of treatment, advocate for their needs with other healthcare providers, and serve as a guide to monitor new or progressive activities. The patient was the central focus within these comments, representing a priority in the patient therapist relationship. If you can think of the patient sitting down and the therapist pointing their finger over top of em, more of a, Ive got my arm around you. Like, I understand what youre going through. I understand you gotta get this house project done. I know its hard, but you know, if you want that tissue to calm down or that inflammation to calm down you know, we, lets lets figure out a different way to do this. (Participant 21) Professional Lens The final theme represents participants personal perspectives and experiences that may inform their professional lens of CDM. This encompasses concepts of their personal and professional identity, as well viewpoints towards the human body and movement that may influence their clinical approach. The APTA identifies physical therapists as movement system practitioners (American Physical Therapy Association, 2015). When asked to consider if they would identify themselves as movement system experts all participants were reflective in their MOVEMENT IN CLINICAL DECISION MAKING 49 identity of this label and described ways that movement was central to their individual practice of physical therapy and of the profession. I do it on a daily basis now. Its just ingrained in, you know who I am as a professional, as a person, you know, Im always kind of observing movement. (Participant 10) Participant 5 compared this identity to other health professions as follows. I don't think that there's any other profession that understands movement science the way that a physical therapist could and be able to integrate it fully into their program from a rehab standpoint we've got a lot of different healthcare models like chiropractic care acupuncture personal, they're all creeping into certain avenues. And the one thing that really sets us apart is the movement analysis component and the fact that we are multifaceted, that we are trained across these different genres, and we can pull from each of them individually based on the individual as opposed to, for lack of a better term, trying to make a single patient fit. (Participant 5) While the majority of participants resonated with an identity as movement system experts from a professional lens and were readily able to describe how physical therapists uphold this identity, some participants were hesitant to accept this label from a personal perspective. Supporting statements continued to describe their use and prioritization of movement within practice, yet a struggle with the verbiage of expert due to a recognition of lifelong learning and pursuit of knowledge. And so I, I look at it as though our practice dictates that we're lifelong learners. And so even though we're movement experts, that there's still lifelong learning happening and there's still things that, and maybe I didn't see in my approach that when I'm mentoring, I, I get my residents to see or my students will say something I didn't see. (Participant 19) MOVEMENT IN CLINICAL DECISION MAKING 50 All participants recognized movement as a central concept to the profession and while discomfort in the status of expert may have been present, they readily acknowledged the value of the profession in using movement for patient benefit. As far as physical therapists not very many people know the anatomy and physiology that we dowe dont pat ourselves on the back, but then again, we dont. And so for me to come out and say, yes, Im a movement specialist, its a little hard for me, but in my mind, in my thought process, I am the movement specialist. I am the best person for this patient. This patient is coming in for me, and Im the best one to treat them. Im not gonna refer them out to somebody else, to you know to some other profession that I know that I can do, I can do the job better. (Participant 2) Beyond the stated identity as movement system experts, many participants acknowledged the influence of their education and post professional training in implementation of their treatment sequence or preference towards certain examination measures. A lengthier subjective history, monitoring concordant signs or asterisks, and consistently using measure, treat, remeasure (Participant 7), are examples of items participants explicitly linked to their post professional training that influence their patient management. The variation in post professional training as seen in Table 1 was broad, and no consistent approach was found that dictated participants use of movement or approach towards movement analysis. Participants professional lens also included influence from their perspectives on movement, often speaking to factors such as the kinetic chain, the importance of looking at the whole body, and acknowledgment that everything is working together. Specific comments spoke to factors of regional interdependence and anatomical connections, yet others spoke to a broad perspective in acknowledgement of the human body as a whole. MOVEMENT IN CLINICAL DECISION MAKING 51 And I'm like, well, that muscle is a part of a giant system and everything has to work together. And then what seems like initially a simple kind of problem ends up actually being a much larger kind of scenario that we work through, because nothing in our body works in isolation. And so drew me to orthopedics from that perspective versus just like, you have one torn muscle, one torn tissue, one broken bun, nothing works in isolation. So typically whatever someone comes in with, we look at the big picture of how everything works together and then work from there. (Participant 8) Many participants spoke to the importance of this whole-body perspective within their mentorship of students when facilitating their CDM in practice. I just, you know, that's one thing I try to make sure students are educated on as well is don't just look at, just don't focus on just what the injury, what the diagnosis is, but what's happening around the diagnosis if you will. So that way it's getting a full body approach versus just a focused approach. (Participant 1) Various comments reflected participants personal viewpoints on movement and other treatment priorities that complement their professional lens, with movement consistently integrated as a pillar within their practice. One particular pattern like movement is notis a part that's gonna be integrated into any of those but then it's like somebody might need more or less manual, somebody might need more or less pain science education. But there's always gonna be a movement component through any of those facets. (Participant 5) Discussion The purpose of this grounded theory study was to examine how movement informs the CDM of expert orthopedic physical therapists in clinical practice. Despite the foundational MOVEMENT IN CLINICAL DECISION MAKING 52 presence of movement within physical therapy practice, there is little understanding into the process of how movement integrates within a physical therapists CDM (Huhn et al., 2018). Greater understanding of this process may provide further guidance of educational curricula and clinical pathways to drive best practice. The researcher identified five themes illustrating how participants perceived their use and application of movement in the context of their individual experience. These five themes included collection, reasoning, application, patient centricity, and professional lens. The relationship between these themes is represented in Figure 2 as participants described their use of movement across the continuum of patient management, fluidly moving between stages to facilitate their CDM. By evaluating these themes and categories within, a better understanding is gained into how movement is integrated within a physical therapists CDM, as well as the role of influencing factors. The remainder of this discussion serves to examine this process by first reviewing the central theory that emerged, followed by a discussion of each contributing theme. The central theory of Movement: An Implicit Medium represents the continual presence of a communication channel as physical therapists described their use of movement not in single data points yet cyclical in providing an accessible channel to efficiently collect, reason, and apply movement data repetitively. Jensen et al. (2007) previously described physical therapists use of movement as almost subconscious, with results speaking to this implied manner as participants relied on think aloud techniques to reveal tacit practices surrounding movement. The implicit medium of movement upholds the multidimensional and integrative nature of movement reported to be central to expert clinical practice (Huhn et al., 2018; Jensen et al., 2007). Collection MOVEMENT IN CLINICAL DECISION MAKING 53 The theme of collection directly addressed the research purpose of understanding what components of movement are identified by expert clinical orthopedic physical therapists. These components represented data points derived from observational targets of movement as well as patient factors of individualized movement patterns. Upholding a core concept in physical therapy, participants relied heavily on their use of observation to collect information from their patients (Skjaerven et al., 2008). Participants spoke to this value in a consistent use of movement observation to gather critical data points across time. Literature is sparse on educational pathways and practice of skilled observation in physical therapy, yet physical therapists are recognized for their integral use of this skill (Dekkers et al., 2022). The priority of this skill was evident through participants early use of observation, prioritization in student mentorship, and continual use throughout patient management. Dekkers et al. (2022) stated that observation allows a physical therapist to give meaning to visual, auditory, and sensory information, aligning with participants use of observation to understand their patient better and direct individualized treatment. Of interest, within this study, only a small number of participants standardized their approach to visual observation speaking to specific strategies in performance. This variability carried through in the observational targets identified by expert physical therapists with wide variation in observation targets such as quality, alignment, efficiency, motor control, coordination, tone, and speed. This finding echoes results of national studies of excellence revealing wide variability in approaches toward movement evaluation as well as recommendations across literature to address this variation for advancement of research and practice (Jensen et al., 2017; Sebelski et al., 2019). The 4-element Movement Model serves as a recent model that provides a systematic approach to movement evaluation with explicit observation targets in control, amount, speed, symmetry, and symptoms (McClure MOVEMENT IN CLINICAL DECISION MAKING 54 et al., 2021). These observation targets may be used to guide qualitative descriptions of a functional movement task. Limited use of this model is documented in literature (Zarzycki et al., 2022) yet participants use of observation suggests the breadth of data they collect may not be fully represented by observation targets represented in this recent model. This underscores the challenge of standardizing movement evaluation and developing frameworks that capture the depth of information collected through observation. The pervasive use of observation described by participants reflects the signature pedagogy in the human body as teacher as they continually collect information individual to their patient through recurring observation (Jensen et al., 2017). The human body as teacher demands close attunement to the human body for knowledge acquisition, consequently fostering the development of a keen sensitivity to movement (Jensen et al., 2017). Participants in this study embodied this pedagogy by frequently observing for individualized data collection while also speaking to reported gaps in the standardization of language and key elements (Sebelski et al., 2019). Guiding principles have been developed to educate towards skilled observation in medical education, but similar standards are not evident within physical therapy (Boudreau et al., 2008). This suggests that continued exploration of expert practice in observation may not only work towards standardization of these elements but also further support the signature pedagogy of the profession. A depth of literature reveals a wide range of factors that may alter an individuals movement performance (Dingenen et al., 2018). Recognition of this variability is evident in orthopedic research as multiple studies support individualized treatment in consideration of patient specific variables and functional demands (Bittencourt et al., 2016; Van Dillen et al., 2021). Participants frequently spoke to the importance of individualized patient factors to evaluate their patients movement patterns and everyday demands, assigning significance to MOVEMENT IN CLINICAL DECISION MAKING 55 examining their movement within the context of their lived world. This is consistent with studies describing patient-centered care within expert practice and efforts to tailor treatment to the individual by targeting the patients functional demands (Edwards et al., 2004; Jensen et al., 2007; Resnik & Hart, 2003). Frequent use of task-based movement analysis such as a squat, or sit to stand were used, yet participants readily described adaptability in this approach by building functional analyses that were reflective of their patient's movement demands. Perhaps unique to this study, participants voiced a reluctance to avoid symptom limiting patterns yet rather explore movement within the parameters of patient comfort and their desire to reach individualized longterm goals. For example, when a patient is told they shouldnt run, using physical therapy to explore the tolerance of this activity and similar movements to establish a baseline instead of operating from preconceived movement limitations. Multiple frameworks have been presented to educate physical therapists in the performance of task-based movement analyses and guide data collection. These frameworks recommend early use of movement analysis to identify impairments warranting further testing and to generate possible hypotheses (McClure et al., 2021; Quinn et al., 2021). Aligning with these recommendations, participants in this study used task-based movement analyses in initial steps of their examination, supporting their ability to direct further tests and measures. Of interest, participants expanded on their use of movement evaluation throughout patient management, frequently returning to these measures to gauge symptom response or readiness for progression. The subcategory Movement as Indicator supported movement as a guide not only for tests and measures but as a gatekeeper for multiple areas of treatment. Notably, the use of movement throughout the study was often supported by a desire to collect data in an efficient manner. Participants used their patients movement to collect multiple MOVEMENT IN CLINICAL DECISION MAKING 56 pieces of data at once often relying on their anatomical and biomechanical knowledge to make the bridge from observation to inference in the moment. Specific clinical outcomes of patients described in this study are unknown, yet prioritization of movement to increase the efficiency of treatment was apparent. Rodeghero et al. (2015) demonstrated fellowship status may contribute to greater clinical outcomes including treatment efficiency, and Hart and Dobrzykowski (2000) demonstrated board certified orthopaedic physical therapists were more efficient in their treatment duration and length than their non-specialized peers. Limited research is present on the clinical outcomes and treatment efficiency of expert physical therapists yet participants experience aligns with preferences towards the evaluation of movement to optimize these variables in practice. Expertise across professions has been characterized by an ability to solve problems faster and perform skills faster than their novice counterparts (Ericsson, 2009), presenting the possibility that physical therapists use of movement may be one avenue in which this is accomplished. Reasoning Within the theme of reasoning, participants exemplified practices of reflection and pattern recognition consistent with literature surrounding CDM (Ziebart & MacDermid, 2019). Through these steps specific research questions were answered regarding how movement components are prioritized in their reasoning process. In early reasoning stages, participants focused on their patients movement for objective problem identification, attempting to isolate the underlying driver of patient symptoms. They sought to identify problems by watching their patient move and visualize areas of limitation through movement of the human body. These actions were consistent with literature on deductive reasoning and the development of an initial hypothesis (Edwards et al., 2004; Huhn et MOVEMENT IN CLINICAL DECISION MAKING 57 al., 2018; Rothstein et al., 2003). While deductive reasoning is more commonly utilized by novice professionals, (Gilliland & Wainwright, 2017) this problem identification directly integrated into participants expectations surrounding their movement performance and initial steps of pattern recognition. Throughout participant interviews this problem identification brought a focus on normalized or quality movement with a keen sense of observation to identify when something falls outside of their expectations. Of interest, participants revealed a commanding knowledge base in preferred movement patterns yet demonstrated difficulty in verbally defining quality movement. This echoes statements from Skjaerven et al. (2008) as they investigated physiotherapists perceptions of movement quality noting the inherent difficulty to explicitly describe the phenomenon despite an internal sense of understanding. Movement presents with a degree of complexity considering influences from biomechanical, physiological, psycho-socio-cultural, and existential arenas (Skjaerven et al., 2008). Furthermore, multifactorial considerations of movement include interactions of the individual, task, and environment (Shumway-Cook & Woollacott, 2007). These variables may support the complicated process of defining quality movement. Participants frequently recognized the wide variability in quality movement due to a diversity of patient factors and instead focused on their experience in building an understanding of quality movement. Experience directed their definition of quality movement and similarly served to develop their pattern recognition of various diagnoses. A robust use of pattern recognition was present reflecting the depth of literature on expert use of higher-level reasoning strategies (Higgs et al., 2019; Kumar et al., 2021; Schmidt et al., 1990). It was evident participants used pattern recognition to organize their thinking process and consider appropriate intervention strategies for their patient. Participants acknowledged advancement of this skill with greater experience and purposefully brought students alongside MOVEMENT IN CLINICAL DECISION MAKING 58 them to foster their own pattern recognition through observation of various movement patterns and diagnoses. Multiple frameworks exist to guide students CDM processes (Baker et al., 2017; Kirk-Sanchez et al., 2022; Macauley et al., 2017; McClure et al., 2021), but notably none of these were used by participants in the study. A growing body of literature supports pattern recognition within orthopedic physical therapy and digital platforms have recently implemented orthopedic pattern recognition tools for student and clinician education (Bittencourt et al., 2016; Ludewig et al., 2017; Ludewig et al., 2022; Wong, 2022). Many of these tools are presented as researchers encourage a shift in focus from pathoanatomic labels to wider diagnostic consideration through movement system evaluation. Reasoning for this shift has included concerns in diagnostic accuracy (Barreto et al., 2019), patient perceptions of pathoanatomic labels (Miller-Spoto & Gombatto, 2014), limitations in sensitivity and specificity of special tests (Hegedus et al., 2012; Smith et al., 2015), and disconnect between symptoms and pathology (Barreto et al., 2019). Bittencourt et al. (2016) presented a complex systems approach to drive pattern recognition of sports injury, and Ludewig et al. (2022) have brought forth a movement system diagnostic classification framework surrounding shoulder pathology. Explicit ways to foster pattern recognition require further research, yet participants in this study demonstrated consistent use of pattern recognition to prioritize their reasoning and identify effective treatment strategies. The depth of participants pattern recognition was further represented by their repeated alignment of movement data with other collected data points. Participants continually spoke to a process of data alignment to reason through presented information, understand data relationships, and clarify appropriate treatment pathways. Within medical literature a primary cause of misdiagnosis has been reported to result from misinterpretation of critical data and poor MOVEMENT IN CLINICAL DECISION MAKING 59 integration amidst the entirety of the problem (Groves et al., 2003). Participants processes in data alignment may suggest expert practice in the purposeful practice of this skill as they regularly integrate movement data with other findings. Of interest, participants did not voice singular evaluation points where this alignment occurred but rather spoke to a cyclical process of collecting and reasoning throughout the patient management process. They engaged in the implicit medium of movement repetitively with a continual use of reassessment to identify gaps in their understanding and gauge treatment effectiveness. This upholds current literature as recent conceptualizations of clinical reasoning speak to the iterative process and nonlinear characteristic of this decision making process (Christensen et al., 2017; Huhn et al., 2018). Expert physical therapists utilize reflective practices at greater frequency, distinguishing themselves from their novice peers in their ability to complete reflection in action and continually self-assess their performance (Wainwright et al., 2010). Participants in this study spoke to these practices as they described their use of reflective practice within their reassessments and broadly across treatments. A clear use of reflection was evident in driving their decisions and subsequently determining their effectiveness. Master Adaptive Learners have been shown to engage in a cycle of planning, learning, assessing, and adjusting to readily adapt to a plethora of clinical scenarios (Cutrer et al., 2017). This cycle has been prioritized in developing practitioners able to thrive in increasingly complex healthcare environments (Abraham et al., 2022). Descriptive comments supported many of these stages as participants used reflection to assess and adjust their approach to the patient. Participants were not algorithmic in their management of patients but rather intentional in using reflection to tailor an individualized plan. This reflection created refinement in their treatment approach as they easily moved from the theme of reasoning to application. MOVEMENT IN CLINICAL DECISION MAKING 60 Application The application theme illustrated participants direction in treatment with evident prioritization on fostering their patient's ability to understand and adapt their movement. Education was synergistically applied within their practice as they used various forms of feedback and embodiment principles to drive optimal outcomes. Embodiment of movement was recognized as participants made decisions in their treatment applications that prioritized giving their patients a sense of body and movement awareness. A great diversity in treatment approach was expressed by describing different cuing and feedback modalities, with evident preference towards strategies that gave their patients an ability to feel and understand movement. Consistent with previous studies, participants recognized their own body awareness as a helpful piece in teaching their patients, making clear connections to their training and experience to develop this skill set (Skjaerven et al., 2008; Skjaerven et al., 2010). Interestingly, Skjaerven (2008; 2010) has supported that a physical therapists movement awareness is both a precondition for practice, by grounding ones ability to observe and understand movement, and also a means in which movement quality may be promoted. This represents the concept of a physical therapists embodied presence. While the participants made a direct link to their training and experience to foster their patients movement awareness this was through think aloud methods with multiple remarks toward the first time they entertained these thoughts. Participants described practices consistent with literature but not explicitly targeted in their personal or professional development. This leads to questions on the participants professional formation in their understanding of movement in practice and what experiences directed the development of their embodied presence. Accreditation criteria for entry level programs does not reflect a physical therapists use of movement in practice and pathways MOVEMENT IN CLINICAL DECISION MAKING 61 towards understanding how movement is embodied in practice are ill defined (Commission on Accreditation in Physical Therapy Education, 2020; Covington & Barcinas, 2017). There is sparse literature surrounding embodiment in orthopedic physical therapy with participants in this study providing a preliminary understanding into how they integrate movement in practice. These results support the research purpose of understanding how embodiment plays a role in the decision making process of orthopedic physical therapists, illustrating a prioritization of building experiences and treatment approaches that provide a sensory awareness of movement. The diversity in feedback methods described within the theme of application speaks to participants adaptability in creating a patient centered approach. Consistent with research many visual methods were reported to assist patients in visualizing effective movement patterns (Hensley et al., 2020), as well as additional strategies using kinesthetic and auditory senses. Literature is sparse on use of the senses for data collection, yet programs of excellence have been shown to uphold the signature pedagogy of human body as teacher through emphasis on the senses to hear, feel through touch, and see how the body is moving (Jensen et al., 2017). Participants supported this level of expertise speaking to the value of multiple senses in collection and application of movement concepts, frequently adapting their feedback methods between various senses. A patient centered approach is evident through the multiple methods described in breaking movement down, trial practice, and continued reflection toward embodied practice as participants individualized their patient treatment. This allowed participants to integrate patient specific movements and functional activities within treatment. Multiple frameworks and classification-based systems have been presented to direct orthopedic physical therapy treatment across a variety of diagnoses (Alrwaily et al., 2016; Enseki et al., 2023; Lam et al., 2018), yet participants in this study did not voice reliance on these tools but rather MOVEMENT IN CLINICAL DECISION MAKING 62 adaptability in their treatment decisions directed by their sense of embodiment and tailored feedback approach. The final category in the theme of application represents participants use of movement for pain management. This does not reflect a specific aim of this study but rather emergent data on participants application of movement to manage their patients pain and symptoms. The relationship between pain and movement is not well researched yet a growing body of literature in physical therapy elucidates pain mechanisms and the variation in clinical presentation (Butera et al., 2016; Chimenti et al., 2018; Kumar & Saha, 2011). Participants in this study recognized movement as a pain mediator and expressed the importance of addressing pain responses early in their patient management. When describing their decisions toward patient treatment, a priority was placed on recognizing pain limiting factors and modifying their movement to give them control over their pain and symptoms. This directly speaks to patient understandings of movement through empowerment and the ability to gain self confidence and trust (WikstrmGrotell & Eriksson, 2012). While this avenue towards patient empowerment was seen within the theme of application when addressing pain management, significant patient centered perspectives were also seen from the theme of patient centricity. Patient Centricity Outside of the patient management cycle, significant influences emerged from participants intention toward a patient centric approach. This intentionality carried through their practice as they frequently spoke to principles of collaboration, shared decision making, and assurance to provide individualized treatment. The aptitude of expert therapists to forge partnerships with their patients is well represented in literature as multiple studies have documented their ability to embrace clinical practice from a collaborative lens, building MOVEMENT IN CLINICAL DECISION MAKING 63 treatment approaches that are selective and specific to the patient (Jensen et al., 2007; Resnik & Hart, 2003). This is consistent with perspectives provided by participants as they prioritized a practice model that was relevant and shared with their patient. Within CDM literature clinical reasoning strategies have been defined that represent the knowledge processes used by physical therapists (Edwards et al., 2004). A few of these specific strategies include interaction representing a social aspect of communication such as sharing stories, procedure representing the therapeutic use of movement and communication through movement, and collaboration representing the meeting of perspectives and transfer of power to the patient (Edwards et al., 2004). May et al. (2008) noted that expert physical therapists in shoulder or upper limb pathologies used collaborative strategies within their reasoning processes, and Gilliland et al. (2017) demonstrate the trajectory towards these reasoning strategies identifying the struggle of students to integrate factors surrounding the patients life context. These higher-level reasoning processes are supported by the theme of patient centricity as the expert orthopedic physical therapists made intentional steps in crafting a patient centric approach with strong threads of collaborative reasoning and attempts to understand personal factors. The readiness for participants to understand and integrate personal factors is consistent with a biopsychosocial approach whereby biological, psychological, and sociological factors are considered in the context of an implemented healthcare model (Leonardi et al., 2022). The widely recognized International Classification of Functioning model includes categories of personal and environmental factors, and more recently developed frameworks such as the 4element movement model, and movement scripts integrate these categories (Kirk-Sanchez et al., 2022; Leonardi et al., 2022; McClure et al., 2021). These tools provide a framework for physical therapists to guide their patient management and decision making process, with participants in MOVEMENT IN CLINICAL DECISION MAKING 64 this study embodying this application in practice. It was evident participants carried a skillful consideration of personal factors and placed value on partnership with their patient. Specific to orthopedic physical therapy these results shed new light on the prioritization of patient centricity in practice. Frameworks mentioned previously provide physical therapists prompts to drive patient centricity yet little research is present on collaborative reasoning in orthopedic physical therapy and complimentary processes such as shared decision making (Hoffmann et al., 2022). Researchers have made recommendations for integration of these concepts in research and practice (Hoffmann et al., 2022; Miciak & Rossettini, 2022) with results of this study offering a preliminary understanding of expert clinical orthopedic physical therapists actions towards patient centricity. The final category of assurance within the theme of patient centricity represented participants use of movement as a means to build confidence and empower their patients. Concepts of empowerment can be seen in literature surrounding CDM and expert practice (Jensen et al., 2007; Resnik & Hart, 2003) with participants exemplifying this value in practice as they provided rich descriptions into how movement was used to give control to their patients, provide means of coping, and develop healthy ways to self-manage. These factors appear to represent a holistic use of movement as participants made decisions in their use of movement to provide meaningful experiences for their patients. The concept of movement in physical therapy has been described as emotional, articulated through concepts of well-being and self-confidence, and as a personal value, articulated through concepts of independence (Wikstrm-Grotell & Eriksson, 2012). Literature speaking to a holistic perspective of movement in orthopedic physical therapy is sparse with little understanding into how physical therapists integrate holistic perspectives in practice (Covington & Barcinas, 2017). The results of this study provide a basis MOVEMENT IN CLINICAL DECISION MAKING 65 for understanding how expert orthopedic physical therapists consider a wider perspective of movement within their reasoning and take actionable decisions toward fulfillment in practice. These described concepts within the theme of patient centricity are viewed as influencing factors serving to illustrate variables that impact how they manage their patients. In similar fashion, the other theme resting outside of the patient management cycle yet directly influencing their practice is represented by the theme of professional lens. Professional Lens The professional lens theme represented participants perspectives and prior experiences that influence their clinical practice. In the context of this study, participants professional lens is believed to influence how often and to what degree they engage with the implicit medium of movement. The APTA (2015) calls for a professional identity grounded in expertise as a movement system practitioner, and participants largely embraced this identity. Participants descriptions toward profession identity represented movement as a central concept and beliefs in the proficiency of physical therapists over other healthcare professional to act as movement system experts. DallAlba (2009) has described learning to become a professional as a process of embracing knowledge and skills through a theory of knowing, and applying or acting this out through a theory of being. Participants acknowledged their knowledge base in the human body as well as their experience and patient relationships in crafting their professional identity. These findings directly speak to research aims in understanding how orthopedic physical therapists prior experience driven from both knowing and being influence their CDM. As broad curricular mapping for the movement system has been presented and further development progresses this presents opportunities in professional development pathways for physical therapists as movement system practitioners (Hoogenboom & Sulavik, 2017). Development of a greater MOVEMENT IN CLINICAL DECISION MAKING 66 knowledge base in movement principles complimented by application in practice may allow a professional lens supported by both a way of being and a way of knowing. Other categories within the theme of professional lens speak to broad perceptions of movement participants held. Carrying a whole-body perspective and frequent acknowledgement of the kinetic chain were concepts that directed their engagement in the implicit medium of movement. This suggests the more a physical therapist values these factors they would engage in the implicit medium of movement more frequently. Participants failed to delineate a pathokinesiologic vs kinesiopathologic treatment approach but rather recognized the interconnectedness of the human body within their professional lens. In orthopedic physical therapy conflicting treatment approaches exist from both pathokinesiologic and kinesiopathologic approaches with no evident consensus on best practice standards (Barreto et al., 2019; Cools & Michener, 2017; Friedman et al., 2021; Ludewig et al., 2022; Zadro et al., 2021). The results of this study do not allow interpretation on the preference towards one approach yet affinity towards individualized approaches can be considered due to participants explicit prioritization of movement. Limitations Limitations of this study include the use of snowball sampling and the possibility of a selection bias. With recruitment driven from the primary researchers network and subsequent participants network it is possible maximum diversity may not have been achieved with early participants carrying greater influence on the sample. Furthermore, it bears mentioning that two participants failed to complete the Qualtrics instrument prior to the interview, limiting the direct application of case-based think aloud questions within the interview. Participants were MOVEMENT IN CLINICAL DECISION MAKING 67 encouraged to think about a recent clinical patient in the moment, but lack of prior reflection toward a targeted case may have affected depth of insight for these two participants. Future Directions The conceptual framework developed through this study represents initial conceptualizations into how movement integrates within orthopedic physical therapists CDM. Movement is recognized as a central concept to successful practice but how this data source is accessed and integrated within ones reasoning has been largely unknown. The implicit medium of movement allows educators and physical therapists to better understand the communication channel of movement and how engagement in this medium throughout the patient management cycle may further direct successful clinical decisions. Considering the grounded theory method of this study, the implicit medium of movement presents as an original theory requiring further research to test its validity and refine developed themes. One area of study exists in the skill of observation. The value of skilled observation is widely accepted in physical therapy yet surprisingly sparse literature exists on best practice and guiding principles. Additional opportunities exist in understanding visual perceptions of quality movement. With a pervasive use of observation described by participants and continued calls for standardization of movement terminology, further research in this skill may help elucidate key variables of practice. Competing voices towards the use of movement in orthopedic practice may speak to limitations due to an indirect assessment through observation. Expanding our understanding of skilled observation may allow greater standardization of terminology and objectivity in fostering successful clinical performance. Further areas of study include pattern recognition within orthopedic physical therapy. Pattern recognition is said to develop through clinical experience, but other explicit ways to MOVEMENT IN CLINICAL DECISION MAKING 68 foster this high level reasoning process are unknown. Additionally, models and frameworks providing physical therapists with pattern recognition tools present little empirical evidence in their effectiveness. Research into the use of pattern recognition amongst orthopedic physical therapists, pathways toward skill development, and key components in experience may provide greater knowledge to foster this skill. Lastly, as the profession embraces an identity as movement system practitioners this presents opportunity in developing the professional lens of movement system experts. Participants in this study resonated with an identity in the movement system through an innate understanding of movement. This presents opportunities in exploring how future professional may embrace both ways of being and ways of knowing in becoming movement system experts. Conclusion The APTA calls for physical therapists to embrace a vision of Transforming society by optimizing movement to improve the human experience (American Physical Therapy Association, n.d., para. 3). To advance this vision, a keen understanding of movement in clinical practice is needed with a richer understanding into how movement directs a physical therapists CDM. The results of this study provide a novel theory by illustrating this process within orthopedic physical therapy. Movement presents as an implicit medium allowing communication between therapist and patient through a cyclical process of collection, reasoning, and application. Engagement in this communication channel may be influenced by factors within ones professional lens and patient centricity. Further investigation of this theory may work to greater develop the understanding of movement within CDM and key components within. MOVEMENT IN CLINICAL DECISION MAKING 69 References Abraham, K., Green-Wilson, J., Hartley, G. W., Deusinger, S., Altenburger, P., Blackinton, M., Byl, N., Nordstrom, T., & Tschoepe, B. (2022). 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International Journal of Sports Physical Therapy, 17(1), 18-26. https://doi.org/10.26603/001c.30173 Ziebart, C., & MacDermid, J. C. (2019). Reflective practice in physical therapy: A scoping review. Physical Therapy, 99(8), 1056-1068. https://doi.org/10.1093/ptj/pzz049 Zoom. (2022, November 3). End-to-end (E2EE) encryption for meetings. https://support.zoom.us/hc/en-us/articles/360048660871-End-to-end-E2EE-encryptionfor-meetings MOVEMENT IN CLINICAL DECISION MAKING 86 Table 1. Demographic Characteristics Participant Age 1 36-45 United Years in States Practice Region of Practice Southwest 11-15 Advanced Certification Weekly Practice Hours 2 36-45 Southwest 11-15 FAAOMPT 31-40 3 36-45 Southeast 11-15 OCS, FAAOMPT 21-30 4 36-45 Midwest 11-15 MTC 31-40 5 36-45 West 11-15 OCS 31-40 6 7 8 9 10 26-35 26-35 26-35 26-35 36-45 Northeast Midwest West Midwest West 6-10 6-10 6-10 6-10 16-20 SCS MTC OCS MTC OCS, FAAOMPT 31-40 >40 >40 31-40 31-40 11 26-30 Northeast 0-5 SCS 31-40 12 13 46-55 36-45 Southwest 26-30 Southeast 16-20 FAAOMPT OCS, FAAOMPT >40 >40 14 15 NA 36-45 West Midwest NA 16-20 OCS, FAAOMPT MTC 31-40 20 16 26-35 Southeast 6-10 OCS 20 17 18 NA 26-35 West Midwest NA 6-10 MTC MTC 31-40 31-40 19 36-45 West 6-10 SCS, MTC >40 20 21 46-55 36-45 Midwest Midwest 21-25 11-15 OCS, FAAOMPT OCS, FAAOMPT, MTC >40 NA MTC 20 MTC=Manual therapy certified, FAAOMPT=Fellow of the American Academy of Orthopedic Manual Physical Therapy, OCS=Orthopaedic Certified Specialist, SCS=Sports Certified Specialist, NA=Not Answered. MOVEMENT IN CLINICAL DECISION MAKING Table 2. Aggregate Demographics Demographic Frequency Percentage 26-35 36-45 46-55 NA 7 10 2 2 33.3 47.6 9.5 9.5 Northeast Southeast Midwest Southwest West 2 3 7 3 6 9.5 14.3 33.3 14.3 28.6 0-5 6-10 11-15 16-20 21-25 26-30 NA Advanced Certification SCS OCS MTC FAAOMPT Weekly Practice Hours At least 20 21-30 31-40 >40 NA 1 7 6 3 1 1 2 4.8 33.3 28.6 14.3 4.8 4.8 9.5 3 9 8 8 33.3 42.9 38.1 38.1 3 1 10 6 1 33.3 4.8 47.6 28.6 4.8 Age Practice Region Years in Practice MTC=Manual therapy certified, FAAOMPT=Fellow of the American Academy of Orthopedic Manual Physical Therapy, OCS=Orthopaedic Certified Specialist, SCS=Sports Certified Specialist, NA=Not Answered. 87 MOVEMENT IN CLINICAL DECISION MAKING 88 Table 3. Emergent themes and corresponding categories Theme & Category Collection Definition Observation The use of observation to collect, assess, or analyze patient movement patterns or impairments. Patient The prioritization of Considerations evaluative techniques and treatment approaches specific to patients functional demands or lived experience. Movement as The use of movement as a Indicator guide to further objective testing, using results of movement analysis to direct tests and measures or gauge progression or readiness for activity. Efficiency The use of movement evaluation or treatment to produce outcomes or collect data in an efficient manner, such as obtain the most data for a single assessment tool. Reasoning Problem The pursuit of a root Identification cause in therapist investigation towards primary limitations and/or underlying diagnoses to direct most effective treatment. Pattern The identification of Recognition learned patterns or scenarios gained through experience and/or education. Reflection Using reflection-onaction, or in-action to Example Quote I think as skilled physical therapists can appreciate the quality of the movement, especially after they practice it quite a bitIt's not as objective as we would like it to be, but some, I think there's some nuance to movement that we can't always measure objectively that is very valuable to clinical decision making. So that's how I prioritize itlike their, their goals on what they wanna get back to. Do they wanna get out in the yard and squat down? Do they need to get up their stairs? Do they need to, things like that. So I try to keep in mind their goals and prioritize those activities. Cuz I wanna see again like a movement screen. So I wanna see does your upper trap go up, does your scap move, does your, like the compensations you're having. And then I feel like that leads me to what I'm testing. But like I think as you grow experience, just looking at big picture and like the functional stuff has definitely been much more like a focus of mine versus like, oh I'm gonna do this little test and this little test and kinda put all of that together. Like obviously special tests have a, a place and are important, but I think you just realize like they only give you like a little bit of information So obviously that was an, an abnormal you know, movement. You know, my goal was to figure out again, why, was it because of weakness? Was it because of lack of mobility? Was it because of fear of doing it? And then, you know, find all those impairments and say, all right, which one do I think is gonna give me the most juice out of this squeeze? And let's start there and then continue to reassess and see what happens. I mean, he's kinda one of these guys that stands at attention, leans back kind of top heavy and broad shoulders, smaller torso. And so he's always in extension. So I was like, okay, like his glutes are gonna be a little bit stiffer, a little bit shorter, just based on how he stands. Are there other things that you could do to help speed it along? Maybe, possibly. That's where we, in that clinical MOVEMENT IN CLINICAL DECISION MAKING 89 evaluate treatment or management approach to come to new understandings or appreciation. practice learning phase, we kind of throw out ideas and with everyone's experience and expertise, kind of seeing, okay, we're doing this and they're responding this way, could we do this or could we tweak this? Or could we adjust this and probably get a, a quicker response? Maybe. Embodiment The therapists use of techniques to foster greater patient awareness of their body, movement patterns, and a mindful connection. Feedback The use of tactile, visual, or auditory feedback to elicit optimal performance within patient treatment or provide patient a means of self-assessment. Pain The use of movement to Management reduce or gauge patient pain and symptom response, or provide a means of pain control. Patient Centricity I feel like sometimes people struggle with knowing where they are in space, you know what different, what their different body parts are doing through an activity. So sometimes it's, you know, drawing attention to that, to those things and letting them kind of work through that and figure it out. Sometimes we can put em in front of a mirror and have em actually take a look at themselves and say, you know, you can see how much your shoulders elevated, this is what we need to do, to, you know, to normalize that, you can see that. Patient Centricity Therapist attempt to understand their patient, including individual preferences and biopsychosocial factors to better gauge appropriate treatment and expectations. Assurance Using movement in clinic to build patient's confidence and/or awareness for greater participation in daily life. Includes references to fostering patient independence. Collaboration Recognizing the patient as a key partner in providing alignment of treatment towards patient values or needs and/or deepen the PT's understanding of these factors. I think we gotta give people a little bit more credit for knowing their bodies than, that what we do. Even us being specialists, we, we really don't know what they're feeling. Everybody perceives pain in a different way. And so if we can get a better understanding of, of their perception of their injury and kind of work with that, that goes a long way because the mind is, is very powerful. Application The way that I would proceed with that would say, can I make a change with their symptoms right then and there and is there some way that they are moving, moving that seems to correlate to what their pain pattern is. And so if we can teach your brain that movement doesn't hurt, then you should be more confident with your movement and you can move through those patterns better and things like that. She's gonna start adding some triathlon stuff in between now and next time I see her. So just being there as somebody to kind of guide her through the various movements that she would do. MOVEMENT IN CLINICAL DECISION MAKING 90 Professional Lens Professional Identity The attitudes, beliefs, and values that an individual prescribes to in their practice as a physical therapist. I think more than any other profession, that's probably what we're trained to do is, understand the musculoskeletal system down to its core and we deal with that more than, I would say in terms of the fully body, more than any other profession. Whole Body Perspective Recognition that the body functions as a unit and is the sum of all parts, acting together. Kinetic Chain Therapists speaking to treatment principles along the kinetic chain. Recognition that everything is connected. that's one thing I try to make sure students are educated on as well is don't just look at, just focus on just what the injury, what the diagnosis is, but what's happening around the diagnosis if you will. So that way it's getting a full body approach versus just a focused approach. I'm always kind of gonna for sure focus on the body region, but I'm looking at the entire kinetic chain. And I'm going through a screening protocol with regards to what does their trunk control look like, what does their pelvic control look like, what does their femoral control look like you know, what are their you know knee positioning upon loading or mid-stance and then ankle and foot if there's anything that correlates to symptoms. MOVEMENT IN CLINICAL DECISION MAKING Figure 1. Visual Representation of Steps Taken Throughout Study 91 MOVEMENT IN CLINICAL DECISION MAKING Figure 2. Conceptual Model 92 MOVEMENT IN CLINICAL DECISION MAKING 93 Appendix A Interview Guide Thank you for allowing me to interview you today. As an orthopedic physical therapist, I am interested in exploring the role of movement among expert clinicians of orthopedic physical therapy and how it informs your clinical decision making. I appreciate your willingness to participate and provide your perspective on this topic. The purpose of this study is to better understand how orthopedic physical therapy practitioners utilize the data source of movement and what components of this data source are prioritized in your patient management process. You were recruited to provide the perspective of an expert orthopedic physical therapist. The interview should take 45-60 minutes. The responses you provide are for the purposes of this study only. Every attempt will be made to keep what you say confidential. Should data from your interview be used to support findings through publication or professional presentations, no identifying information will be used. Your participation is completely voluntary. You may stop the interview at any time, and if there is a question that you prefer not to answer, please let me know. Do you have any questions that I can answer at this time regarding the interview process? To capture your responses accurately, I would like to audio record the interview. Is it ok if I start recording now? (Turn on recording) The recording has started. 1. To start off, Id like to know what it is like for you to practice as an orthopedic physical therapist? a. Prompt: How would you describe your treatment model? MOVEMENT IN CLINICAL DECISION MAKING 94 b. Prompt: Do you find your treatment model to be more kinesiopathologic or pathokinesiologic? Why? c. Prompt: Describe any direct movement training you have had. 2. How do you feel about identifying yourself as a movement system expert? a. Prompt: What are some examples of how your current evaluation and treatment approach represent this identity? b. Prompt: Do you find movement evaluation important for your reasoning process? 3. Describe how you utilize movement evaluation throughout your patient evaluation process? a. Prompt: Describe any technology, tools, or frameworks you use to assist in this process. b. Prompt: Would you describe your use of movement evaluation as integrative or focused on specific movement tasks and why? c. Prompt: When performing a task specific movement analysis describe what you are observing for? 4. Requirements of movement encompass four basic elements in motion, force, energy, and motor control. Describe how you identify these components within your patient management process. a. Prompt: Are there any elements you would remove or add as requirements for movement and why? b. Prompt: How and when do you typically re-assess these components? 5. Describe what senses guide your evaluation of movement such as auditory, visual, and kinesthetic? MOVEMENT IN CLINICAL DECISION MAKING 95 a. Prompt: Which of these do you find most critical and why? 6. How do you prioritize movement impairments within your evaluation and treatment plan? a. Prompt: Explain to me how this helps direct your diagnosis. b. Prompt: Can you provide an example of how you educate patients regarding their movement impairments? 7. In educating students and/or colleagues how do you direct their clinical decision making process? a. Prompt: Describe what clinical reasoning algorithms or frameworks are included in your educational process. b. Prompt: Can you provide an example of how you educate students or colleagues on observational analysis of movement? 8. Would you consider yourself to have good body awareness and why? a. Prompt: Can you tell me how this serves to integrate within your skill set as a physical therapist? b. Prompt: Describe how you as a physical therapist use your body in therapistpatient interactions. c. Prompt: How do you feel this contributes to your decision making process? 9. I have reviewed your case based questions within your study information sheet and Id like to ask you to share your thoughts on a few areas. a. Prompt: What about this patient case did you find most memorable? b. Prompt: Can you describe your thought process in evaluation of this patient? MOVEMENT IN CLINICAL DECISION MAKING 96 c. Prompt: Can you describe how measures taken within this patient case reflect typical treatment approaches you prescribe to as a physical therapist? 10. Is there anything else you would like to share on your use of movement evaluation within clinical practice? Thank you for taking time to talk with me today. If you have any questions regarding the study or data collected, please feel free to contact me at 704-533-5753 or mlambert@uindy.edu. You may also contact Dissertation Committee Chair Dr. Lisa Borrero at borrerol@uindy.edu. All data collected today, including recordings and transcripts, will be stored on a password protected computer. I will contact you following data analysis through email to share overall themes that emerged and provide an opportunity to confirm the accuracy of information obtained. Thank you again for your time. MOVEMENT IN CLINICAL DECISION MAKING 97 Appendix B Qualtrics Study Information Sheet & Reflective Case Vignette Minimal Risk UIndy Study # 01828 Study Version: 1 Study Version Date: 2/16/2023 Informed Consent Form (ICF) Version: 1 ICF Version Date: 2/16/2023 Department of Interprofessional Health & Aging Studies KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS You are being invited to participate in a research study exploring how clinical experts of orthopedic physical therapy use movement to inform their clinical decision making. Your participation in this study is voluntary. Please take your time reviewing the following information and ask the research investigator to explain any information you do not understand. Should you agree to participate in the study you will be asked to complete the following form including demographic information and six reflective patient case questions. You will also be asked to complete a virtual interview through Zoom that will be audio recorded, and communicate with the researcher to review conclusions gained following data analysis. We expect that your interview should take 45 min 1 hour. Participants will also be contacted approximately 4-8 weeks after the interview to confirm the initial themes drawn by the researcher from the original interview. There is no risk to participating in this study. CONSENT TO PARTICIPATE IN RESEARCH STUDY The Role of Movement in Clinical Decision Making: Exploring the Practice of Expert Clinicians in Orthopedic Physical Therapy Study Principal Investigator (PI): Dr. Lisa Borrero, PhD UIndy Email: borrerol@uindy.edu UIndy Telephone: (317)788-5299 Primary Researcher (Co-investigator): Melanie Lambert, PT, DPT UIndy Email: mlambert@uindy.edu UIndy Telephone: (800)232-8634 x 5944 Dr. Lisa Borrero, PhD, from the Department of Interprofessional Health & Aging Studies and Doctor of Health Science student Melanie Lambert, PT, DPT at the University of Indianapolis (UIndy) is conducting a research study. MOVEMENT IN CLINICAL DECISION MAKING 98 You were selected as a possible participant in this study because you reflect a clinical expert of orthopedic physical therapy due to the following eligibility criteria. 1. Advanced certification in one of the following: Orthopaedic Certified Specialist, Sports Certified Specialist, Fellow of the American Academy of Orthopaedic Manual Physical Therapy, Manual Therapy Certified. 2. At least 3 years of clinical practice 3. Engage in teaching students and/or colleagues within the profession a. Evidenced by formal mentorship within the profession, regular acceptance of student clinical rotations, or engagement in teaching through workshops, seminars, or long term courses within the last year. 4. Practice for at least 20 direct patient care hours weekly in an orthopedic department or practice. Your participation in this research study is voluntary. Why is this study being done? This study is being performed due to a lack of research supporting the role of movement within a physical therapists decision making process. Movement serves as a critical data source to orthopedic physical therapists and the use of movement within patient management has been supported as an attribute of expert practice. Despite this recognition how this data source drives clinical decision towards ones patient remains ill defined. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Complete this form, including listed demographic information and six reflective questions surrounding a patient case you have experienced. Schedule and complete a 45-60 minute virtual interview through Zoom with the primary researcher Communicate with the primary researcher through email 4-8 weeks following your interview to confirm initial themes drawn by the researcher from the interview. How long will I be in the research study? Participation will take up to four to six months from time of invitation to completion of final communication for theme review. Are there any potential risks or discomforts that I can expect from this study? There are no anticipated risks or discomforts for participation in this study. Are there any potential benefits if I participate? You will not directly benefit from your participation in the study. The results of the research may contribute to physical therapy educational curricula and evidence-based practice surrounding movement in physical therapy. MOVEMENT IN CLINICAL DECISION MAKING 99 Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences or used for teaching purposes. However, only aggregate data and de-identified quotes will be used. Personal identifiers will not be used in any publication, presentation or teaching materials. Upon agreement for participation, you will be assigned a patient identifier code for deidentification of all data collected. Only the primary researcher will have access to this master log of codes, stored securely in a locked cabinet. Will the data from my study be used in the future for other studies? It is possible that de-identified data from this study could be used for future research or shared with other researchers for use in studies, without additional informed consent. De-identified means that any codes and personal information that could identify you will be removed before the data is shared. What are my rights if I take part in this study? You can choose whether or not you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you, and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and still remain in the study. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments or concerns about the research, you can talk to one of the researchers. Please contact: Study Principal Investigator (PI): Dr. Lisa Borrero, PhD UIndy Email: borrerol@uindy.edu UIndy Telephone: (317)791-5944 Primary Researcher (Co-investigator): Melanie Lambert, PT, DPT UIndy Email: mlambert@uindy.edu Telephone: (800)232-8634 x 5944 The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or MOVEMENT IN CLINICAL DECISION MAKING 100 calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. Follow up studies We may contact you again to request your participation in a follow up study. As always, your participation will be voluntary and we will ask for your explicit consent to participate in any of the follow up studies. Q1 How do I indicate my informed consent to participate in this study? If you consent to participate in this study, then you affirm that you satisfy inclusion criteria and your consent is voluntary. To indicate your voluntary consent and proceed with the questionnaire, select one of the following options. o I voluntarily consent to participate in this study (1) o I do NOT consent to participate in this study (2) Q4 Participant Demographics Please fill in or check the appropriate responses. Q5 Name No identifying information will be used within the study and in the dissemination of results. Use of your name on this form serves to match your reflective case questions, found in block 3 of this form, to your upcoming individual interview. _____________________________________________________________ Q6 Age o 25-30 (1) o 26-35 (2) o 36-45 (3) o 46-55 (4) o 56-65 (5) o 66-75 (6) o >75 (7) MOVEMENT IN CLINICAL DECISION MAKING Q8 Which state do you practice in? ________________________________________________________________ Q9 How many years have you been in practice? o 0-5 yrs (1) o 6-10 yrs (2) o 11-15 yrs (3) o 16-20 yrs (4) o 21-25 yrs (5) o 26-30 yrs (6) o 31-35 yrs (7) o 36-40 yrs (8) o > 40 yrs (9) Q10 Graduate program of attendance for physical therapy degree. ________________________________________________________________ 101 MOVEMENT IN CLINICAL DECISION MAKING 102 Q11 Regular teaching commitments include which of the following. Select all that apply. Formal mentorship with students and/or colleagues (1) Regular acceptance of student clinical rotations (2) Acting as adjunct or part time faculty within an entry-level DPT program (3) Teaching at workshops, seminars, or long term courses (4) Acting as faculty of a post-professional program (ex. residency or manual therapy program) (5) Q12 What advanced certification(s) do you hold? Select all that apply. Orthopaedic Certified Specialist (OCS) (1) Sports Certified Specialist (SCS) (2) Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT) (3) Manual Therapy Certified (4) Q13 Weekly hours in orthopedic clinical practice. o at least 20 hours (1) o 21-30 hours (2) o 31-40 hours (3) o >40 hours (4) MOVEMENT IN CLINICAL DECISION MAKING 103 Q14 What type of clinic do you practice within? o Orthopedic private practice (1) o Cash based orthopedic private practice (2) o Hospital based outpatient practice (3) o Hospital satellite outpatient practice (4) o Government based clinic (VA, military base) (5) o Industrial health (employer based setting) (6) o Other (7) __________________________________________________ Q15 Have you completed any additional training on movement analysis not represented by your educational programs above? ________________________________________________________________ Q16 Reflective Case Vignette Think back to a patient you treated recently whom you feel as if movement played a central role. Using this patient, answer the following questions. Please do not include any identifiable patient information in any of your responses. Q17 What was the patient's primary complaint? ________________________________________________________________ Q18 During their evaluation, what evaluative measures helped you arrive at a diagnosis? ________________________________________________________________ Q19 Describe how you evaluated their movement. ________________________________________________________________ Q20 How did you prioritize the information you gained within your evaluation? ________________________________________________________________ MOVEMENT IN CLINICAL DECISION MAKING 104 Q21 Throughout the course of their treatment, how often did you re-assess their movement and how was this performed? ________________________________________________________________ Q22 Throughout the course of their treatment describe how the patient's movement directed your treatment. ________________________________________________________________ Q23 Is there anything else you would like to share regarding this patient's treatment? ________________________________________________________________ End of Block: Block 2 ...
- Creator:
- Lambert, Melanie
- Type:
- Dissertation
14. Navigating Sleep: Perceptions of Graduate Health Professions Students
- Keyword matches:
- ... Navigating Sleep: Perceptions of Graduate Health Professions Students Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Amanda Hood-Abernethy, RPSGT Copyright December 6th, 2023 By: Amanda Hood-Abernethy, RPSGT All rights reserved Approved by: Laura Santurri, Ph.D., MPH, CPH, aPHR Committee Chair ______________________________ Elizabeth Stith, DHSc, OTR/L, BCG Committee Member ______________________________ Joyce K. Lee-Iannotti, MD FAASM Committee Member ______________________________ Accepted by: Lisa Borrero, Ph.D., FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, Ph.D. Dean, College of Health Sciences University of Indianapolis ______________________________ NAVIGATING SLEEP 1 Navigating Sleep: Perceptions of Graduate Health Professions Students Amanda Hood-Abernethy Department of Interprofessional Health & Aging Studies, University of Indianapolis Author Note I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Amanda HoodAbernethy, University of Indianapolis, 1400 E. Hanna Ave. Indianapolis, IN 46227. Email: hoodabernethya@uindy.edu NAVIGATING SLEEP 2 Abstract Background: Sleep health is a term used to describe the characteristics of individuals that influence how much sleep they get and how well they sleep throughout the night. Postsecondary students are at a greater risk of poor sleep health due to the demands and changes in college. Purpose: The purpose of this basic interpretative qualitative study was to understand how being a graduate health profession student influenced sleep practices and habits in Doctor of Physical Therapy (DPT) and Occupational Therapy Doctorate (OTD) students: DPT and OTD students enrolled in traditional (face-to-face) programs were recruited for this study. Method: Using the purposeful sampling approach, the researcher recruited eleven participants who met the studys inclusion criteria. Participants were interviewed about their sleep experiences in a private setting through Zoom. Data analysis was performed through a review of the transcripts. Identifying themes explained participants' experiences, and interpretations were shared with participants as part of the analysis process. Results: Four themes emerged: factors influencing sleep health, consequences of poor sleep, sleep education, and proposed student support. Discussion: The sleep experiences of DPT and OTD students identified the need for sleep education and prioritization in graduate health science programs. Knowledge about sleep, specifically sleep hygiene, could assist graduate health science students in their role as clinicians. Keywords: graduate health science students, sleep hygiene, sleep habits, sleep health NAVIGATING SLEEP 3 Acknowledgments I would like to thank my family, friends, and professors for their guidance, support, and encouragement throughout the past three and half years. First, and foremost, I would like to thank my husband, Jeremy and son, Chance, for always praying for me, being supportive, and encouraging me to keep pushing forward. I would also like to thank my committee members: Dr. Laura Santurri, Dr. Elizabeth Stith, and Dr. Joyce Lee-Iannotti. Thank you for sharing your knowledge and providing me with the guidance to complete this amazing journey. NAVIGATING SLEEP 4 Table of Contents Title Page ........................................................................................................................................ 1 Abstract ........................................................................................................................................... 2 Acknowledgments........................................................................................................................... 3 Chapter 1: Introduction ................................................................................................................... 6 Problem Statement ...................................................................................................................... 6 Purpose Statement ....................................................................................................................... 7 Research Question ...................................................................................................................... 7 Significance of the Study ............................................................................................................ 7 Definition of Terms..................................................................................................................... 8 Chapter 2: Literature Review .......................................................................................................... 8 Sleep and Health ......................................................................................................................... 8 Sleep and Mental Health ......................................................................................................... 9 Sleep Hygiene ............................................................................................................................. 9 Sleep Assessments .................................................................................................................... 10 Sleep and Postsecondary Students ............................................................................................ 10 Sleep Hygiene and Postsecondary Students ......................................................................... 11 Sleep Quantity and Postsecondary Students ......................................................................... 12 Sleep Quality and Postsecondary Students ........................................................................... 13 Sleep Interventions in Postsecondary Students..................................................................... 15 Sleep in the PT and OT Disciplines .......................................................................................... 16 Chapter 3: Method ........................................................................................................................ 17 Study Design ............................................................................................................................. 17 Participants ................................................................................................................................ 17 Setting ....................................................................................................................................... 18 Procedures ................................................................................................................................. 18 Sampling/Recruitment .......................................................................................................... 18 Informed Consent.................................................................................................................. 20 Data Collection ..................................................................................................................... 21 Data Management and Analysis ........................................................................................... 21 Rigor/Trustworthiness............................................................................................................... 23 Chapter 4: Results ......................................................................................................................... 24 Factors Influencing Sleep Health .............................................................................................. 25 Sleep Hygiene ....................................................................................................................... 25 Mental Health........................................................................................................................ 28 NAVIGATING SLEEP 5 Educational Program ............................................................................................................. 30 Consequences of Poor Sleep ..................................................................................................... 32 Sleep Education ........................................................................................................................ 34 Proposed Student Support ......................................................................................................... 35 Chapter 5: Discussion and Conclusion ......................................................................................... 36 Sleep Hygiene ........................................................................................................................... 36 Mental Health............................................................................................................................ 38 Consequences of Poor Sleep ..................................................................................................... 39 Sleep Education ........................................................................................................................ 39 Limitations ................................................................................................................................ 40 Implications and Future Research ............................................................................................. 40 Conclusion ................................................................................................................................ 42 References ..................................................................................................................................... 43 Table 1 Participant Characteristics ............................................................................................... 53 Table 2 Theme Table .................................................................................................................... 54 Appendices .................................................................................................................................... 55 Appendix A Interview Guide .................................................................................................. 55 Appendix B Study Description ............................................................................................... 58 Appendix C Recruitment Flyer ............................................................................................... 59 Appendix D Informed Consent Form ..................................................................................... 60 Appendix E Eligibility Screening Questions .......................................................................... 63 NAVIGATING SLEEP 6 Navigating Sleep: Perceptions of Graduate Health Professions Students Sleep hygiene describes how well individuals take care of their sleep health (Hale et al., 2020). Sleep hygiene is about specific factors, including individual behaviors and the sleep environment, that influence sleep health (Suni, 2022a). Unfortunately, poor sleep hygiene is rising due to work demands, family responsibilities, and technological advancements (Ford et al., 2015). It is estimated that 25% of adults in the U.S. do not get enough sleep (Office of Disease Prevention and Health Promotion [ODPHP], 2022). As a population, graduate students are particularly vulnerable to irregular sleep patterns and behaviors that limit their ability to achieve good sleep hygiene (Komarov et al., 2020). Attributes of being a graduate student include balancing coursework, work schedules, and family responsibilities. To meet coursework, employer deadlines, and household obligations, students sometimes prioritize those activities over managing good sleep hygiene (Komarov et al., 2020). As a result, students reduce the number of hours they sleep by staying up late and waking up early (Anwer et al., 2021) and experience diminished sleep quality (Allen et al., 2020). Graduate students majoring in health science professions alter their sleep health to prioritize the rigorous demands of graduate coursework (Nugent et al., 2020). Many health sciences programs, like the Doctor of Physical Therapy (DPT) and Occupational Therapy Doctorate (OTD), also include clinical application and research work requiring students to balance courses and other responsibilities (Accreditation Council for Occupational Therapy Education [ACOTE], 2022; Commission on Accreditation in Physical Therapy Education [CAPTE], 2022). Problem Statement NAVIGATING SLEEP 7 Despite increased efforts to study sleep hygiene in graduate students, there has been little information on the lived experiences of health science graduate students to understand their perceptions of sleep. The lack of knowledge about sleep hygiene is important to DPT and OTD professions because sleep is a critical factor to promoting healthy lifestyles in their respective disciplines. To date, there is limited information about sleep in DPT and OTD students. Purpose Statement This qualitative study aimed to understand the sleep experiences and sleep quality of graduate students enrolled in DPT and OTD programs. Of particular focus were the perceptions of sleep hygiene at different stages within the programs. Research Question This study addressed the following research questions: 1. What are the perceptions and experiences of sleep in DPT and OTD students? a. How do DPT and OTD students perceive sleep hygiene? b. How do DPT and OTD students describe both the quantity and quality of their sleep? c. How do DPT and OTD students perceive sleep at different stages within their programs? Significance of the Study Gaining a better understanding of the experiences of DPT and OTD students may help provide support and educate health science professionals. The results may assist graduate health science faculty in supporting their students sleep health by providing strategies for getting enough sleep and eliminating sleep disturbances. Additionally, graduate health science students NAVIGATING SLEEP 8 may better understand sleep hygiene and, therefore, be able to promote sleep within their professions. Definition of Terms Sleep hygiene Behaviors and environmental cues that impact how sleep is initiated and maintained (Suni, 2022a). Sleep health Factors that contribute to the overall well-being of ones health (Hale et al., 2020). Literature Review Sleep and Health Sleep is a necessary process that allows regular neurological, cardiovascular, and endocrine changes to occur (National Institutes of Health [NIH], 2021). The brain needs sleep to recall events, process information, and produce hormones (Suni, 2022b). Insulin and other hormone production are necessary to control appetite, process foods eaten, fight off infections, and control the sleep-wake cycle (Centers for Disease Control and Prevention [CDC], 2020). The circadian rhythm, the bodys internal clock that tells people they are hungry and thirsty, also lets them know when sleep is needed (NIH, 2021). During normal healthy sleep, melatonin, the hormone that assists the body in going to sleep, is produced when the heart rate and blood pressure drop (Suni, 2022c). Disruptions in the circadian rhythm can increase appetite and decrease the bodys ability to produce insulin, contributing to an increased risk of obesity and type 2 diabetes (CDC, 2020). Significant health events such as heart attacks and strokes can also occur because, without sleep, heart rate and blood pressure continue to remain elevated throughout the night (Suni, 2022c). Therefore, sleep is as essential to the human body as food and water (CDC, 2020). NAVIGATING SLEEP 9 Sleep and Mental Health There is a cause-and-effect relationship between sleep and mental health (Scott et al., 2017). Mental health conditions include depression, schizophrenia, post-traumatic stress disorder (Freeman et al., 2020), anxiety, and stress (Scott et al., 2017). While sleep issues are a primary cause of mental health conditions, sleep disturbances are common in patients being treated for mental health conditions (Freeman et al., 2020). During sleep, the brain undergoes a detoxification process that helps the brain retain information, manage emotions, and regulate cell activity (Suni, 2022b). Sleep deprivation, the bodys response to delayed sleep or frequent awakenings, blocks cells from transmitting regularly (Krysta et al., 2017). When placed into flight or fight situations, where anxiety and stress levels are high, the body responds by raising heart rate and blood pressure, making it difficult for the brain to regulate the sleep-wake cycle naturally (Freeman et al., 2020). Anxiety and stress can stem from practicing poor sleep hygiene, and insufficient sleep hygiene can also prolong the symptoms associated with anxiety and stress (Scott et al., 2017). Over time, irregular and fragmented sleep patterns can cause mental health conditions (Krysta et al., 2017). Sleep Hygiene Sleep hygiene is influenced by sleep quantity and sleep quality. Sleep quantity consists of the hours of sleep people achieve each night (Suni, 2022a). Sleep quality is a combination of elements that describe how well people think they sleep (e.g., the number of awakenings during the night and feelings upon awakening) (Suni, 2022a). Sleep hygiene habits are established in childhood but can change throughout adulthood. Sleep patterns and behaviors learned as children can carry over into adolescence and adulthood (Barnes & Drake, 2015). Sleep behaviors include using caffeine, alcohol, food, and electronics near or at bedtime (Suni, 2022a). Internal factors, NAVIGATING SLEEP 10 such as stress management, and external factors, such as the frequent use of electronics, influence how sleep hygiene is viewed (Belmon et al., 2018). Currently, there is a public health initiative to educate the public about sleep hygiene, including its relationship with safety and overall health (Paton, 2020). Poor sleep hygiene increases the risk of car accidents, work injuries, and chronic health issues (CDC, 2022c; NIH, 2021; Office of Disease Prevention and Health Promotion [ODPHP], 2020). The Centers for Disease Control and Prevention [CDC], (2022b) recommends that adults get at least seven hours of sleep each night and establish good sleep hygiene. Sleep Assessments Various tools are available to measure sleep quantity and sleep quality associated with sleep hygiene. Researchers have gathered subjective information about sleep quantity and quality utilizing a variety of instruments such as the Pittsburg Sleep Quality Index (PSQI), Sleep Hygiene (SHI), Epworth Sleepiness Score (ESS), Measure Circadian Preference (MEQ), Functional Outcomes of Sleep (FOSQ-19), and the Sleep Quality Questionnaire (SQQ). The most widely used instrument in this literature review is the PSQI (Allen et al., 2020; Awasthi et al., 2020; Baroni et al., 2017; Blome et al., 2021; Corra et al., 2017; Kato, 2014; Shafique et al., 2021). The PSQI consists of ten questions with scores ranging from 0-21 (Buysse et al., 1989). Good sleep quality is referenced when a score is at or below 5, and anything over 5 is scored as poor sleep quality (Buysse et al., 1989). The PSQI gives a glimpse into a person's sleep during the corresponding months of completion. The PSQI captures an array of information, including the average hours of sleep each night, the number of awakenings, the causes of awakenings, and overall, how one feels about their sleep (Buysse et al., 1989). Sleep and Postsecondary Students NAVIGATING SLEEP 11 Sleep in postsecondary students, specifically, graduate health science students were not studied frequently. The research from undergraduate students may be utilized for insights into the graduate health science population. Poor sleep quality is common among undergraduate students of all majors. For example, in a study on psychology students using the PSQI instrument, 60.4% indicated poor sleep quality (Humphries et al., 2021). Studies on students pursuing a bachelor's degree in medicine also reflected PSQI scores greater than 5, which is associated with poor sleep quality (Awasthi et al., 2020; Corra et al., 2017; Shafique et al., 2021). Additionally, 89% of undergraduate nursing students had poor sleep (Blome et al., 2021). They described feeling un-refreshed when awakened and tired during the day (Blome et al., 2021). Graduate students also have poor sleep quality; however, the sleep quality is significantly different in health science students. In a study of various graduate degree majors, 38% of the participants scored higher than 5 on the PSQI (Allen et al., 2020). In a cross-sectional study among graduate PT, OT, and Physican Assistant (PA) students, that number increased with only 45.5% scoring within the normal PSQI range (Ohl et al., 2019). Among a cohort of DPT students, 46% were identified as having poor sleep quality (Coffyn & Siengsukon, 2020). Using the Pittsburgh Insomnia Rating Scale, Nugent et al. (2020) discovered that 56.6% of graduate health science students rated their sleep quality as fair or poor. In relation to the college student population, there is a sleep quality deficient among graduate health science students. Sleep Hygiene and Postsecondary Students Undergraduate students consistently had poor sleep hygiene that appeared to be behaviorally induced. Students who engaged in online gaming and consumed more caffeine near or at bedtime, experienced a delay in going to sleep and when asleep were awakened on and off NAVIGATING SLEEP 12 throughout the night (Awasthi et al., 2020; Blome et al., 2021; Shafique et al., 2021). Students also used their rooms for other means rather than sleeping, such as studying, watching electronic devices, and socializing with friends (Humphries et al., 2021). Hamilton et al. (2020), Todd and Mullen (2013), and Zhang et al. (2020) found a lack of personal motivation in undergraduate students to establish and practice good sleep hygiene. Students had little to no desire to adopt new behaviors to prioritize better sleep (Todd & Mullen, 2013). Living arrangements, school-work-life balance, and habits can influence how undergraduate students feel about sleep health and how likely they are to have good sleep hygiene (Shafique et al., 2021). Some patterns form because of college lifestyle changes, but ultimately student attitudes decide whether to adopt good sleep habits (Zhang et al., 2020). Collectively, undergraduate students engage in poor sleep behaviors because the patterns carry over from childhood or the demands of college influence the sleep habits formed (Zhang et al., 2020). Behaviors associated with graduate health science students' poor sleep hygiene correspond to where and how they study (Nugent et al., 2020), and caffeine intake (Ohl et al., 2019). Compared to other students, graduate health science students have more responsibilities (Nugent et al., 2020). These students typically do not have designated study areas and often study in bed or watch television simultaneously (Nugent et al., 2020). Graduate health science students also often consume more caffeine to get through the rigorous nature of the programs and to compensate for lost sleep (Ohl et al., 2019). Sleep Quantity and Postsecondary Students NAVIGATING SLEEP 13 Sleep quantity has significantly declined in American adults in the past three decades largely due to technology advancements, increased work responsibilities, and busy lifestyles (Ford et al., 2015). With 1 in 3 adults not getting enough sleep (Centers for Disease Control and Prevention [CDC], 2022a), this reinforces the public health initiative to improve sleep health, and overall quality of life (Office of Disease Prevention and Health Promotion [ODPHP], 2022). Postsecondary students, a subset of this population, are not getting the recommended seven hours of sleep each night. A study on undergraduate medical students reported an average of 6 hours of sleep (Corra et al., 2017). In a cross-sectional study among graduate students, researchers found that they get 6.4 hours of sleep each night (Allen et al., 2020). For PT, OT, and PA students, the range was between 4-9 hours per night, with 15.6% being less than 6 hours per night (Ohl et al., 2019), which is indicative that students do not get the recommended hours of sleep (Coffyn & Siengsukon, 2020). Sleep quantity is a significant issue for postsecondary students, including those in their first year. 38.1% of graduate health profession students enrolled in their first year achieved less than 7 hours per night (Hoying et al., 2020). Sleep Quality and Postsecondary Students The causes of poor sleep quality in undergraduate students not pursuing a health science degree included stress, anxiety, and depression (Humphries et al., 2021; Ng et al., 2021; Peltz et al., 2020). Undergraduate students in a mid-sized institution reported that financial burdens, brought on by the need to pay for college expenses, were associated with increased stress, and an overall deficiency in their sleep quality (Peltz et al., 2020). In a correlational study, Ng et al. (2021) predicted and concluded that students who experienced higher anxiety levels also had difficulties with sleep. In addition to financial concerns, course loads (Humphries et al., 2021) and long working hours (Peltz et al., 2020) were linked to stress and anxiety. NAVIGATING SLEEP 14 The causes of poor sleep quality in undergraduate students pursuing a health science degree also included stress; however, the contributors to stress were different. Shafique et al. (2021) found an association between academic stress and sleeping difficulties. Health science students in another study reported increased stress due to the rigorous program, which required additional hours outside the classroom (Othman et al., 2013). There were also notable differences between where the students were in their health science programs. Students during their first and second years of a program experienced worse sleep quality compared to students further along in the programs (Corra et al., 2017). Researchers concluded that trying to maintain good grades in the classroom and demonstrate appropriate in-clinic practice were factors of inadequate sleep quality in undergraduate health science students (Awasthi et al., 2020; Blome et al., 2021: Corra et al., 2017). Graduate students experience more stress than undergraduate students because of academic, work, and family obligations (Allen et al., 2020). The increase in graduate school stressors and reduced sleep have contributed to burnout in many students (Allen et al., 2020). A circle of support is necessary to combat burnout and remain successful in graduate school. Many graduate students rely on large support networks to help with family responsibilities, work obligations, academic demands, and encouragement (Walsh et al., 2021). Ickes et al. (2015) found that a lack of social support was linked to increased stress among graduate students compared to the experiences of undergraduate students. The program year in which a graduate student is enrolled in can also play a role in stress levels. There was a strong link between stress, anxiety, and depression among graduate students entering their first of a health profession program, with 14.2% ranked as having moderate anxiety and 6.6% having severe anxiety NAVIGATING SLEEP 15 (Hoying et al., 2020). The contributing factor pointed back to unhealthy behaviors, such as getting inadequate sleep (Hoying et al., 2020). Sleep Interventions in Postsecondary Students Education about what happens when sleep occurs, good sleep hygiene, and ways to practice healthy sleep habits are vital to undergraduate and graduate students (Hamilton et al., 2020). Undergraduate and graduate students face potential academic consequences and, most importantly, health issues if they are consistently sleep-deprived because of poor sleep hygiene (Barnes & Drake, 2015). Sleep health has recently been at the forefront of public health, fostering good sleep hygiene and improving the population's overall health (Barnes & Drake, 2015). Several experimental studies have been performed on undergraduate students to see if improvements in sleep hygiene occur when provided with the knowledge and skills to practice healthy sleep habits (Kloss et al., 2015; Gipson et al., 2018; Gao et al., 2014; Baroni et al., 2017). For example, there was a notable increase in sleep quality when undergraduate students received text messages explaining sleep hygiene, behaviors, and ways to relieve stress (Gipson et al., 2018). Other educational strategies included participation in sleep education courses where students learned how to track sleep habits and document why they did not achieve good sleep (Baroni et al., 2017; Kloss et al., 2015). In addition, students who participated in a sleep education course that included music therapy and relaxation techniques showed a remarkable increase in the number of hours slept and better feeling the following day (Gao et al., 2014). Poor sleep hygiene is a common trait in undergraduate students because they are unaware of what it is, the risks associated with it, the behaviors that contribute to poor sleep, and how to make the necessary changes to have good sleep hygiene (Humphries et al., 2021). Graduate NAVIGATING SLEEP 16 students, conversely, have grown accustomed to behaviors that significantly influence their sleep hygiene (Nugent et al., 2020). Furthermore, the lack of knowledge about sleep hygiene in health science professions (Caudwell et al., 2020) demonstrates that interventions aimed at providing information and practicing good sleep hygiene begin with educating graduate health science students. DPT and OTD health science students are taught within their curriculums to use evidence-based practices within their patient care roles (Kaplan et al., 2016; Kemp et al., 2021). This evidence-based practice includes sleep education (American Physical Therapy Association [APTA], 2020; "Occupational Therapy Practice Framework: Domain and Processfourth Edition," 2020). PT and OT students are encouraged to screen patients for sleep issues and provide sleep interventions such as sleep hygiene education to improve overall health ("Occupational Therapy Practice Framework: Domain and Processfourth Edition," 2020; Siengsukon et al., 2017). Sleep in the PT and OT Disciplines PT and OT disciplines have similar perspectives on sleep. The PT discipline views sleep as a necessity to performance and learning (Siengsukon et al., 2017). Sleep related issues are linked to deficient in memory recall, immune support, and overall system functions (Siengsukon et al., 2017). The OT discipline views sleep as an Activity of Daily Living (Leive & Morrison, 2020). Sleep quantity and quality fall under the sleep domain of OT, indicating the importance of educating patients on good sleep hygiene ("Occupational Therapy Practice Framework: Domain and Processfourth Edition," 2020). Both disciplines value the role of sleep, as well as their roles in promoting good sleep health through patient education (Leive & Morrison, 2020; Siengsukon et al., 2017). NAVIGATING SLEEP 17 To date, there is limited research on sleep in graduate health science students in traditional DPT and OTD programs. DPT and OTD programs are required by their professional licensing associations to engage in clinical rotations and case-based learning objectives (Connelly Ortega et al., 2022; Stephenson et al., 2020). Due to the nature of these two health science programs, with a focus on rehabilitation, a significant amount of information must be learned and applied. There is limited information on how DPT and OTD students view sleep hygiene, if enough sleep is obtained, how sleep quality is described, and how that information is used to support their patients. Method Study Design This study used a basic interpretative qualitative design. The basic interpretative approach in qualitative research describes how participants view and place meaning on a phenomenon (Merriam & Grenier, 2019). This study explored the perceptions of sleep hygiene among DPT and OTD students. Specifically, this researcher sought to understand how two specific health professions perceived sleep hygiene. Participants Current DPT and OTD graduate students from traditional programs, where students participate in classroom and clinical activities year-round, were recruited for this study. By prioritizing these health science graduate students, the researcher captured information unique to the DPT and OTD traditional curriculums, which may also include fieldwork, clinicals, and research. The inclusion criteria for this study included being currently enrolled in a traditional (non-hybrid or online) DPT or OTD program. Individuals who do not speak or read English were excluded, as all study activities took place in English. NAVIGATING SLEEP 18 Setting The primary recruitment method for current DPT and OTD students was through a private, mid-sized, non-profit institution in the Midwest United States. The DPT and OTD programs at this institution involve approximately a three-year commitment. The DPT program requires a total of 115 credit hours, and the OTD requires a minimum of 105 credit hours. Secondary recruitment for current DPT and OTD students occurred through a variety of online support groups for graduate health science students. Professional associations were also utilized as a third recruitment option. Procedures Sampling/Recruitment Purposeful sampling was used to recruit participants from the DPT and OTD programs at a higher education institution and through social media groups. In purposeful sampling, the researcher seeks to increase knowledge about a unique phenomenon (Patton, 1990). Purposeful sampling involves selecting participants from a specific population to understand their experiences associated with the phenomenon (Patton, 1990). In this study, the researcher followed an information power model to determine when there was sufficient information about the phenomenon to answer the research questions (Malterud et al., 2015). The researcher used five criteria: the aim of the study, specificity, theory, interview quality, and data analysis to evaluate that enough information was collected from a smaller sample size (Malterud et al., 2015). In this study, the researcher narrowed the focus, specifically on capturing the experiences of two disciplines of health science graduate students about one phenomenon. The two disciplines provided key information unique to health science professions. Although this study was limited by established theory, a smaller sample size is NAVIGATING SLEEP 19 commonly expected in qualitative research due to the depth of the information obtained (Creswell & Poth, 2018). The lead researcher followed an interview guide (Appendix A) to enhance the quality of the conversation. This interview guide was piloted with a person of similar interest to help the researcher gain more experience with the interview technique. Finally, the researcher used a case study analysis, which provided more information with fewer participants, to convene what is represented about the phenomenon (Malterud et al., 2015). The researcher referred to the study's purpose to determine if enough information was captured or if additional recruitment was necessary (Malterud et al., 2015). Using the guidance from Malterud et al. (2015), this study's sample size consisted of eleven participants total, with five from DPT programs and six from OTD programs. Once approval was obtained from the University of Indianapolis Institutional Review Board, the researcher began recruiting participants. First, the researcher sent an email template with a brief description of the study (Appendix B) and an attached recruitment flyer (Appendix C) and informed consent form (Appendix D) to the administrative assistants of the DPT and OTD programs at the higher education institution. Next, the administrative assistants of the DPT and OTD programs sent that email and attachments to the students on behalf of the researcher. Consecutively, the researcher posted the study description, recruitment flyers, and informed consent form in the online support groups. In addition, the researcher sent the study description, recruitment flyers, and informed consent form to professional associations to share with PT and OT members on behalf of the researcher. The informed consent form explained the study, the population the researcher was studying, how interested individuals could participate, and the benefits and risks involved. It also included a notification that all participants would receive an Amazon gift card in the amount of $10 to be given after the interview. In addition, the informed NAVIGATING SLEEP 20 consent form provided participants with information about their right to participate or refuse voluntarily and instructions on how to participate. Lastly, this informed consent form included what happens after the data is collected and the study is completed. Current DPT and OTD students interested in participation accessed a secure link from the email or post that took them to a password-protected Google Form, where participants answered screening questions (Appendix E) to determine their eligibility, provide demographics, and proceeded to sign up to participate in the study. The researcher included hard-stop questions on the Google Form asking about the type of DPT or OTD program, and if it was the first time completing the form. Those eligible to participate selected a four-digit identifier next to their preferred interview day and time on the Google Form. Current DPT and OTD students contacted the researcher directly for any questions prior to participation. The researcher's contact information was provided in the email and post. The researcher reviewed data collected from the Google Form daily. Interviews were then confirmed; participants received an encrypted email to alert them to the date and time of their interview. After interviews were completed, participants received their gift cards through email. Informed Consent During the recruitment process, prospective participants received the informed consent form attached to the email that the administrative assistant sent out on behalf of the researcher or from the online post. Before beginning the interview, the researcher reviewed the informed consent form with the participant. At the end of that review, the researcher asked the participant if they had any questions before proceeding with the interview. After the informed consent form NAVIGATING SLEEP 21 had been reviewed with the participant and all questions were answered, verbal informed consent was obtained. Data Collection Once verbal consent was obtained, the researcher used a semi-structured, in-depth interview guide to conduct the interview. The interview guide was developed with the guidance of content experts and piloted prior to implementation. Participant interviews were video recorded through Zoom with Otter AI. The interview began with the researcher thanking the participants for agreeing to participate in the research study. Next, the researcher reviewed with the participants that the interviewer was a student at the University of Indianapolis and was conducting the research as a dissertation project. Participants were informed of the purpose of the study, that the recording was to be used for transcribing purposes, and the approximate length of the interview. Participants were notified that participation was voluntary, responses were to be kept confidential, and participants could withdrawal from the study at any time. Participants were informed that they could skip any question they felt uncomfortable answering, take time to reflect on responses before answering, and ask questions at any time. Before moving into the interview questions, participants were asked if they had any questions, and a review of the demographics took place. The interviews lasted approximately one hour. After the interview, the researcher asked participants if they had questions or anything to add. The interview concluded with thanking the participants for their time and for sharing their perspectives. In addition, participants were notified that an encrypted email would arrive in two to three weeks for member checking. Memoing reflection occurred during the interviews; the researcher recorded personal feelings and reactions in the memo section of the Dedoose, Version 9.0.46 software. Data Management and Analysis NAVIGATING SLEEP 22 The recordings were transcribed simultaneously as the interviews occurred using Zoom with Otter AI transcription service. The transcripts were also cleaned up using the Otter AI transcription service and saved within the software system. To deidentify participant information, each participant selected a four-digit identifier. The key that contains this information was stored separately from the data on a password protected Google file accessible on the researchers computer. In addition, the data analysis software, Dedoose, held the cleanedup transcriptions. Access to the Google Drive, Otter.AI transcription service, and Dedoose analysis software required a password. A virtual private network (VPN) was used as an additional layer of protection on the computer where the software and Google drive was accessed. After dissemination, the researcher will keep the data for a minimum of three years. Once transcriptions were complete, the researcher conducted data analysis in alignment with the seven steps described by Colaizzi (Phillips-Pula et al., 2011). Colaizzi's data analysis method helped the researcher know if the research questions provided enough information to fully understand the participants' experiences (Phillips-Pula et al., 2011). The basic interpretive approach is grounded in phenomenology, which makes Colaizzis seven-step data analysis process appropriate for this study (Phillips-Pula et al., 2011). In the first step, the researcher read each participant's transcript about the descriptions of the phenomenon more than once (PhillipsPula et al., 2011). In the second step, the researcher re-read each participant's transcript and begin highlighting the words and phrases relevant to the phenomenon line by line (Phillips-Pula et al., 2011). The third step involves giving meaning to the highlighted words and phrases and assigning code names and definitions that describe what participants stated (Phillips-Pula et al., 2011). Steps 1-3 were repeated for each transcript (Phillips-Pula et al., 2011). NAVIGATING SLEEP 23 For the first transcript, the researcher, and an analysis expert, who was brought in to assist with the data analysis to enhance the rigor of the process, individually performed steps 1 and 2, then met to discuss the highlighted words and phrases. Then, the researcher and analysis expert performed step 3, formulated the codebook with code names and definitions (Phillips-Pula et al., 2011). In the fourth step, the researcher generated themes representing a larger picture of the experiences (Phillips-Pula et al., 2011). In the fifth step, the researcher linked the themes with the code names and provided definitions for the themes (Phillips-Pula et al., 2011). The codebook was in Dedoose with four columns: code name, code definition, quotes, and source information. Themes linked to code names by a specific highlighting color. In the sixth step, the researcher developed a statement that described what all participants experienced about the phenomenon (Phillips-Pula et al., 2011). In the sixth step, the researcher performed member checking (Phillips-Pula et al., 2011). Participants received an encrypted email summarizing the researcher's interpretations of what participants experienced and the emerging themes. Member checking allowed participants to provide feedback (Henderson and Rheault, 2004). Following Colaizzi's seventh step, the researcher revised accordingly when member checks resulted in new information (Phillips-Pula et al., 2011). Rigor/Trustworthiness Rigor and trustworthiness were maintained throughout this study by following Guba's Model of Trustworthiness, which includes the following criteria: credibility, dependability, confirmability, and transferability (Henderson & Rheault, 2004). Credibility is how well the research holds its' integrity (Henderson & Rheault, 2004). In this study, the researcher used memoing, a method of reflexive journaling, to enhance the study's credibility (Henderson & Rheault, 2004). The researcher used memoing reflection during the interviews to reduce personal NAVIGATING SLEEP 24 bias and during coding to check annotations against the study's purpose (Stuckey, 2015). During the analysis process, the researcher used member checking to confirm that the transcripts were accurate, further influencing the study's credibility (Henderson & Rheault, 2004). Dependability is the accuracy of the results compared to other studies with a similar population (Henderson & Rheault, 2004). To strengthen the study's dependability, the researcher reviewed the codes and codebook multiple times to verify that phrases and words corresponded to the meanings. This code-recode procedure demonstrated that the researcher thoroughly examined the transcriptions in detail (Henderson & Rheault, 2004). Confirmability means the study is free from researcher bias (Henderson & Rheault, 2004). To increase confirmability, the researcher sought the assistance of an analysis expert to review transcripts, discuss commonalities, and establish the codebook (Henderson & Rheault, 2004). The analysis expert also checked the study to see if the same understanding of the phenomena existed (Henderson & Rheault, 2004). Transferability relates to whether the results can be applied to other sample populations (Henderson & Rheault, 2004). Finally, to address transferability, the researcher collected demographics and provided detailed steps during the data collection and analysis phases so that other researchers could perform similar research on a larger sample (Henderson & Rheault, 2004). Results The purpose of this study was to understand the sleep experiences of DPT and OTD students enrolled in traditional programs. Specifically, researchers studied students' perceptions of sleep hygiene. Eleven participants, nine females, one non-gender conforming, and one male, aged 21 to 25, completed the study (Table 1). Ten participants identified as White/Caucasian, and one participant identified as Asian/American. Five participants were enrolled in DPT programs, and six were in OTD programs. Three participants were in the first year of their NAVIGATING SLEEP 25 respective programs, five were in the second year, and three were in the third year. Six participants considered themselves "morning larks," and five indicated they were "night owls." Four themes emerged from the data: factors influencing sleep health, consequences of poor sleep, sleep education, and proposed student support. Subthemes emerging from the data further described participants experiences (Table 2). Factors Influencing Sleep Health The primary theme, factors influencing sleep health, includes participants experiences of impairments to their sleep. The subthemes emerging from the data are sleep hygiene, mental health, and educational program. Sleep Hygiene Sleep hygiene is participants perceptions of their behaviors and environmental factors influencing sleep. Characteristics participants used to describe their sleep hygiene impacted the amount of sleep they got and the quality of their sleep. Participants described an array of difficulties they faced with their sleep, specifically during the first year of their program. They also shared how they prioritized sleep throughout the program. Participants described what preparations they took to get ready for sleep. Characteristics that describe those experiences included hygiene activities, such as showering and brushing teeth. There were similar bedtime routines across all interviews. Similarities in environmental factors were also noted in all interviews. Various tools were reported, including sound barriers, reduced lighting, and alternating sleeping locations. Participant 1234 shared changing the sleep environment, NAVIGATING SLEEP 26 When I am not sleeping well, or if I wake up a couple of times, like through the night or something, then I usually like move locations. So, I'll try to like sleep on the couch, or even sometimes I sleep on the floor. Participants described their experiences with screentime, such as laptops, phones, and TVs. In expressing perceptions about screentime, participants described significant use for schoolwork and leisure activities. When asked how much time was spent looking at a screen daily, participant 5889 responded, "Oh, it's gonna sound very bad, but eight to ten hours probably a day, just with everything I need to do." Participants reported using screentime for notetaking, studying, and completing assignments. Some participants also used screentime for work-related duties. For example, participant 1234 stated, "I'm on my computer when I'm at work. Basically, I'm just staring at a computer all day." Additionally, participants described engaging in screentime activities outside of schoolwork. In nearly all participants, the use of phones was the primary outlet for leisure activities. Participants reported using their phones to engage in social media. For example, participant 0501 stated, "I feel like when I'm not doing schoolwork, I need to like be on my phone catching up with everyone else that's not around me." Nearly all participants communicated that they look at their phones before bedtime. For example, participant 0604 stated, I put my phone on that night mode and sit on my phone for a little while. Some participants shared that they engage in other screentime use before bed. For example, participant 1221 stated, "I just go lay in bed for like an hour or half hour before, like really wanting to fall asleep, watch my show, and go to bed." Despite significant use of screentime, particularly near bedtime, participants perceptions were that screentime did not impact their sleep. NAVIGATING SLEEP 27 Nearly all participants believed caffeine intake, exercise, and study environments had mitigated any sleep-related impacts. For example, participant 0807 stated, I am a coffee drinker. I would say I only have one cup. When asked about physical activity, participant 0501 responded, I actually try to work out for at least 45 minutes to an hour, five to six times a week. When asked to describe their study environment, participant 1991 stated, I have a room upstairs where I have a whiteboard, and then I set up my laptop and things around that.. Minimal caffeine intake, weekly physical activity, and dedicated study locations indicated that nearly all participants were knowledgeable about these factors' impact on sleep. Prioritizing sleep with academics and responsibilities created irregularities in sleep-wake cycles. Participants explained that studying took priority over getting adequate sleep. Some participants described staying up later and getting up earlier to study more. For example, participant 5889 stated, I work outside of school. So, a lot of times, Im up very late studying to be able to complete assignments and get things done. Others reported shifting their cycles to complete tasks yet allowing for the same amount of sleep. For example, participant 0501 said, If I have something that I have to get up early for, I'm doing my bedtime routine earlier, and I'm trying to move everything up on my schedule so my routine can stay the same but that I can get at least six hours of sleep. Acquiring better time management skills was an important factor in meeting sleep needs. For example, participant 5889 stated, When Im able to efficiently balance my schedule, and I do physical activity, and I get all my homework done, and theres not really stress, I sleep very good. Participants in their second and third years described prioritizing sleep and going to bed earlier. For example, participant 1991 stated, And then the second year, I think it got a little bit better, where I got better at putting my own health at a good place. So, I started going to sleep a NAVIGATING SLEEP 28 little earlier. Another participant, participant 0501, reported, Ive definitely gotten better about sleeping more and having more of a routine around sleep. The changes surrounding the prioritization of sleep indicated that participants observed differences in their sleep and sought to address some impairments. During interviews, there was also discussion about current personal sleep concerns. Participants' responses were reflective of their perceptions on sleep hygiene. Some participants expressed that they were most concerned about the amount of sleep they were getting, as identified by participant 3008, My concern is getting enough sleep. Other participants expressed issues with falling asleep. For example, participant 3598 stated, I take a while to fall asleep. Then, some participants, like participant 1738, were concerned about the quality of their sleep, I dont have an issue with falling asleep. But my concern is like my quality of sleep. Nearly all participants reported having average to poor quality of sleep. For example, participant 5889 stated, I would say [sleep quality] its in the mid-range. Another participant, 1234, added, I would say that, on average, its poor, but I still have good nights, which is nice. I would probably have two really good nights a week. And then my other five nights, I would say, are poor or bad. All participants reported personal concerns with sleep but described significant factors that impeded good sleep hygiene. Mental Health The theme of mental health includes participants perceptions of the emotional impact of being a graduate health science student. Anxiety and stress were the predominant factors that participants described as impairments to their sleep. NAVIGATING SLEEP 29 Participants expressed that the demands and skills they needed to learn to be successful students made it difficult to sleep uninterrupted throughout the night, making them anxious about the next day. According to participant 1991, "I used to not sleep as well leading up to exams and things. I woke up a lot, had lots of nightmares about missing the test or sleeping through it." Some participants even shared vivid stories that described waking them up at night and making it difficult to go back to sleep. Participants also described the role of social support on their mental health and sleep. Like many graduate programs, some participants were required to move to attend school. One participant described how making weekend trips home helped mentally, but it did not support the quantity of sleep. According to participant 0501, I go home pretty much every weekend, which home is not super far, but its far enough to take me away from the school setting. So, I feel that impacts my sleep a little bit because as much as Im going home to get more sleep with the people that Im surrounded with all the time, I am also losing hours of school time that I feel I need to catch up on when everyone else is sleeping. Another participant described what it was like not being close enough to visit. According to participant 0807, "Being like eight and a half hours away from friends and family that was definitely a big adjustment, too, and could be stressful at times." The additional stress was not only due to being further away but also being in unfamiliar places. According to participant 0501, I feel like coming to grad school, I moved away from family, and I was living alone. And now I'm just living with pretty much strangers." The inability to be near family left some participants with added stress and sleep difficulties. Participant 0501 described the anxiety felt from sleeping away from home, If I wake up in the middle of the night, Im probably going to NAVIGATING SLEEP 30 like fixate on a sound or something that I might have heard that might have woke me up. And then Ill be scared or something. Social support, especially from others going through similar experiences, was helpful. Some participants described the benefits of having a support network. For example, participant 1738 stated, I feel like I have a good management system of therapy and family and friends support groups to really manage my anxiety and stress levels well. Another participant, participant 0501, added, I feel like building relationships with people in my class and having those conversations like, Oh, were all stressed. We all dont know whats going on in the program, that makes me feel better like that Im not the only one. Participants reported several sources of social support, including their clinical instructors. Participant 1221 stated, I think there was a lot of relief, and even I was able to verbalize what Im talking about with my clinical instructor. There were various sources of social support, and participants found these beneficial to being a graduate health science student. Educational Program The workload of the educational programs created significant impacts on participants sleep. Nearly all participants shared that it was difficult not to think about what they were learning while sleeping, specifically during the first year. Participants expressed that the amount of work required for studying and completing assignments impacted their ability to get sufficient sleep. For example, participant 1991 stated, "I'd say at the start of the program, I didn't sleep very much at all." Some participants described getting between six and seven hours of sleep each night during the first year. When asked how many hours of sleep, participant 0501 responded, Probably six and a half. I dont even think I was getting seven when I first started. There were NAVIGATING SLEEP 31 other participants who expressed impacts on the quality of their sleep. Participants described diminished sleep quality due to constantly thinking about assignments and what they needed to do the next day. For example, participant 1234 stated, So, theres just like a lot more on my plate, which stretches my day to be longer, which I sleep less. And then also the quality of sleep, obviously, because Im thinking about all those things I have to do. Some weeks had back-to-back assignments, and keeping up with assignments and prioritizing sleep was a challenge. Participant 3008 stated, The biggest things in the programs are the presentations and just like the amount of work. Participants reported trying to find ways to cope with the demands of the program and their sleep in various ways. Some participants shared that they tried over-the-counter medications but did not use them regularly. Other remedies included relaxation techniques and writing out what they were thinking about. For example, participant 0604 spoke about making lists, Writing things down always helped me beforehand. Like being able to write out those lists that were constantly going in my head. If I wrote them down before bed, it was a little easier for me to get to sleep. The lack of consistency with didactic coursework and start and stop times also created sleep difficulties. Participants reported having to alter their sleep schedules because of the course fluctuations. For example, participant 1991 stated, If I had class at eight, then I was gonna get up at maybe six, but if I didnt have class till ten, I wasnt gonna get up until eight or nine. So, I definitely changed everyday. And now its a set schedule with clinicals. NAVIGATING SLEEP 32 Additionally, each semester brought on new changes, having to learn the pace of the course and plan for sleep accordingly. For example, participant 0501 shared, Now that were in a routine and have a set class schedule, and Im more familiar with the stuff that Im doing in school, I feel like my sleep habits have gotten better. As participants continued in their respective programs, they described some improvements in their sleep quantity and quality. According to participant 0501, "I feel like definitely coming in the program, I was getting less sleep than what I am now." Another participant, participant 0604, shared, "Sometimes, the quality still isn't great. But, overall, it is definitely better now that I'm through my first year. Participants noted significant impacts on their sleep experiences as they progressed throughout the programs. When participants moved from didactic coursework into clinical rotations, they reported feeling and sleeping better because the workload was not as significant, and there was more consistency. According to participant 1221, "I felt like there was a lot of pressure that was off of me, because I knew I got through that first and second year." Another participant, participant 0604, stated, I think that the workload was a lot less, which probably contributed to my anxiety, which contributed to how well I slept. In addition to a decrease in the demands, some participants shared how the structure and routine of clinical rotations improved their sleep. For example, participant 3008 stated, I sleep better when I have clinicals than when Im in school. Another participant, participant 3598, added, I think its more consistent than classes. As participants progressed from year one to clinical rotations, they noticed considerable improvements to their sleep. Consequences of Poor Sleep NAVIGATING SLEEP 33 The theme of the consequences of poor sleep encompasses participants' descriptions of how they felt following a night of poor sleep. Nearly all participants described being fatigued. For example, participant 0807 stated, "I know when I'm not getting enough, I'm just kind of groggy that, like brain fog, fatigued in general. Some participants described being so fatigued that they had difficulty getting their day started. For example, participant 0501 stated, I feel I'm definitely tired. When I wake up when my alarm goes off in the morning, I'm not as apt to get up to it. Some participants openly expressed that staying awake in class the next day was challenging. The impact of a night of poor sleep made it difficult to pay attention in class., as stated by participant 0604, Being present within class was more difficult depending on the quality of sleep that I got. If I went to class and was just thinking about how tired I was and how exhausted I was, I wasn't able to focus on what we were actually learning. Some participants described how poor sleep impacted their ability to retain information. For example, participant 5889 stated, [Poor sleep] definitely impacts my performance levels. So, my ability to concentrate on the task at hand is a huge one. And then just overall, comprehending and understanding concepts. Some participants added that it was difficult to separate learning the material from when it was time to sleep. For example, participant 3008 stated, The biggest challenge is trying to get my brain just turn off. Even though participants sleep influenced how they learned course material, the sheer mental exhaustion was insufficient to bring on sleep. Over time, the lack of uninterrupted sleep resulted in a series of repetitive anxiety and stressful events. For example, participant 0604 described the role of mental health and sleep as, "I think that having a stressful day impacted my sleep, and having a not-great sleep impacted my next day, and so that made like a vicious cycle of stress and anxiety and was related to my sleep." NAVIGATING SLEEP 34 Sleep Education Participants described what sleep quality and sleep promotion meant to them. Sleep quality and promotion characteristics were related to participants knowledge about sleep. Participants provided various meanings for both terms. For example, when asked what sleep quality meant, participant 1991 stated, "It would be getting a good night's sleep every night where you wake feeling rested and healthy." Some participants defined sleep quality as getting a certain number of hours. When asked what sleep promotion meant, participant 1221 stated, "I feel like sleep promotion to me is more than an internal thing because I know, as a health professional, that it is something that could affect your mind, your physical activity, and your social." Nearly all participants expressed difficulty defining both terms. Participants described what they had learned about sleep in their respective programs. Participants shared what was discussed in the program about the need for sleep. For example, participant 1991, They just said that we're gonna want to stay up all night studying but not to and that if we want the information to stick, we need to sleep and that sleep is important. We didn't get much more information other than that. Participant 0501, added, I feel weve definitely talked about sleep as an occupation and how sleep is important for, again, everyday functioning. Participants expressed that there was a lack of sleep education in their programs. Some described lectures on mental health but stated receiving minimal information on sleep. For example, participant 0604 stated, I will say they do a good job about emphasizing, especially in the beginning about, mental health, which I think they sleep and mental health kind of go hand in hand. So, I will say theyre good about that but sleep specifically, I would say education, not much. NAVIGATING SLEEP 35 Participants also described their experiences with educating patients on sleep. Some participants talked about what the program had discussed to do or say in the clinical setting. For example, participant 3008 stated, "We talked about sleep and rest as an activity of daily living. So that is stuff that we would ask a patient about." Other participants shared that information on how to educate patients about sleep was not provided. Participants in their clinical rotations were asked how they promote sleep in those settings. Some participants shared that they ask patients about their sleep, but given their priorities, time does not allow for more discussion. For example, participant 3598 stated, Were just seeing people for an hour a day; they come and go. Every once in a while, theyll be like, oh, I didnt sleep well at night. And I kinda of ask them if there a reason they didnt sleep well. Another participant, 1221, responded, I think right now I only use it to help with body positioning and using pillows to comfort patients so they can get better sleep. The lack of sleep education in the didactic and clinical settings indicated that participants were limited in discussing sleep with their patients. Proposed Student Support Participants described recommendations for ways to help students with their sleep health and their role as clinicians. Before the conclusion of the interview questions, participants were asked what changes programs could make to assist students with better sleep. Participants expressed that it would be helpful to have consistent schedules. As previously shared, the inconsistent start and stop times influenced sleep schedules significantly. Participants also expressed that it would be beneficial to spread out the coursework. For example, participant 5889 stated, Trying to lessen that load just slightly or spread it out more. So, students arent having to cram for five nights a week to be able to get everything done. NAVIGATING SLEEP 36 Participants described ideas they felt would be beneficial to know about sleep hygiene. Some participants expressed that they did not know much about sleep hygiene but would find it helpful to learn more about it and how many hours of sleep they should get. For example, participant 1234 stated, I think itd be beneficial to know how to have good sleep hygiene and how to promote sleep. Participants shared how beneficial it would be to incorporate sleep education into their learning. For example, participant 0604 stated, I think it would be nice to have like an educational talk with the students. I know they emphasize mental health a lot and support. They're good at supporting us with our mental health. So, maybe just including that in that original talk or even the smaller talks that we have throughout the program. Overall, participants expressed how important they felt sleep was to not only themselves but also as future clinicians. Participants said they could apply what they learned within the program to the clinical setting. The additional education could be valuable across both disciplines. Discussion and Conclusion This basic interpretative study explored the sleep experiences of DPT and OTD students enrolled in traditional programs. Participants shared their sleep hygiene perspectives, feelings, and personal concerns about how their sleep was impacted by their experience as health science graduate students. The studys overarching themes were factors influencing sleep health, consequences of poor sleep, sleep education, and proposed student support. Sleep Hygiene The influence of poor sleep hygiene was a key finding in our study. Participants perceptions of their sleep hygiene were similar across all interviews. Bedtime routines, NAVIGATING SLEEP 37 screentime, and time management contributed to poor sleep hygiene and were supported in the literature. For example, Nugent et al. (2020) concluded that graduate health science students engaged in screentime while in bed and that the intensity of the workload caused significant changes to their bedtime schedules. Participants in our study described significant screentime viewing near bedtime and changes to their sleep-wake cycles due to the rigorous nature of the program. Being able to prioritize sleep was also a key finding in our study and is like the studies by Awasthi et al. (2020), Blome et al. (2021), Corra et al. (2017), and Komarov et al. (2020), where students were prioritizing their academics over getting adequate sleep. This was most notable during the first year and is supported by the Corra et al. (2017) and Hoying et al. (2020) studies when sleep in the first year was inconsistent, less than the recommended amount, and poorer quality. While sleep quality and quantity did improve some, transitions between semesters and academic years were the most difficult because sleep pattern adaptations occurred to accommodate course and clinical schedules. Participants who were in clinical rotations reported improved sleep, which is likely due to the consistency within the schedules and decreased workload. Various tools, including sound barriers such as fans, were used to achieve better sleep. Over-the-counter medications such as melatonin were also occasionally used with other remedies. Despite making these changes, poor sleep continued to exist. While bedtime routines, screentime, and time management were characteristics of sleep hygiene, researchers also gathered information about caffeine intake, physical activity, and study environment. Unlike the study by Blome et al. (2021), where researchers concluded that increased caffeine consumption contributed to poor sleep quality, participants in our study had minimal caffeine use. Although not supported in the literature, our study revealed that physical NAVIGATING SLEEP 38 activity was an essential daily/weekly regimen. Like the study by Nugent et al. (2020), where TV watching simultaneously occurred with studying, some participants in our study described performing this behavior as well. Overall, the findings from our study are consistent with the literature on sleep quality and quantity reported by Nugent et al. (2020), Allen et al. (2020), and Anwer et al. (2021), where researchers concluded diminished sleep quality and less than the recommended hours of sleep on average among postsecondary students. Mental Health Mental health contributed to the sleep experiences explored in our study. While the Ohl et al. (2019) study found a link between students sleeping six to seven hours each night and increased caffeine use and stress, only higher than everyday stress and anxiety levels were discovered in our study. Like the study by Hoying et al. (2020), stress increased significantly at the beginning of the program. Allen et al. (2020), Humphries et al. (2021), Ng et al. (2021), and Peltz et al. (2020) concluded that stress and anxiety had a direct effect on students sleep quality, as evidenced by participant 0604, "I think that having a stressful day impacted my sleep, and having a not-great sleep impacted my next day, and so that made like a vicious cycle of stress and anxiety and was related to my sleep." Academic pressure to know the material and be successful students anticipated deficiencies in sleep quality and quantity (Shafique et al., 2021). Consistent with the Othman et al. (2013) study, our study revealed that a graduate health science program is in-depth and requires a lot of information to be learned. Sleep related issues have most commonly been associated with mental health (Hale et al., 2020), and considering the brains need for sleep (Suni, 2022b), mental health issues such as stress and anxiety, are exacerbated by the lack of consistent good quality sleep. NAVIGATING SLEEP 39 Consequences of Poor Sleep Sleep played a significant role in students' success in their respective programs. While the Komarav et al. (2020) study found no significant difference between increased stress and fatigue, our study revealed that the effects of stress, difficulty falling asleep, and frequent awakenings lingered the following day. Being sleepy and feeling in a fog made it challenging to absorb what was being presented in class. This finding is consistent with the literature in the Anwer et al. (2021) study, where concentration issues hinder the learning process. Uninterrupted sleep is essential for the brain to process information (Barnes & Drake, 2015). This lack of consistent sleep limits the ability to perform tasks effectively, and ultimately increases the risk of injuries and accidents (Watson et al., 2015). Like physicians, any health care professional such as in the PT and OT disciplines are more likely to encounter patient care errors when they are fatigued (Rosenbluth & Landrigan, 2018). The consequences of poor sleep not only make it difficult to focus, but it limits response/reaction times, creating a potential safety hazard in any health care discipline that involves working with medically fragile populations. Sleep Education A notable finding from our study shows a lack of knowledge about sleep quality, sleep promotion, and, most importantly, sleep hygiene in DPT and OTD students. Participants described little to no sleep education in their respective programs. This finding is consistent with the literature reported by Ohl et al. (2019) and Caudwell et al. (2020) studies, where health science professionals lacked knowledge about sleep hygiene. Participants in our study described having to figure out how to achieve better sleep independently. Managing time better and alternating approaches helped, but participants needed more information. The more participants were knowledgeable about sleep, the more they felt they could help in their future clinician roles. NAVIGATING SLEEP 40 This finding is consistent with clinicians who incorporated sleep hygiene education into patient care (Siengsukon et al., 2017). Despite the OT discpline recognizing sleep as an occupation, and it is a framework of patient care, our study found that there was a lack of modeling appropriate sleep health in both programs. Additionally, many populations, PT and OT patients specifically, require sleep to allow the biological functions to occur for healing. Without sufficient sleep, the healing process is delayed (Bhakta & MacRae, 2020), and the potential for mental health issues increase (Krysta et al., 2017) causing additional medical concerns. Considering that the goal of PT and OT is to help patients return to baseline, sleep knowledge is necessary to promote good sleep health in all treatment plans. Limitations A limitation of this study is that the primary researcher completed all participant interviews. A secondary researcher assisted in the coding and theme processes but was not involved in the data collection. While memoing was used to help protect researcher bias, and the researcher did not know any of the participants, not including a secondary researcher in the data collection is a limitation to this study. Another limitation of this study is that researchers did not explore how other factors, gender, and marital status, influence sleep health. For example, nine of the participants were female and two participants were married. Another limitation is that the researchers did not explore participants sleep preferences chronotypes in depth in this study. During the demographic collection process, participants were asked if they were either night owls or morning larks. Although participants did not note any impacts of their sleep preferences on sleep health, future studies are warranted in this area. Implications and Future Research NAVIGATING SLEEP 41 The implications of our study suggest that sleep interventions are needed in graduate health science programs, specifically in DPT and OTD programs, to educate students about sleep and sleep hygiene. Baroni et al. (2017), Gao et al. (2014), Gibson et al. (2018), and Kloss et al. (2015) studies noted changes in students sleep hygiene when formal sleep education was provided. With improved sleep hygiene, there can be a notable improvement in stress and anxiety (Allen et al., 2020). To elaborate on the experience of being a first-year graduate health science student, participants reported more challenges with stress and anxiety due to unfamiliarity, workload, and, for some, lack of social support. University graduate health science program faculty should acknowledge these issues and provide support through orientation, existing campus resources, and frequent check-ins. In summary, graduate health science programs can include the findings from this study to improve sleep health among their graduate health science students. These implications include but are not limited to the following: Orientation sessions that include the fundamentals of sleep health Initiate sleep and mental health support in the first year of graduate health science programs Ongoing education for students sleep and mental health Frequent interactions with students to check-in on their wellbeing Maintain consistency with course schedules and workload The implications of our study warrant further studies on sleep health. Participants in our study frequently mentioned that they did not know enough about sleep, but felt it was important to be knowledgeable in that area. Future studies are needed to evaluate the effectiveness of sleep education in graduate health science programs, and after graduation, particularly as practicing NAVIGATING SLEEP 42 clinicians. Additionally, expanding this research to include how sleep education helps patients in their recovery efforts would be important to know. More research is also needed on the role of sleep health in the clinical decision-making process for all health care disciplines, with specific focus on the link between limited cognitive abilities and medical errors. Further studies are also warranted on how sleep preference chronotypes play a role into postsecondary students sleep health. Understanding how sleep preference chronotypes, night owls versus morning larks, influence sleep hygiene would be beneficial across all health care disciplines. Conclusion Sleep hygiene is something that graduate health science students encounter. Participants in our study collectively struggled to have good sleep hygiene. Perceptions about sleep hygiene were the experiences shared during these interviews, and implications should be considered to improve sleep hygiene, and ultimately sleep health among graduate health science students, specifically DPT and OTD students. NAVIGATING SLEEP 43 References Accreditation Council for Occupational Therapy Education. (2022). ACOTE Accreditation Standards. https://acoteonline.org/accreditation-explained/standards/ Allen, H. K., Barrall, A. L., Vincent, K. B., & Arria, A. M. (2020). Stress and burnout among graduate students: Moderation by sleep duration and quality. International Journal of Behavioral Medicine, 28(1), 2128. https://doi.org/10.1007/s12529-020-09867-8 American Physical Therapy Association. (2020, December 15). Physical Therapy and Sleep Health. APTA. Anwer, S., Li, H., Antwi-Afari, M., Shaphe, M., Alghadir, A., & Wong, A. (2021). Evaluation of sleep habits, generalized anxiety, perceived stress, and research outputs among postgraduate research students in Hong Kong during the Coronavirus (COVID-19) pandemic. Journal of Multidisciplinary Healthcare, 14, 31353149. https://doi.org/10.2147/jmdh.s325479 Awasthi, A., Taneja, N., Maheshwari, S., Gupta, T., & Bhavika. (2020). 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Predicting hand washing and sleep hygiene behaviors among college students: Test of an integrated social-cognition model. International Journal of Environmental Research and Public Health, 17(4), 1209. https://doi.org/10.3390/ijerph17041209 52 NAVIGATING SLEEP 53 Table 1 Participant Characteristics Participant Gender Age Ethnicity Married Program ID 3008 Female 23 White/Caucasian No OTD Program Sleep Year Preference 2 Morning Lark 3598 Female 24 White/Caucasian Yes OTD 2 Night Owl 0604 Female 22 White/Caucasian No OTD 2 Night Owl 2563 Non-Gender 22 Asian/Asian No OTD 1 Morning Conforming 1234 Female American 23 White/Caucasian Lark No DPT 1 Morning Lark 0807 Female 25 White/Caucasian No DPT 3 Night Owl 1738 Male 21 White/Caucasian No DPT 1 Night Owl 1991 Female 23 White/Caucasian No OTD 2 1221 Female 25 White/Caucasian Yes DPT 3 Morning Lark Night Owl 0501 Female 25 White/Caucasian No DPT 3 5889 Female 22 White/Caucasian No OTD 2 Morning Lark Morning Lark NAVIGATING SLEEP 54 Table 2 Theme Table Theme Sub Theme Participant Quotes Factors Influencing Sleep Health Sleep Hygiene Mental Health Educational Program I am a TV watcher before bed as well. So, I have my phone on when I get into bed, but sometimes I spend 45 minutes watching TV. Participant 0807. Consequences of Poor Sleep I was just constantly feeling kind of groggy, tired, my body just felt very weak. Participant 0604. Sleep Education Weve been told a lot that we should do it, and its important, and thats how were gonna get the information to stick, but thats about it. Participant 1991. Proposed Student Support They could talk about sleep more and, I dont know, maybe move up the sleep lecture talking about how to talk to patients about your sleep may move that up. Because things that benefit us too. Participant 1234. NAVIGATING SLEEP 55 Appendix A Interview Guide Thank you for agreeing to participate in this interview. As a Doctor of Health Science student at The University of Indianapolis, I am conducting this interview as part of my dissertation. The purpose of this study is to understand the sleep experiences of DPT and OTD students. The interview will be recorded to ensure the accuracy of capturing your responses. The recording will be used for transcribing purposes only. Before we begin, do you have any questions? Do you consent to participate in this video-recorded study? I am going to start the recording now. (start the recording) We are now recording. As per the Informed Consent form, the anticipated time frame for the interview will be 1 hour. Your participation in this interview is entirely voluntary. Your responses are for the purpose of this only and will remain confidential. As we move through the interview questions, please let me know if you need to pause or have a moment to collect your thoughts. Also, know that you can skip any question you feel uncomfortable answering, and you can stop the interview at any time. Interview Questions 1. Tell me about your experiences in the DPT/OTD program that impact your sleep. a. Can you tell me more about when you first started the program? b. Can you tell me about when clinicals began? 2. What are your personal concerns about sleep? a. Describe your experiences with stress and anxiety. NAVIGATING SLEEP 3. How do your responsibilities at home and work influence your sleep? a. Tell me about your screen time. i. Tell me about the use of your phone or tell me more about the use of it b. Tell me about your physical activity. c. Tell me about your caffeine intake. d. Tell me about your study environment. 4. In what ways has your sleep changed throughout the program? a. On average, how many hours of sleep do you get each night? b. Can you describe the challenges you face with your sleep? a. How does poor sleep impact you? b. Tell me more about how you feel the next day. c. What do you do to remedy any sleep disturbances? d. Can you give me an example of a positive experience that occurred with your sleep? 5. What changes have you made to your sleep patterns from year to year? a. Tell me how your sleep changed between in-classes and clinicals. b. What tools have you used to achieve better sleep? (i.e., medications, sound machine, light therapy) 6. What does sleep quality mean to you? a. Can you describe your sleep? b. Can you describe what you do to get ready for sleep? 7. What does sleep promotion mean to you? a. Describe sleep promotion in your life? 56 NAVIGATING SLEEP 57 b. What do you do in the clinical setting to promote sleep? c. Can you describe the sleep education you have received within the DPT/OTD program? 8. As a DPT/OTD student, can you think of anything that would be beneficial to know about sleep? a. What affect did sleep have on being a successful DPT/OTD student? b. What would you recommend DPT/OTD programs do to support students sleep? Is there anything else that youd like to share about this topic that we havent discussed? Thank you for participating in the interview today. You will receive a follow-up email in about two to three weeks for the purpose of providing feedback on my interpretations of the information. In the meantime, if you have any questions, you may contact me through phone or email. NAVIGATING SLEEP 58 Appendix B Study Description I am a student in the Doctor of Health Sciences (DHSc) program at the University of Indianapolis. I am inviting you to take part in a research study that will serve as my dissertation for the DHSc degree. The purpose of this study is to understand the sleep experiences of Doctor of Physical Therapy (DPT) and Occupational Therapy Doctorate (OTD) students. Please see the flyer and informed consent form below for more information. This research project has been approved by the University of Indianapolis Institutional Review Board (IRB). Approval date 7/3/2023; Approval number 01872. NAVIGATING SLEEP 59 Appendix C Recruitment Flyer NAVIGATING SLEEP 60 Appendix D Informed Consent Form Interprofessional Health & Aging Studies KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS Participation in this study is completely voluntary, and you have the right to stop participation at any time. If you withdraw from the study, the data collected will be destroyed. If you decide to take part in this study, you will consent to participate in the research during the interview. The purpose of this study is to understand how being a graduate health profession student influences sleep in Doctor of Physical Therapy (DPT) and Occupational Therapy Doctorate (OTD) students enrolled in a traditional (face-to-face) program. This study will involve a videorecorded interview by the researcher for approximately one hour. Approximately 2-3 weeks after the interview, you will receive an encrypted email with meanings of the common words and phrases used. You will review those to make sure they represent your experiences. This review is expected to take approximately fifteen minutes. There are no anticipated risks or discomforts in participating. Upon completion of all interviews, you will receive a $10 Amazon gift card through an encrypted email. CONSENT TO PARTICIPATE IN RESEARCH STUDY Navigating Sleep: Perceptions of Graduate Health Professions Students Study Principal Investigator (PI): Laura Santurri UIndy Email: santurril@uindy.edu UIndy Telephone: 317-788-2409 Study Co-Investigator: Amanda Hood-Abernethy UIndy Email: hoodabernethya@uindy.edu Laura Santurri, Ph.D., MPH, CPH, and Amanda Hood-Abernethy from the Interprofessional Health & Aging Studies at the University of Indianapolis (UIndy) are conducting a research study. You were selected as a possible participant in this study because you are currently enrolled in a traditional DPT or OTD program. Your participation in this research study is voluntary. Why is this study being done? This study is being done to add new information about sleep experiences of graduate students enrolled in DPT and OTD programs. Despite increased efforts to study sleep hygiene in graduate students, there has been little information on the lived experiences of health science graduate students to understand their perceptions of sleep. NAVIGATING SLEEP 61 What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Access a link from an email or social media post to complete a password-protected Google form. Answer questions on the Google Form to proceed with scheduling a day and time for the interview. Participate in a semi-structured one-hour video-recorded interview through the Zoom platform, where the researcher will follow an in-depth interview guide. Two to three weeks after the interview, check for an encrypted email from the researcher that has meanings for the words and phrases used in the interview. Review meanings for accuracy and confirm with the researcher. How long will I be in the research study? Participation will take a total of about one hour and fifteen minutes. The study will involve short-term follow-up, two to three weeks after the interview. Are there any potential risks or discomforts that I can expect from this study? There are no anticipated risks or discomforts. Are there any potential benefits if I participate? You will not directly benefit from your participation in the research. The results of the research may assist graduate health science faculty in supporting their students sleep health and educate health science professionals on sleep hygiene to be better equipped to promote sleep with their professions. Will I be paid for participating? You will receive a $10 Amazon gift card through an encrypted email after all interviews have been completed. Will I receive course credit for participating? No, you will not receive credit for participating. Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences, or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation, or teaching materials. Each participant will select a four-digit identifier to keep information confidential. The key that contains the identifiers and email addresses that participants provide will be stored separately from the data on a password-protected Google file. NAVIGATING SLEEP 62 Will the data from my study be used in the future for other studies? It is possible that de-identified data from this study could be used for future research or shared with other researchers for use in studies, without additional informed consent. De-identified means that any codes and personal information that could identify you will be removed before the data is shared. What are my rights if I take part in this study? You can choose whether you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and remain in the study. Your choice to participate or not participate in this study will not affect your status in your academic program. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments, or concerns about the research, you can talk to one of the researchers. Please contact: Amanda Hood-Abernethy at 828-302-5223 or hoodabernethya@uindy.edu The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. How do I indicate my informed consent to participate in this study? You do not need to sign this or any other document to indicate your consent. Completion of the interview indicates that you are willing to participate. NAVIGATING SLEEP 63 Appendix E Eligibility Screening Questions 1. Please enter your password to continue. 2. I have read and reviewed the Informed Consent Sheet. 3. Is this your first time completing this form? 4. Are you currently enrolled in a DPT or OTD program? 5. Which of the following describes the DPT or OTD program you are enrolled in? a. Traditional (face to face) b. Hybrid (combination of face to face and online) c. Online only 6. Which of the following best describes your student year in the DPT or OTD program? a. 1st year b. 2nd year c. 3rd year d. Other: 7. Which program of study are you enrolled in? a. DPT b. OTD 8. Which of the following best describes your ethnicity? a. White/Caucasian b. Black/African American c. Hispanic or Latino d. Asian/Asian American e. Pacific Islander f. Indigenous or Native American g. Middle Eastern or North African h. Other i. Prefer not to answer 9. What is your age? 10. Which of the following is your preferred gender recognition? a. Male b. Female c. Non-Gender Conforming d. Prefer not to answer NAVIGATING SLEEP 64 11. Are you married? a. Yes b. No 12. A morning lark has a preference for waking up early and going to bed early. A night owl has preference for staying up late and waking up later. Which one best describes yourself? a. A morning lark b. A night owl NAVIGATING SLEEP 65 ...
- Creator:
- Hood-Abernethy, Amanda
- Type:
- Dissertation
15. Simulated Escape Room Influence on Student Physical Therapists’ Perceptions of Clinical Reasoning
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- ... Simulated Escape Room Influence on Student Physical Therapists Perceptions of Clinical Reasoning Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Jessica L. Sullivan, PT, DPT Copyright October 25, 2023 By: Jessica L. Sullivan, PT, DPT All rights reserved Approved by: Elizabeth S. Moore, PhD Committee Chair ______________________________ Briyana Morrell, PhD, RN, CCRN-K, CNE Committee Member ______________________________ Karen E. H. Grossnickle, PT, DHSc Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ PERCEPTIONS OF CLINICAL REASONING 1 Simulated Escape Room Influence on Student Physical Therapists Perceptions of Clinical Reasoning Jessica L. Sullivan Department of Interprofessional Health and Aging Studies, University of Indianapolis PERCEPTIONS OF CLINICAL REASONING 2 Abstract Background: Clinical reasoning is a complex skill that requires clinicians to apply foundational knowledge and practical skills to a unique patient encounter to provide comprehensive care in a dynamic healthcare setting. Healthcare educators must facilitate the development of clinical reasoning early and consistently across the educational curriculum to aid in developing this critical skill. Utilizing a simulated environment to create a realistic healthcare setting may assist in developing clinical reasoning by creating a meaningful and engaging learning experience. Purpose: This basic interpretive qualitative research study aimed to understand physical therapy students perceptions of clinical reasoning and its development, including the impact of a simulated escape room experience. Method: The transcribed data from semi-structured interviews were analyzed using open and axial coding to interpret the educational experiences from the students perspectives. Study results can inform healthcare educators of the influence of a simulated escape room experience on student perception of clinical reasoning development. Results: The main themes that influenced the development of clinical reasoning in physical therapy students were understanding the why, the graduate learning experience, the application of knowledge in practice, and growth. Conclusion: Meaningful, realistic, and engaging learning activities are crucial in developing clinical reasoning. Integrating a simulated escape room learning activity can facilitate clinical reasoning development through the real-world application of knowledge and practice of skills in a safe and engaging environment, emphasizing adaptability and collaboration. Keywords: simulation-based learning, simulated educational escape room, clinical reasoning PERCEPTIONS OF CLINICAL REASONING 3 Acknowledgments Lifelong learning requires tremendous time, effort, and an unwavering support system. Many individuals have been vital to the success of this dissertation, and I am forever grateful for the guidance and support of everyone involved. To my committee, thank you for allowing me to learn and grow professionally and personally. Dr. Moore, you have been instrumental as my committee chair and in many courses throughout this journey. Dr. Morrell, your experience implementing escape rooms within and across disciplines has challenged me to dig deeper and better understand this innovative and engaging learning activity. Dr. Grossnickle, thank you for always providing that little nudge of confidence and being the driving force behind clinical education and the escape room for our students. Of course, my family for always supporting me in these crazy endeavors; I would not be where I am without you. To my dad, who instilled the value of hard work and staying humble at a young age. To my mom for reminding me that relaxing days are always necessary and always pointing out the importance of the little things in life. To my gram, for being that inspiration to never quit and always give your all in everything you do. To my barrel racing family for constantly believing in me and bringing a smile to my face through that little bit of sarcasm. And finally, to my friends who are family. Holly, your continuous encouragement has not gone unnoticed. To my current and past colleagues, thank you for your continuous encouragement and support over my career and this journey. Without you, there would be no patient or student success, and I am forever grateful for your positive influence. And finally, thank you to the students who have challenged me to improve and hone my skills as an educator and clinician. I PERCEPTIONS OF CLINICAL REASONING never would have imagined this as my career path, but it has been and will continue to be an enjoyable journey. Never forget, be adaptable and be excellent. 4 PERCEPTIONS OF CLINICAL REASONING 5 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgments........................................................................................................................... 3 Chapter 1: Introduction ................................................................................................................. 10 Background ............................................................................................................................... 10 Problem Statement .................................................................................................................... 11 Purpose Statement ..................................................................................................................... 12 Research Question(s)................................................................................................................. 12 Significance of the Study .......................................................................................................... 13 Definition of Terms ................................................................................................................... 14 Chapter 2: Literature Review ........................................................................................................ 15 Clinical Reasoning .................................................................................................................... 15 Clinical Reasoning in Physical Therapy ............................................................................... 16 Experiential Learning ................................................................................................................ 18 Simulated Educational Escape Room .................................................................................... 20 Chapter 3: Method ........................................................................................................................ 23 Study Design ............................................................................................................................. 23 Participants ................................................................................................................................ 23 Setting........................................................................................................................................ 24 Procedures ................................................................................................................................. 25 Sampling and Recruitment..................................................................................................... 25 Informed Consent .................................................................................................................. 26 Data Collection...................................................................................................................... 27 PERCEPTIONS OF CLINICAL REASONING 6 Data Management and Analysis ............................................................................................ 30 Rigor and Trustworthiness ........................................................................................................ 32 Results ........................................................................................................................................... 34 Overview of Findings ................................................................................................................ 34 Theme 1 Understanding the Why........................................................................................... 37 Subtheme Create Meaning.................................................................................................. 38 Subtheme Necessary Skills.................................................................................................. 39 Theme 2 Graduate Learning Experience ................................................................................ 40 Subtheme Adaptation to the Graduate Program ................................................................ 40 Subtheme Instructor Guidance ........................................................................................... 41 Subtheme Interweaving of Concepts................................................................................... 42 Theme 3 Application of Knowledge in Practice .................................................................... 43 Subtheme Clinical Education I or Mock ........................................................................ 43 Subtheme Simulation .......................................................................................................... 45 Subtheme Simulated Escape Room ..................................................................................... 46 Theme 4 Growth..................................................................................................................... 48 Subtheme Embracing Being Uncomfortable ...................................................................... 49 Subtheme Self-Reflection .................................................................................................... 49 Subtheme Peer Collaboration ............................................................................................ 50 Summary of Results .................................................................................................................. 51 Chapter 4: Discussion ................................................................................................................... 53 The Role of Clinical Reasoning in Physical Therapy Practice ................................................. 53 Defining Clinical Reasoning ................................................................................................. 54 PERCEPTIONS OF CLINICAL REASONING 7 Communication and Clinical Reasoning ............................................................................... 55 Adaptability and Clinical Reasoning ..................................................................................... 56 Learning Activities Facilitating Clinical Reasoning Development ....................................... 58 Transfer of Knowledge to Clinical Practice .......................................................................... 60 Growth through Self-Reflection ............................................................................................. 61 The Impact of Outside Learning Experiences ....................................................................... 62 The Process of Clinical Reasoning Development.................................................................. 62 The Role of a Simulated Escape Room Activity on Clinical Reasoning Development ........... 64 Influence of Real-World Learning Experiences .................................................................... 65 Experiential Learning ............................................................................................................ 65 Kolb's Experiential Learning Cycle ...................................................................................... 69 Motivation for Learning ........................................................................................................ 73 Limitations and Bias.................................................................................................................. 75 Future Research ......................................................................................................................... 76 Conclusion .................................................................................................................................... 77 References ..................................................................................................................................... 78 Appendix A ................................................................................................................................. 111 Appendix B ................................................................................................................................. 113 Appendix C ................................................................................................................................. 118 Appendix D ................................................................................................................................. 119 PERCEPTIONS OF CLINICAL REASONING 8 List of Tables Table 1: Simulated Escape Room Design.......89 Table 2: Understanding the Why........93 Table 3: The Graduate Learning Experience......95 Table 4: Application of Knowledge in Practice......97 Table 5: Growth........101 PERCEPTIONS OF CLINICAL REASONING 9 List of Figures Figure 1: Clinical Education Series Structure .105 Figure 2: Clinical Education I Mock Course Design ...106 Figure 3: Students Perceptions of Clinical Reasoning Development Central Theme Model...107 Figure 4: Influence of Effective Communication in Clinical Reasoning108 Figure 5: Comparison of Kolbs Experiential Learning Cycle and Central Themes..109 PERCEPTIONS OF CLINICAL REASONING 10 Chapter 1: Introduction Background Developing clinical reasoning is necessary to ensure clinicians can synthesize multiple forms of data to create a safe and positive patient outcome within the clinical setting (Huhn et al., 2019). Clinical reasoning requires complex higher-order cognitive processing or metacognition; thus, the clinician must be proficient and efficient in using this skill within the fast-paced and challenging healthcare environment (Kosior et al., 2019). Facilitating the acquisition of this complex skill within healthcare education can be challenging. The student learner must be motivated to learn and engaged in learning to facilitate acquiring and transferring knowledge related to critical thinking, clinical reasoning, and clinical judgment for application in the clinical setting (Carroll & Morse, 2022). The ability of students to transition foundational knowledge and skill into the real-world environment is challenging due to the complexity and variation of patient presentations, which is difficult to depict in textbooks or peer-to-peer practice (Christensen et al., 2017). Student physical therapists often encounter a steep learning curve during the didactic portion of the Doctor of Physical Therapy (DPT) curriculum due to the immense amount of foundational knowledge required for competent, independent practice. This learning curve is further complicated when students transition from didactic coursework to clinical experiences. In the transition, they must apply foundational knowledge in novel situations by employing critical thinking, problem-solving, and clinical reasoning skills (Christensen et al., 2017). To aid in the transition to student clinician, instructional methods that create a realistic and meaningful learning environment while allowing the safe practice of knowledge and skill application are essential to developing high-order cognitive functions, such as clinical reasoning PERCEPTIONS OF CLINICAL REASONING 11 (Prendergast, 2022). An engaged and active learner facilitates the synthesis of foundational knowledge, psychomotor skill acquisition, and continuous self-reflection, which promotes the development of clinical reasoning in complex situations for positive patient-provider experiences (Gonzalez et al., 2021). With the evolution of technology, experiential learning methods, including simulation, are being utilized within healthcare education programs. Environments that engage the learner and provide authentic experiences in a controlled setting offer unique opportunities to stimulate the development of critical thinking (Morse et al., 2019). Recently, many different healthcare education programs have initiated the use of a simulated escape room (SER) learning experience to engage learners and simulate real-world environments (Carmack et al., 2022; Frost et al., 2020; Fusco et al., 2021; Hardie et al., 2021; Kavanaugh et al., 2020; Plakogiannis et al., 2020). SERs introduce gamification to the healthcare learning environment using clues and puzzles during a simulated patient experience, facilitating collaboration, and mimicking the time constraints of the clinical setting (Franco & DeLuca, 2019). Learning through practice and exposure to problem-based situations, or experiential learning, may facilitate students ability to transfer knowledge into sound clinical reasoning skills and improve clinical performance during clinical education experiences and as novice clinicians (Flowers et al., 2019). Problem Statement Developing clinical reasoning within the didactic curriculum in healthcare education programs is difficult due to the complexity of the skill, the educational environment, the student learner, and the educator (Young et al., 2020). Creating and implementing instructional methods that stimulate learner engagement through realistic and meaningful learning activities is crucial in developing the higher-order cognitive process of clinical reasoning. The SER experience uses PERCEPTIONS OF CLINICAL REASONING 12 experiential learning to facilitate the transfer of didactic knowledge to clinical skills with the added elements of gamification (Flowers et al., 2019). The addition of gamification simulates the time constraints of the clinical setting and enhances peer collaboration to escape the room. Understanding the student physical therapists perception of how an SER activity impacts the growth and development of their clinical reasoning skills will assist educators in adapting and modifying this technique to address the development of this complex skill. Purpose Statement This qualitative study aimed to understand student physical therapists perceptions of their clinical reasoning skills and how an SER influenced the acquisition of this complex skill within the physical therapy curriculum. Understanding the students perceptions of clinical reasoning and how this educational method impacted this skill will assist educators in adapting future learning activities to address the needs of the student and the profession. Research Question(s) 1. How do first-year DPT students describe the role of clinical reasoning within professional practice? a. How do students define clinical reasoning? b. How do students describe the use of clinical reasoning during physical therapy practice? c. How do students think their clinical reasoning has evolved since they began the physical therapy program? i. How do students think the learning activities they have experienced since beginning the physical therapy program have influenced their understanding and development of clinical reasoning skills? PERCEPTIONS OF CLINICAL REASONING 13 2. How do first-year DPT students perceive the influence of a simulated educational escape room activity in developing their clinical reasoning skills in preparation for their first clinical rotation? a. How do students describe their experience with the simulated escape room activity? i. How do they think this activity impacted their clinical skills? ii. How do they think this activity used clinical reasoning? iii. How do they think this activity impacted their attitude toward clinical practice? b. How do students describe their thought process during the learning activity? i. How do students describe their performance during the escape room activity? Significance of the Study Gaining insight into students perceptions of their growth and use of clinical reasoning will benefit multiple stakeholders, including educators, clinical instructors, students, and the educational program. Understanding the students perspective of how an SER impacted their development of clinical reasoning and transition to clinical practice will assist educators in developing and implementing learning activities that align with students needs. With the inclusion of more simulation-based instructional methods, this study aimed to provide insight into students perception of how the SER impacted their growth and development of clinical reasoning as they transitioned into their first external clinical experience. The cultivation of clinical reasoning skills in students is difficult to address and measure in healthcare education PERCEPTIONS OF CLINICAL REASONING 14 programs; thus, the student perspective is necessary to address any potential limitations within the educational and professional setting. Definition of Terms Clinical reasoning utilizing cognitive skills through critical thinking and clinical judgment to provide positive patient-centered care related to the specific healthcare profession (Gonzalez et al., 2021) Simulated educational escape room a teaching method emphasizing learning and engagement through various puzzles based on the specific problem or scenario (Anderson et al., 2021) Simulation or simulation-based learning using standardized patients to play a role while the student completes an assigned task or relevant clinical decision-making for the presented patient scenario (Society for Simulation in Healthcare, n.d.) PERCEPTIONS OF CLINICAL REASONING 15 Chapter 2: Literature Review Healthcare clinicians employ multiple strategies during patient encounters to ensure safe and effective care regardless of the discipline. Due to the highly unpredictable nature of the healthcare setting and increasingly complex and uncertain patient presentations, clinicians must competently employ a multifaceted skill, or a process, called clinical reasoning (Kosior et al., 2019). The complexity of clinical reasoning is evident in the lack of a concrete definition across and within healthcare disciplines (Furze et al., 2022). Utilizing clinical reasoning efficiently and effectively within clinical practice requires an awareness of ones cognitive processes to adapt those cognitive strategies for successful problem-solving, better known as metacognition (Kosior et al., 2019). Due to the complex nature of clinical reasoning, educators must address the development of clinical reasoning early in the educational process and assess it continuously to ensure learner competency (Pinnock et al., 2019). The Commission on Accreditation in Physical Therapy Education (CAPTE) emphasizes the critical role of clinical reasoning in physical therapy practice by requiring accredited programs to assess students for competency in professional practice (CAPTE, 2020). Clinical Reasoning Young et al. (2019) discovered that healthcare education literature uses several definitions of clinical reasoning. Such literature describes several multi-dimensional components of clinical reasoning, such as problem-solving, critical thinking, diagnostic reasoning, and clinical judgment. The healthcare curriculum must include a variety of instructional methods to ensure the learner is equipped with the knowledge and experience to utilize complex clinical reasoning skills throughout all aspects of clinical practice (Young et al., 2020). PERCEPTIONS OF CLINICAL REASONING 16 Clinical reasoning is much more than memorization and regurgitation of content. It requires higher-order executive functions to be attentive to and able to analyze and interpret multiple forms of information during the unique patient encounter (Roitsch et al., 2021). Clinicians are guided by previous experience, knowledge, intuition, and best practice evidence when applying critical thinking during clinical decision-making (Roitsch et al., 2021). Students in healthcare education programs must develop a deep understanding of foundational concepts, apply knowledge and skills in a clinical setting, and effectively reflect in action for positive patient-centered outcomes (Parodis et al., 2021). This application requires students to manage their cognitive, psychomotor, and affective processes by attending to what is essential, ignoring irrelevant data, controlling their emotions, and assessing their clinical reasoning through constant and constructive self-reflection (Kosior et al., 2019). Clinical Reasoning in Physical Therapy Clinical reasoning in physical therapy builds upon the knowledge and understanding of the basic sciences, including human anatomy and physiology, the influence of movement on the various body systems, biopsychosocial factors of the individual, and contextual factors within the rehabilitation process (Gilliland & Wainwright, 2017). Individual patient presentation is unique to the specific injury, surgical procedure, or chronicity of the condition, requiring the physical therapist to integrate multiple sources of information and collect sufficient data to create a comprehensive patient-centered care plan. Gilliland and Wainwright (2017) found that the development of clinical reasoning skills for physical therapy practice requires the inclusion of multiple instructional methods to facilitate knowledge and skill acquisition and is also highly dependent on the student learner. The learner must be active in the learning process, motivated to PERCEPTIONS OF CLINICAL REASONING 17 practice learned skills and be able to self-reflect before, during, and following the learning activity (Huhn, 2017; Prfontaine et al., 2022; Re et al., 2019). Student clinicians often rely on what they are taught when making clinical judgments using critical thinking and clinical reasoning due to their limited clinical practice experience. Experienced clinicians can use forward reasoning by quickly identifying patterns to move from specific observations to a physical therapy diagnosis (Edwards et al., 2004). In contrast, student clinicians often utilize hypothetico-deductive reasoning, creating multiple initial hypotheses and moving toward a more specific diagnosis due to limited experience in pattern recognition (Edwards et al., 2004; Higgs et al., 2019). Novice physical therapy student clinicians are provided a foundational framework through educational activities from which to build their clinical reasoning skills and gain the experience necessary to reason at higher cognitive levels. This framework gives student clinicians a strong base for developing their clinical reasoning skills during physical therapy practice to meet the demands of patients and the profession. There is consensus in the literature that clinical reasoning in physical therapy practice is a complex, multidimensional process that is highly contextual and requires the physical therapist to integrate psychomotor, cognitive, and affective skills (Christensen et al., 2017; Gilliland & Wainwright, 2017; Huhn et al., 2019). Although there is consensus on the complexity of clinical reasoning in physical therapy practice, how clinical reasoning can be effectively taught and assessed within DPT programs is much less clear. Current guidelines by the CAPTE (2020) identify the standards and required elements for accreditation of physical therapist education programs, including Standard 7B, which ensures that the curriculum implements learning opportunities and content delivery related to clinical reasoning. PERCEPTIONS OF CLINICAL REASONING 18 Current literature in physical therapy education relates to developing clinical reasoning skills and identifies distinct differences within and across programs (Huhn et al., 2019). The notable differences may relate to unestablished definitions of clinical reasoning and differences in the modes of instruction and the assessments used (Christensen et al., 2017; Huhn, 2017; Huhn et al., 2019). Christensen and colleagues (2017) discovered that the most common frameworks utilized when teaching and developing clinical reasoning skills were the PatientClient Management Model described in the Guide to Physical Therapist Practice and the International Classification of Functioning, Disability, and Health (ICF) model by the World Health Organization. Standard modes of assessment of clinical reasoning skills found by Christensen and colleagues (2017) emphasized practical/written examinations and clinical experiences, with the most common tool utilized to assess clinical reasoning being the Physical Therapist Clinical Performance Instrument (PT CPI version 2.0) of the American Physical Therapy Association (2006). Very few programs offer a specific course related to clinical reasoning skill acquisition, and experiential learning methods are not as prevalent as coursework integration and clinical experience (Christensen et al., 2017). Experiential Learning With the evolution of technology, interactive teaching strategies such as the use of a flipped-classroom approach (Re et al., 2019) and the use of simulated or experiential learning environments (Sabus & Macauley, 2016; Smith & Crocker, 2017) have emerged as valid educational tools for facilitating the development of clinical reasoning skills in student physical therapist. Experiential learning, which emphasizes the constructivist theory through studentcentered learning, enhances the acquisition and retention of complex skills through applying knowledge and practicing skills within a realistic clinical setting (Smith & Crocker, 2017). PERCEPTIONS OF CLINICAL REASONING 19 Current research suggests that using experiential learning methods improves learner selfawareness or confidence in practical skills and provides a safe environment, allowing mistakes to be corrected and multiple practice opportunities (Flowers et al., 2020; Smith & Crocker, 2017). Literature related to traditional methods of instruction, including lectures and laboratory activities, demonstrates that these methodologies are often insufficient in preparing students for clinical practice (van Lankveld et al., 2019). Research has found that traditional instructional methods oversimplify clinical reasoning, limiting student understanding of the complex cognitive, psychomotor, and affective components required and the unique attributes the individual clinician contributes to the clinical reasoning process (Christensen et al., 2017; Pritchard et al., 2016). Clinical reasoning is a complex process that requires active learner participation in developing and refining this skill. Traditional lecture-based content delivery methods emphasize passive learning and limit realistic relatability (Harris & Welch Bacon, 2019). Although learning occurs through active and passive instructional strategies, research supports the added benefits of active learning, including greater in-depth development of higherorder cognitive processes, thus lending itself well to addressing clinical reasoning development (Harris & Wlech Bacon, 2019). Current research on clinical reasoning has focused on methods to measure students ability to utilize clinical reasoning in physical therapy practice (Elvn et al., 2019; TorresNarvez et al., 2018). Research has also focused on determining the amount of clinical experience required to facilitate the development of clinical reasoning skills (Flowers et al., 2020; Huhn, 2017). Although research on measuring clinical reasoning is available, there is limited research regarding students perception of the impact of educational experiences, such as simulation-based learning (SBL), virtual reality, or the flipped classroom, on developing clinical PERCEPTIONS OF CLINICAL REASONING 20 reasoning skills. Understanding the students view of lived educational experiences may allow educators to adapt instructional methods to emphasize active learning and create more meaningful learning environments, thereby enhancing knowledge retention and transfer. Gathering this perspective may also aid educators in providing the necessary rationale for students to understand the meaning of the learning experience, creating greater buy-in to the learning activity. This improved understanding of the meaning behind the learning activity may better equip students to be active participants and better identify and address their knowledge gaps related to clinical reasoning. SBL has been an integral instructional delivery method in healthcare education programs over the past two decades (Bearman et al., 2019; Macauley et al., 2017), with many studies examining the implementation of this educational method. Bearman et al. (2019) found that learning through simulation provided opportunities for the effective practice of clinical skills. Further review of the research demonstrated that students tended to have positive perceptions and emotions during and following SBL activities (Collins et al., 2021; Penman et al., 2020) as well as positive emotions associated with the learning experience (Behrens et al., 2021; Rogers et al., 2019). Collins and colleagues (2021) found that students perceptions of a simulated interprofessional experience were positive and that it was beneficial in developing role identity and affective skills necessary to be successful in the complex healthcare environment. Penman and colleagues (2020) highlighted the value found by students in a simulation as it improved their confidence and aided in preparing them for clinical practice. Simulated Educational Escape Room Educational strategies to improve learner engagement by integrating SBL, including gamification of the experience through an escape-room format, have also been developed and PERCEPTIONS OF CLINICAL REASONING 21 implemented recently (Franco & DeLuca, 2019). Not only does the escape room add an element of competition to the learning process, but it also allows for the acquisition and refinement of team building, communication skills, and opportunities for peer-to-peer learning within a controlled environment (Morrell et al., 2020; Mullen & Seiler, 2019; Sarage et al., 2021; Valdes et al., 2021; Zhang et al., 2018). Much of the current evidence supporting the use of an SER learning activity in healthcare education has been within the field of nursing and supports the use of this education method to improve the identification and implementation of safe practice techniques (Backhouse & Malik, 2019; Daniels et al., 2022; Diemer et al., 2019; Jaffe et al., 2022; Zhang et al., 2019) as well as ways to incorporate complex learning situations in a more realistic environment. Nursing escape rooms have included clinical care for individuals with heart failure (Plakogiannis et al., 2020), diabetes management (Kavanaugh et al., 2020), and maternal health during labor and delivery (Hardie et al., 2021). The research has demonstrated that this gamification within the learning environment has improved learner knowledge retention (Sanders et al., 2021), engagement during the learning experience (Dacanay et al., 2021; Grande-de-Prado et al., 2021), and transfer of knowledge from the didactic curriculum to clinical skills (Mullen & Seiler, 2019). There is also evidence that this interactive educational strategy decreases student anxiety and stress (Lpez-Belmonte et al., 2020; Molina-Torres et al., 2021) and improves skills such as active listening, teamwork, and leadership (Morrell et al., 2020). Additional literature addresses the use of SER learning activities to develop skills related to interprofessional education. Providing accurate and timely diagnoses, prognoses, and patient treatment requires collaboration and teamwork within and across professions (Fusco et al., 2021). Although this area of inquiry is in its infancy, positive results related to healthcare student PERCEPTIONS OF CLINICAL REASONING 22 success have been found with the use of a SER format for improving the collaborative experience and understanding of the importance of interprofessional relationships (Carmack et al., 2022; Collins et al., 2021; Friedrich et al., 2020; Frost et al., 2020; Fusco et al., 2021). SERs require learners to not only attend to the simulated environment but they must also be aware of time and other contextual factors, thereby challenging the learners to manage multiple tasks at once, reflective of the day-to-day healthcare environment (Anderson et al., 2021; Morrell et al., 2020). Anderson and colleagues (2021) emphasize the importance of ensuring a real-world design of the SER to allow for the transfer of practical skills to the clinical setting. Transforming a recreational game into a healthcare learning activity to facilitate student transition to clinical practice requires educators to think outside the box in aligning the educational objectives with the escape room format (Eukel & Morrell, 2021). A wealth of evidence supports the importance of developing clinical reasoning in the healthcare education setting, as it is an essential skill within clinical practice. However, due to the complex nature of clinical reasoning, implementing specific learning activities addressing this skill has not been consistent within curricula (Christensen et al., 2017; Huhn, 2017; Huhn et al., 2019). Few research studies have aimed to understand the student perspective on developing clinical reasoning and the educational experiences necessary for the successful execution of this skill in the clinical setting. Research related to the impact of an SER on the development of clinical reasoning, as viewed through the student perspective, is limited. Understanding the perceived impact of this instructional method on the development of clinical reasoning will assist educators in successfully implementing and adapting this innovative strategy to facilitate learner knowledge and skill acquisition. PERCEPTIONS OF CLINICAL REASONING 23 Chapter 3: Method Study Design This basic interpretive qualitative research study aimed to understand how physical therapy students perceive the influence of an SER on their development and understanding of clinical reasoning. The SER activity utilizes gamification of a simulated real-world environment, or scenario, to improve learner engagement and facilitate the development of practical skills in a safe environment (Franco & DeLuca, 2019). This design allowed the researchers to gain insight into students interpretation of the experiential learning activity through active participation and reflection through the constructivist lens (Merriam & Tisdell, 2016). Based on the constructivist approach of adult learning theories, the learner creates new ideas or concepts actively by comparing newly acquired information to previous experience and knowledge (Mukhalalati & Taylor, 2019; Rob & Rob, 2018). Understanding how students have constructed their meaning of clinical reasoning and their perception of the influence of an experiential learning experience, such as a SER, provides valuable information to the researchers to best guide future instructional methods aimed at developing this complex skill (Creswell & Poth, 2018). Participants Participant recruitment was from a first-year DPT student cohort at a rural, public midwestern university. Participants were recruited from a mock orthopedic clinical education course after they had completed one SER activity with all required components. All participants were 18 years or older and fluent in English. Exclusion criteria included not participating in the in-person SER experience and not completing all the necessary coursework associated with the SER activity. PERCEPTIONS OF CLINICAL REASONING 24 Setting The 16-week Clinical Education I or orthopedic mock course was in the third semester of the students first year. This course is the first in a sequence of five integrated or external clinical experiences for the program (Figure 1). The course structure for this first integrated mock experience included an SER activity during the first and fifteenth weeks of the semester and peer-to-peer low simulation orthopedic mock patient encounters during the second through fourteenth weeks (Figure 2). The SER experience occurred in a simulation center with groups of three to four students, randomly assigned to one standardized patient with one faculty member (including J. L. S. and K. E. H. G.) observing each group. The simulation center mimicked an emergency department where students evaluated and treated the standardized patient based on a clinical scenario in which the patient had sustained a lower limb fracture. Students were required to utilize knowledge and practical skills from the previous two semesters and the current semester of the graduate program to complete an initial evaluation and initiate an intervention for the patient. The student groups had 60 minutes to complete the physical therapy evaluation and treatment learning activity. The SER activity included solving five puzzles, unlocking five boxes, and completing a final word scramble puzzle, highlighting the critical thinking focus of the SER (Table 1). Puzzle design aimed to facilitate the initial evaluation sequence through subjective and objective examination techniques combined with analyzing the gathered information to complete a physical therapy assessment, treatment, and discharge plan. Table 1 provides an overview of the puzzle structure and learning objectives. The simulated emergency department included relevant props, including medication bottles, assistive devices and PERCEPTIONS OF CLINICAL REASONING 25 footwear, patient personal items, and other related technology often encountered in the hospital environment. Procedures Sampling and Recruitment Convenience sampling was utilized based on the availability of students who participated in person during the SER activity and voluntarily agreed to participate. This sampling technique aimed to gather an in-depth understanding of first-year DPT students perspectives on clinical reasoning and the influence of a SER activity on the development of their clinical reasoning (Merriam & Tisdell, 2016). The aim was for a representative sample of 1225 participants to provide information from multiple sources to enhance data triangulation and facilitate the studys trustworthiness (Merriam & Tisdell, 2016). The variance in the number of participants depended on reaching the saturation of gathered information, which was determined during initial data analysis. A systematic review by Hennink and Kaiser (2022) found that saturation, or when no new themes emerge from continued data collection, was reached between 9 and 17 interviews. For this study, saturation was determined when no new themes emerged from subsequent interviews, with the goal of 12 as the minimum number of interviews based on the findings of Hennink and Kaiser (2022). The primary researcher (J. L. S.), a faculty member in the DPT program, sent an initial email (Appendix A) to the entire cohort via University-supported email during the semester in which data collection would occur. The original email message included a copy of the consent form (Appendix B), a brief description of the study and study design, and contact information (email, phone, and office location) of the primary investigator for potential participants to contact with any questions, for clarification of study requirements, and if they were interested PERCEPTIONS OF CLINICAL REASONING 26 in participating in the study. The informed consent emphasized that participation is voluntary and would not impact grades received in the course, addressing the potential influence of the co-instructor role of the primary and co-investigator within the course of interest. As a followup to the initial email, the primary researcher revisited the study invitation and provided an opportunity to answer any questions potential participants might have had regarding participation in the study as part of an in-person lecture during the orthopedic mock course to the first-year cohort. A paper copy of the consent form was also available for students during the brief in-person information session. The primary researcher screened interested participants to determine eligibility once interest had been expressed by phone, email, or in person. Following this screening process (Appendix C), the primary researcher used the University-supported email to contact eligible participants to schedule an in-person or virtual interview based on the researcher's and the participant's availability. All interested participants were determined to be eligible to participate in the study following the screening process. The primary researcher contacted all participants within one week of expressing interest in this research study to disclose their eligibility status. Informed Consent Attainment of informed consent followed the policies and procedures outlined by the Universitys Institutional Review Board (IRB), where the research study was conducted. This study was completed as part of a doctoral dissertation through a different university than where the data were collected. Therefore, it was registered with the IRB of the that institution. The informed consent provided the potential participant with details related to the confidentiality of information, including how data was collected, de-identified, and stored, as PERCEPTIONS OF CLINICAL REASONING 27 well as details related to the structure of the interview process. The potential participants were informed of the interview process, including their ability to stop the interview at any time, defer answering a question, and the ability to voluntarily withdraw from the research study at any time. Once potential participants were screened for eligibility, the primary investigator sent them the consent form via an encrypted University-supported email informing them of their eligibility to participate in the study. An electronically encrypted University-supported email was also used to collect signed conent forms. Paper-signed consent documents were stored in a separate locked file cabinet from where any paper copies of de-identified data were stored and were clearly labeled within the primary investigators University-provided locked office to aid in the protection of participant confidentiality. Electronically received signed consent forms through encrypted University-supported email of the primary investigator were stored in a clearly labeled folder within the University-supported Microsoft OneDrive account of the primary investigator. The consent forms received by email were then deleted. Data Collection Data were collected via individual semi-structured in-person interviews. Before data collection, two volunteer in-person pilot interviews were performed with participants from an earlier cohort of the DPT program who had participated in the SER experience. In-person interviews took place in a closed room for privacy and included the primary researcher and participant. Two handheld password-protected audio recording devices (Digital Voice Recorder by G and Digital Voice Recorder by EVIDA) were utilized with the de-identified file uploaded to the University-supported, password-protected Microsoft OneDrive account of the primary investigator. Verbatim transcription was performed using the University- PERCEPTIONS OF CLINICAL REASONING 28 supported, password-protected Microsoft Word program and saved utilizing the primary investigators University-supported, password-protected Microsoft OneDrive account. Once uploaded to the secure server and transcription verified, the recording was deleted from the recording device. The audio recording devices (Digital Voice Recorder by G and Digital Voice Recorder by EVIDA) were stored in a locked cabinet in the primary investigators University-provided locked office and were only connected via USB to a University-provided laptop of the primary investigator. The transcribed Microsoft Word document was uploaded to the University-supported, password-protected NVivo qualitative data analysis (QDA) software for data analysis. The semi-structured interview process included initial greetings by the primary investigator, followed by reading the introductory paragraph of the interview guide (Appendix D). Following the attainment of verbal informed consent to begin the interview, the audio recording method was initiated, and the interview started. The interview consisted of seven primary questions. Follow-up questions were utilized to clarify responses and encourage elaboration. The first three questions addressed the participants perception of clinical reasoning and how those perceptions have changed throughout the participants educational process. The final four interview questions and sub-questions aimed to elicit the students perspective regarding how an SER activity was perceived as influencing growth as a student physical therapy clinician and the development of clinical reasoning. To conclude the interview, the participant was asked if there was anything else they may want to add related to developing their clinical reasoning throughout their journey through the DPT program. Throughout the interview process, the primary researcher took detailed notes related to the verbal and non-verbal responses of the participant, as well as PERCEPTIONS OF CLINICAL REASONING 29 identifying any potential biases the researcher may have that may influence the data collection process. This field journal also included a reflection of the primary investigator regarding the strengths and weaknesses of each interview following the activity to allow for modifications as needed throughout the data collection process to ensure data collection addressed the research question. After all interview and follow-up questions had been answered, the audio recording was stopped. The participant was thanked for participating in the research study and encouraged to contact the primary investigator with any questions or concerns. Member checking, also known as respondent validation, was performed after interview data collection. The primary investigator provided participants with a summary of the individual interview to ensure the proper interpretation of gathered information had been made (Merriam & Tisdell, 2016). Member checks were communicated via the encrypted University-supported email of the primary investigator. Member checking allowed the participant to provide feedback on the information collected to ensure it accurately represented their thoughts, feelings, and beliefs related to the interview questions (Merriam & Tisdell, 2016). The primary investigator provided the participant with a summary of the interview within three weeks of the interview to ensure accurate recollection of the interview process by both the participant and the researcher. The participant was asked to respond to the summary email within two weeks of receiving the email with reminder emails sent out by the primary investigator at one-week intervals to ensure adequate follow-up was met. Member checking allowed the researcher to identify any biases and limited the possibility of misunderstanding the perceptions of the participants and was one component of triangulation to improve the studys internal validity (Merriam & Tisdell, 2016). PERCEPTIONS OF CLINICAL REASONING 30 Data Management and Analysis The de-identified audio files, de-identified transcribed files of the audio recordings, coded transcriptions, and de-identified observational field notes of the primary investigator collected during the semi-structured interview sessions were stored within the passwordprotected, University-supported NVivo QDA software and Microsoft OneDrive of the primary investigator. Any paper copies, including signed consent forms and the primary investigators observational field notes, were stored in a separate, clearly labeled locked file cabinet in the primary investigators University-provided locked office. Apart from signed informed consent, all files were de-identified using a participant identification number and naming based on this assigned participant identification number. Written informed consent forms were stored separately from the de-identified information to protect participant privacy. Folders and sub-folders were created physically in the locked file cabinet and within the University-supported, password-protected NVivo and Microsoft OneDrive accounts of the primary investigator to organize the collected data, including transcribed files and individually coded interviews. Data analysis began with the transcription of the audio component of the interview using University-provided, password-protected Microsoft Word and saved in the passwordprotected, University-provided Microsoft OneDrive account with the transcribed files then uploaded to the password-protected, University-supported NVivo QDA software. Interviews were transcribed verbatim to gain a detailed analysis of the participants constructed experience, as McLellan et al. (2003) suggested. Each transcribed interview was structured and formatted based on the recommendations of McLellan et al. (2003) and the requirements of the NVivo QDA software to ensure proper saving within the software system. Verbatim PERCEPTIONS OF CLINICAL REASONING 31 transcripts were de-identified using the assigned participant identification number. The transcription document was compared to the audio file by the primary investigator with random external audits performed by a co-investigator to improve the accuracy of the transcribed de-identified data. Following transcription, data analysis continued utilizing the University-supported NVivo QDA software and followed the steps outlined by Merriam and Tisdell (2016). Open coding of the transcribed interviews was performed to allow for identifying significant or relevant information related to the studys purpose. This coding process allowed for the construction of categories or themes by grouping codes related to each other, also known as axial coding (Merriam & Tisdell, 2016). Coding was performed within the transcribed file, whereas category construction was kept separate to combine emergent themes from the other transcribed interviews. Emergent themes were compared across transcribed interviews, allowing for capturing recurring patterns throughout the gathered data (Merriam & Tisdell, 2016). Once all transcribed data were coded and emergent themes identified, categories were sorted for thematic analysis. During the thematic analysis and the sorting process, the original identifying codes, participant identification number, and line number within the transcription were included to enable review and ensure the accuracy of data analysis (Merriam & Tisdell, 2016). An inductive process was performed initially but then transitioned to a more deductive method as data saturation was achieved (Merriam & Tisdell, 2016). Emergent categories were refined to four relevant themes for interpreting results and discussion, with themes meeting the criteria outlined by Merriam and Tisdell (2016), including being exhaustive, mutually exclusive, sensitive, and conceptually congruent. PERCEPTIONS OF CLINICAL REASONING 32 Throughout the data analysis process, the researcher continued maintaining a field journal, emphasizing reflexivity through self-reflection and addressing any potential biases that may impact the accuracy of this process. The field journal included any unexpected or notable findings during the data analysis process to aid in adapting questions in future interviews to best address the study's purpose. Other recordings within the field journal included any ethical dilemmas that may have arisen and any bias that the researcher may have noted related to the data analysis process. This field journal was updated continuously during the data analysis process, specifically following the completion of each transcription and coding of each transcribed interview. Following data analysis of all completed interviews, a co-investigator performed an external audit of the coding and categorizing themes to ensure objectivity and consistency within the data analysis process. Rigor and Trustworthiness Gubas Model of Trustworthiness of Qualitative Research, as described by Henderson and Rheault (2004), was utilized throughout this research study's data collection and data analysis process. Credibility, or the ability to believe the findings, was upheld using a field journal and researcher reflexivity to address any potential biases or assumptions that may have impacted the investigation. To further address credibility, triangulation using multiple interviews, field journaling, external auditors, and member checking through an encrypted emailed summary of the interview was included to identify and assess emergent findings. When addressing transferability, or the ability of the results to be transferred to similar contexts, rich descriptions of the setting and the sample characteristics were included in determining context similarity for the transfer of results (Merriam & Tisdell, 2016). Dependability, or repeatable results, was facilitated by detailed method descriptions and PERCEPTIONS OF CLINICAL REASONING 33 external audits of the data analysis process. Triangulation using multiple participants and the coding procedures outlined by Merriam and Tisdell (2016) further addressed the study's dependability. Finally, reducing research bias through objectivity, or confirmability, was addressed through researcher reflexivity through field journaling and triangulation by including multiple participants in the data collection process. Ensuring methodological rigor, or extensive attention to detail throughout the data collection and analysis process, improved the research study's trustworthiness (Merriam & Tisdell, 2016). Throughout the data collection process, semi-structured interviews aimed to provide the primary investigator with students perspectives of clinical reasoning and how they viewed an SER experience in impacting the development of this skill. Data analysis derived emergent themes through coding and allowed the researcher to examine those themes across interviews to understand students' common thoughts and ideas related to clinical reasoning and the specific experiential learning activity. Using member checking, reflective field journaling, and co-investigators throughout the data analysis process improved the study's internal validity, ensuring the results reflected students perceptions. PERCEPTIONS OF CLINICAL REASONING 34 Results A total of 17 participants met the inclusion criteria for this study and completed the voluntary interview. Of the 17 participants, 13 completed the member-checking process. Participants were in the third semester of their first year in a midwestern DPT program. The semi-structured, in-person interviews ranged from 1435 minutes, with an average of 22 minutes per interview. Questions in semi-structured interviews related to defining clinical reasoning, identifying its role in clinical practice, and how the program influenced the development of clinical reasoning (Appendix D). The questions and sub-questions of the interview aimed to better understand students perspective of clinical reasoning and its development throughout the first year of the graduate program. Overview of Findings Participants identified four significant themes as playing a critical role in the development of clinical reasoning across the first year of the DPT curriculum: understanding the why (Table 2), the graduate learning experience (Table 3), application of knowledge in practice (Table 4), and growth (Table 5). The four tables provide specific participant quotations as supportive evidence of the central themes, including subthemes from data analysis. The themes illuminated the positive influence of the SER on clinical reasoning. The need to understand the meaning and application of clinical reasoning as viewed through the lens of a physical therapy clinician, understanding the why and application of knowledge in practice, combined with the need to reflect on growth and experience, growth and the graduate learning experience, provides insight to educators on how student physical therapists perceive the influence of an SER on the acquisition of clinical reasoning. PERCEPTIONS OF CLINICAL REASONING 35 A conceptual model in Figure 3 depicts the interrelationship (see arrows demonstrating the thematic relationships) among the central themes of understanding the why, the graduate learning experience, application of knowledge in practice, and growth. Participants identified these themes as critical components of their clinical reasoning development. Learning experiences, such as mock and the simulated escape room (knowledge application in practice), were essential in understanding the critical role of clinical reasoning in physical therapy practice (understanding the why). These learning experiences aided in understanding clinical reasoning by creating meaning and justifying the need for skilled physical therapy services (understanding the why). The identified learning experiences were necessary for making the learning activities meaningful and applicable to real-life scenarios (knowledge application in practice). Participants identified a link between the ability to understand the meaning of clinical reasoning as it applies to clinical practice (understanding the why) and the challenges and rigors of the graduate healthcare program (the graduate learning experience). They also highlighted the interrelationship between being challenged to critically analyze situations to provide quality physical therapy services (the graduate learning experience) and its role in facilitating the understanding of clinical reasoning and use in physical therapy practice (understanding the why). Utilizing critical thinking and problem-solving in the clinical setting requires giving meaning to the situation and justifying the need for skilled physical therapy services (understanding the why), facilitating the ability to connect concepts across courses and semesters (the graduate learning experience). Participants identified the role of being pushed outside ones comfort zone and instructor feedback (the graduate learning experience) as critical components in making the learning experiences, such as the SER (knowledge application in practice), meaningful in their PERCEPTIONS OF CLINICAL REASONING 36 development of clinical reasoning. The need for critical thinking and problem-solving during learning activities is greatly influenced by instructor feedback, especially when students struggle or have limited understanding. Participants reflected on the importance of instructor guidance in identifying gaps in clinical reasoning and improving their ability to translate foundational knowledge into clinical practice. They also acknowledged the importance of the learning activity itself (knowledge application in practice) as playing a critical role in their overall learning experience (the graduate learning experience) by pushing their limits of clinical reasoning and demonstrating the need for continuous learning and practice to be able to implement this complex skill successfully in clinical practice. When developing and refining clinical reasoning in practice, participants identified the importance of being continuously challenged in their ability to apply foundational knowledge in real-world situations, thus identifying the interrelationship between growth and application of knowledge in practice. Without identifying areas of needed improvement through constant selfreflection (growth), participation in activities aimed at simulating clinical conditions (application of knowledge in practice) would not be as helpful in developing clinical reasoning skills. The same is true when applying foundational skills in real-world situations; being challenged in their critical thinking and problem-solving in meaningful ways promotes the growth of clinical reasoning and the ability to translate knowledge into clinical practice. Participants also identified the interrelationship between growth and the graduate learning experience. The rigors of a graduate healthcare program are necessary to meet the demands and expectations of the healthcare field, which are challenging and require continuous learning and growth, especially for novice clinicians. Participants identified the importance of experiences within the graduate program, including instructor feedback and interweaving of PERCEPTIONS OF CLINICAL REASONING 37 concepts across courses and semesters. They also highlighted the challenge of interweaving concepts as it required them to reflect on past experiences, a necessary component of clinical reasoning and developing this skill. Participants reported that self-reflection on personal and professional growth since the beginning of the program also aided in their ability to adapt to the program requirements and continue gaining the invaluable experience necessary to be skilled, competent physical therapy clinicians. Through self-reflection and peer collaboration (growth), participants identified the need to understand the role of clinical reasoning and why this complex skill is essential in their journey to becoming skilled physical therapy clinicians (understanding the why). Participants also identified that this rich understanding of clinical reasoning (understanding the why) aided their ability to reflect on their development of this skill (growth) to continue challenging themselves as student clinicians. The interrelationship among themes highlights the intricacies and complexities of clinical reasoning in physical therapy practice and reflects the fluidity of this process, even as student physical therapists. Theme 1 Understanding the Why For the first central theme, understanding the why, participants highlighted the need to create meaning and understand the role of clinical reasoning during the unique patient-provider experience. Throughout the interview process, it was apparent that participants had difficulty verbalizing their interpretation of clinical reasoning. This difficulty was evident by the frequent use of um and rephrasing of their definition or meaning when answering the question: What does clinical reasoning mean to you? as well as by their non-verbal responses to this question, such as looking around the room or away from the researcher, almost as if searching for an explicit explanation. When answering this question, Participant 3 stated, Thats a good PERCEPTIONS OF CLINICAL REASONING 38 question. Participant 14 added, Oh gosh, these are going to be tough questions. Participants did, however, clearly identify the vital role of clinical reasoning within physical therapy practice. Participants were also able to identify learning experiences that aimed to enhance this complex skill across the curriculum, such as multimodal instruction, examinations, simulation experiences, and volunteer opportunities. Being able to create meaning during the patientprovider encounter resonated with participants in that it provided a way to justify why physical therapy services were necessary for the given patient. Participants identified adaptability and effective communication as skills needed for in-the-moment clinical decision-making. Subtheme Create Meaning Participants described the importance of collecting and utilizing all available information to develop a deeper understanding, or meaning, of the patients clinical presentation to justify the need for skilled physical therapy. Participant 6 highlighted clinical reasoning as making your best judgment based off the knowledge that you have on the situation. Creating meaning was further described by Participant 4, who stated, You cant always see whats wrong with the individual, so you have to be able to hear what theyre saying and what theyre describing and then interpret those and being able to use them because you cant just see. Participant 15 further expanded on creating meaning by saying that clinical reasoning means being able to use findings to make decisions based on the patients presentation. When addressing justification for skilled physical therapy services, Participant 1 highlighted: The clinical reasoning and rationale for why you would choose an intervention over another. Participant 6 stated, I cant just give someone an intervention and say do it without knowing why theyre doing it, or the purpose, or what it is going to help. Participants identified the importance of understanding the unique patient presentation and utilizing PERCEPTIONS OF CLINICAL REASONING 39 foundational knowledge for in-the-moment decision-making to provide positive patient-centered care specific to the patient's needs. Subtheme Necessary Skills Participants also stressed the importance of in-the-moment decision-making within the clinical reasoning process, which requires adaptability and good communication skills. Participant 7 highlighted the need for effective communication skills: I think communication is a big [skill], I would say. You have to be able to communicate with your patients and explain to them why you are doing it. If you arent able to, then theyre not going to trust you necessarily. Communication was further emphasized by Participant 8, who said, An attitude for open communication and active listening to really listen to somebody else and be able to relate. This need to be able to communicate effectively was identified as necessary to create a positive patient-provider relationship or build trust by Participant 8. The ability to adapt in the moment was emphasized by Participant 14: Because every person that comes in has a different problem, and then its not always a textbook problem. So, you have to be able to put the puzzle pieces together to figure out, you know, whats wrong with them. Participant responses suggested the importance of adapting to the situation and using strong interpersonal and intrapersonal skills to facilitate a positive patient-provider relationship. Based on the gathered information, participants identified the importance of developing a multifaceted understanding of the patient presentation rather than just attending to what is evident on the surface. With greater depth of knowledge comes an improved ability to justify the need for skilled physical therapy services and better address the patient's needs. Creating a more PERCEPTIONS OF CLINICAL REASONING 40 profound sense of understanding during the patient-provider encounter was identified as a critical skill in using clinical reasoning in practice. Participants quickly identified the need for good communication skills, including active listening, and the need to adapt to the given situation calmly and rationally to utilize critical thinking and problem-solving promptly and effectively. Theme 2 Graduate Learning Experience For the second central theme, the graduate learning experience, participants emphasized the importance of specific and structured experiences in developing their clinical reasoning skills. The participants identified the need to adapt to the rigors of the graduate program and the significance of instructor guidance when implementing clinical reasoning in practice. Additionally, participants identified the importance of interweaving concepts across courses and semesters as an integral component of the graduate learning experience that facilitated the development of clinical reasoning. Participants recognized that they had to make significant personal and professional adaptations upon entering the graduate program. Essential factors for a positive graduate learning experience included transformations in study habits and the ability to work closely with peers and faculty. Additionally, participants expressed the importance of interweaving concepts across courses and semesters in providing significant growth in their clinical reasoning skills. Subtheme Adaptation to the Graduate Program Participants emphasized the importance of adapting to the rigor and requirements of graduate school through refining study habits and time management strategies. Participant 14 stated, It was more rigorous than my undergrad [program]; I had to figure out what worked for me and what didnt. Participant 1 further expanded on this concept: PERCEPTIONS OF CLINICAL REASONING 41 Now I feel Im in a little more, like I have a group of people I study with consistently, and I have faculty I go to, and I know who to go to for what information Im looking for and that kind of stuff. Regarding adaptation to a graduate program, Participant 13 stated, Yeah, it was a big learning curve for sure; I had to completely change how I studied, what I studied, and the order that I studied it in. Participants identified that a change in studying was necessary to improve their ability to critically analyze and problem-solve in unknown or complex situations, enhancing their ability to utilize clinical reasoning. The connection between concepts, courses, and semesters within a graduate-level program requires the learner to critically reason through and identify how these connections relate to physical therapy. Although present in some undergraduate programs, the scaffolding of concepts in graduate programs requires the learner to recognize the complexity of the field early in the educational process to be successful. Participant 8 emphasized this concept: Thats the concept for undergrad; they had all separate classes. You could compartmentalize [classes] a little bit. You cant do that [in grad school] because [classes] all tie back together. It all forms into one final product. [Clinical education] is the first phase of doing that and teaching how to really thrive as a PT and be productive. Participants identified the importance of being able to interpret and apply concepts across courses and semesters rather than just through the experience of memorization and regurgitation of content. Subtheme Instructor Guidance Participants described the importance of instructor guidance in facilitating their development of clinical reasoning. Participant 5 explained, Because you, as professors, get to PERCEPTIONS OF CLINICAL REASONING 42 see what we can do, and then you give me feedback, and then I can grow from there. Instructor input or guidance was also highlighted by Participant 2, who stated, Even if I cant get the full answer right away, kind of being guided to [try alternative strategies or techniques], I think that really helps me. Participant 11 further described the importance of instructor guidance: So, being able to get multiple perspectives has also helped me a lot [with clinical reasoning development] and also you guys clinical experience because we obviously dont have that. So, a lot of it is, were doing it from the book, but like being able to hear, well, Ive tried this, but it hasnt worked, but I have tried this, and it has. So, hearing that has also helped a lot as well. Participants identified the importance of instructor feedback during and following learning experiences, such as in-class activities and practical examinations. One-on-one faculty interactions were reported to amplify the growth of critical thinking and problem-solving skills. Subtheme Interweaving of Concepts Participants described the importance of interweaving concepts across courses and semesters as aiding their learning and development of clinical reasoning skills. Participant 1 highlighted, Theres labs for, you know, multiple classes, so I think transferring information over from not only lecture to lab but across all classes was a new dynamic of learning that I need to work on, just like connecting information. Participant 8 further emphasized this concept: And then we learn the techniques of how to diagnose [pathology] in one class, and then the interventions come along with it. So, its kind of a full circle by the time we get through, and we keep moving along. Participants identified the ability of courses and concepts to flow together as a critical element in developing their clinical reasoning skills. Courses, such as Clinical Education I or mock, have PERCEPTIONS OF CLINICAL REASONING 43 required the participants to incorporate concepts from various sources during a simulated patient encounter. This integration and application of concepts, although identified as challenging at the moment, allows the participants to create a flow in a more realistic clinical environment for physical therapy examination procedures and treatment strategies. Identification of learning experiences encountered by the participants within the graduate program emphasizes the amount of adaptation necessary to transition into the rigorous learning environment of healthcare programs. When developing clinical reasoning, adjusting to the complexity of a graduate program, instructor guidance, and interweaving of concepts aid in participant perception of clinical reasoning development. Understanding how the participants perceive various graduate learning experiences can aid faculty in creating and facilitating future educational experiences specific to developing this complex and necessary skill. Theme 3 Application of Knowledge in Practice The third central theme, the application of knowledge in practice, addresses the importance of transferring knowledge into clinical practice and includes the influence of Clinical Education I . Participants emphasized the importance of mock in developing their clinical reasoning skills and the significance of simulation activities, including a simulated escape room activity, through practice in a realistic environment. Applying learned skills and knowledge in the moment in a safe and meaningful environment enhanced the students ability to utilize and adapt their critical thinking and problem-solving skills. Subtheme Clinical Education I or Mock Participants emphasized the clinical relevance of mock, or Clinical Education I, describing it as an excellent way to pull their knowledge and skills together at one point in time while creating variability or non-textbook scenarios. Participant 10 described: PERCEPTIONS OF CLINICAL REASONING 44 But for mock, the patient could have four diseases or some, four things, four impairments that we need to treat, and its easy to gloss over the three and focus on the one in [interventions lab]. But then, in mock, you kind of have to know all of them and treat all of them. When preparing for external clinical experiences, participants acknowledged that mock, despite the challenges of required weekly preparation, allowed for the practice of skills in reallife situations while providing a safe learning environment. Participant 8 highlighted the importance of the practice element in mock when stating, Its kind of like practicing for something ahead of time. Youre not trying to figure it out on game day. You already know what youre doing. Its maybe developing, getting better, practicing a little bit more. The ability to gain experience with various conditions or diagnoses during the mock peer-to-peer low simulation activities allowed the participants to utilize critical thinking and problem-solving to make clinical judgments in a more realistic setting. Participant 12 discussed the importance of mock related to the development of clinical reasoning: Definitely, mock has helped me out a lot [with the development of clinical reasoning] because we have to kind of think about our patient cases, kind of use like information weve got from other classes, and things like pathologies interventions. Like what will be best most beneficial for the patient. Mock required participants to utilize all their knowledge and skills simultaneously through clinical application in a structured, independent learning environment. It was a common trend that participants identified the variability of the cases presented in mock, which simulated more real-life, non-textbook patient presentations. PERCEPTIONS OF CLINICAL REASONING 45 Subtheme Simulation Participants highlighted that simulation activities created learning opportunities that challenged their ability to translate knowledge into practice while facilitating their critical thinking and problem-solving skills. They also identified the importance of real-life applications in developing their clinical reasoning skills and acknowledged the challenge of applying foundational concepts in a simulated real-life environment, with Participant 13 stating: Well, by having these simulations, it allows me to figure it out myself, and thats the best way to grow, by trial and error, and kind of put your leg in the fire and seeing if you pull it out or not. So, yeah, I guess by not being told what exactly what to do, thats how I developed my own way of reasoning through an [evaluation]. Participant 4 also identified the challenge of the simulation environment: [Simulation experiences] definitely put me in an uncomfortable situation. Im not used to failing and getting things wrong very often, so having to fail and get things wrong have forced me to think in a different way and different methods and be OK with getting things wrong because theres no way Im going to get everything right in the clinic. Participant 10 acknowledged the real-life impact of simulation on clinical reasoning, noting, And so the simulation experiences have provided me with real-life practice with clinical reasoning without any danger to missing things in a real patient. Participants identified the need to be challenged within the healthcare environment to facilitate their development of clinical reasoning skills by simulating how they would react in the moment during patient-provider interactions. PERCEPTIONS OF CLINICAL REASONING 46 Subtheme Simulated Escape Room The SER experience, although reported as being scary by some participants, was generally described as enlightening, memorable, and a lot of fun while directly impacting the participants growth of critical thinking, problem-solving, and clinical reasoning. Participants recognized how the SER activity related to the need to be adaptable and confidently apply their knowledge to make decisions. This learning activity also highlighted the importance of teamwork within the clinical setting. Participant 11 described their escape room experience, And so, going in and having this fake patient and figuring out like what might be wrong with them, it was overwhelming in the beginning just because, even now, I know I dont know everything. Participant 3 reflected on the SER activity, It was good to see through the eyes of a [physical therapist]. Participant 17 stated, Yeah, it showed that you need to be able to multitask a lot better, be able to think on your feet. It just emphasized that kind of, yeah, youre definitely lacking knowledge, and youll have to work on that kind of thing. Participants acknowledged that even though they were still at the beginning of their educational journey, the escape room allowed them to apply the knowledge and skills they possessed. Although their experience was limited, putting their foundational knowledge into practice in the escape room allowed them to begin to feel comfortable growing as student physical therapists. Confidence. Participants recognized the SER experience's influential role in improving confidence in abilities through identifying strengths and areas of needed improvements and gaps in knowledge. Participant 4 stated: It was definitely eye-opening in that I went into it thinking that I was very good at communicating with patients, and I think that I did show that in my work in the escape room; however, it was, it was amazing how much I felt like a fish out of water. PERCEPTIONS OF CLINICAL REASONING 47 Participant 9 described the impact of the escape room on confidence: A couple of my fellow classmates that kind of jumped right into asking questions and kind of communicating [with the patient], and I didnt have the, I guess, jump to do that because I was kind of on edge. I didnt, wasnt super confident in knowing the material, and I guess seeing my fellow classmates do that was kind of a reality check that I needed to get back into school mode and start to learn how to communicate effectively. The SER activity created a realistic environment and made the participants more aware of the depth of knowledge and skill required in physical therapy practice. This activity, although described as stressful, was noted by participants to provide a guided real-life physical therapy examination experience through puzzles within a safe learning environment. Teamwork. The escape room highlighted the importance of collaboration in healthcare and allowed for peer-to-peer learning. Participant 11 underscored the importance of teamwork within the escape room: It was nice to have other people working with me too, because there were things that I would forget about that another person in my group would be like, oh, OK, lets think about this real quick, and I was like, good call. The ability to delegate tasks during the escape room was a benefit of teamwork that translated to success in completing the activity. Participants emphasized the importance of teamwork in strengthening individual weaknesses and making the patient-provider interaction more successful. Working as a team was also challenging due to the need for effective communication and the group's novelty. Adapting to the situation. The escape room allowed students to apply knowledge and skills in the moment in a realistic environment. Participants acknowledged this activity's role in PERCEPTIONS OF CLINICAL REASONING 48 facilitating their critical thinking and problem-solving, especially when using their knowledge and skills in a new environment with a standardized patient. Participant 16 reflected on the escape room with the following: You have to be able to take what we learn, but we have to be able to adapt. And I feel like [the escape room] set us up perfectly for what we needed going forward because not everything is going to be so cut and dry. Participants noted this experience to shed light on the variability of patient presentations and the need to be open to modifying examination procedures or treatment strategies based on the unique situation. It required the participants to move outside the textbook instruction to perform tasks and skills to gain the most accurate and available information. By applying knowledge through practice, participants acknowledged the benefit of activities or environments that portrayed real-world situations. A common thread was that simulation, including a SER activity, required the participants to think independently and apply foundational knowledge outside the textbook. The SER also highlighted the need for teamwork in the healthcare setting and learning process. The realistic environment created by simulation activities emphasizes the crucial role of clinical reasoning within the healthcare setting. Theme 4 Growth The final central theme of growth included the importance of being challenged or pushed outside ones comfort zone in facilitating the development of critical thinking and problemsolving skills. Participants emphasized the need to be comfortable with being uncomfortable, stating that being challenged pushed them to new limits of learning and understanding. The importance of peer or colleague collaboration was also highlighted as a vital factor in developing clinical reasoning, as it forced students to think of things from different points of view. PERCEPTIONS OF CLINICAL REASONING 49 Participants also identified the need for constant self-reflection, focusing on self-improvement, and recognizing how far they have come as student clinicians using complex clinical reasoning skills in physical therapy clinical practice. Subtheme Embracing Being Uncomfortable Participants acknowledged the importance of moving outside of ones comfort zone to be challenged to grow and develop the critical skills necessary to be successful in clinical practice. Participant 1 highlighted, You just got to practice, and youre going to fail a lot, but youre going to get better, even though you might not feel like you are. So, its uncomfortable, but I can see the benefits. Participant 4 further described a similar sentiment: Some of the things I think have probably really helped me are just being challenged in general, being put in situations that make me uncomfortable. They dont feel great when Im in those situations, and it definitely increases my nervousness and anxiety, but thats good because when Im out in the clinic, thats [going to] happen all the time. Although being challenged and pushed outside ones comfort zone is never easy, participants highlighted the need for this as a motivating factor for continued learning and growth as student physical therapists. Participants acknowledged that, even though failing or getting things wrong is not ideal, they learned more from the failure than from getting things right. Being able to learn from mistakes and be consistently challenged to utilize critical thinking and problem-solving skills for in-the-moment decision-making has stimulated and forced significant growth in their clinical reasoning skills. Subtheme Self-Reflection Participants also emphasized the need for constant self-reflection to grow and realize how far they had come to become excellent physical therapists. Participants highlighted the PERCEPTIONS OF CLINICAL REASONING 50 importance of continuous learning to refine complex skills such as clinical reasoning. Participant 7 explained: But I also think I have to look at the positives and not always the negatives to be able to keep going. And that, yes, this is very hard, its a [graduate] program, and it does suck sometimes, but there are a lot of life lessons instilled throughout this first year, and I definitely think I have grown significantly as an individual. Further emphasis on the need for self-reflection was described by Participant 10, Well, it might be good because doubting yourself leads you to look harder into things that could be better for your patients; I guess thats why were here. Participants highlighted the importance of reflecting on progress towards personal and professional goals and the ability to identify areas of needed improvement as essential aspects of the self-reflection process for clinical growth. Subtheme Peer Collaboration Being able to learn, not just from instructors but also from peers, was emphasized as a factor in the growth of clinical reasoning skills. Participants highlighted this need for peer-topeer collaborative learning as identified by Participant 10: But even just talking to my peers, they know things that I havent studied yet, and so, getting that understanding of OK, I need to bring in information on this side instead of just this way. It kind of helps me, helps guide me into my critical reasoning skills for clinical reasoning. Participant 17 also emphasized the importance of collaboration, Peers, Id say probably [help] the most because we can bounce things off of each other. This collaboration, combined with continuous self-reflection and being challenged, was identified by participants as necessary intraand inter-professional skills essential in developing clinical reasoning. PERCEPTIONS OF CLINICAL REASONING 51 Summary of Results This study unveiled several vital factors that play a role in students perceptions of clinical reasoning development. The ability to understand the unique patient presentation while making in-the-moment decisions is heavily influenced by the incorporation of meaningful situations and real-world simulations. The student participants found it difficult to define clinical reasoning; moreover, its development is a complex process requiring student and educator adaptability. Hands-on experiences and real-world situations combined with instructor guidance are key characteristics participants highlight regarding their clinical reasoning development. Participants also identified being able to self-reflect and collaborate with peers as necessary components in the growth of clinical reasoning. The central themes are not stand-alone; instead, they are interrelated and essential elements of the development of clinical reasoning, as depicted by the arrows in Figure 3. Understanding clinical reasoning and its role in physical therapy practice (understanding the why) is critical to utilizing clinical reasoning effectively and efficiently for quality patient-centered care in physical therapy practice. Experiences within the program (the graduate learning experience) influence this deeper understanding, along with activities that allow for the practice and refinement of skills in realistic and safe environments (application of knowledge in practice) and the ability to identify areas of strengths and continued need for skill development through self-reflection (growth). The learning activities to develop clinical reasoning (application of knowledge in practice) are not stand-alone. These activities require the learners active participation in realistic and challenging situations (growth), instructor feedback, and interweaving concepts from multiple courses and semesters (the graduate learning experience). Program experience (the graduate learning experience) provides the students with opportunities to develop and refine critical skills, such as clinical reasoning, to PERCEPTIONS OF CLINICAL REASONING 52 be successful in physical therapy clinical practice by providing collaborative experiences and pushing them outside their comfort zone (growth). Learners must understand the complexity of the clinical reasoning process, and the development of this skill is also complex, requiring practice and refinement through experience and self-reflection. Adding an SER experience creates an authentic healthcare environment, emphasizing the critical components of clinical reasoning development highlighted by the participants. This activity forced the use of foundational knowledge, collaboration, and real-time clinical reasoning, which are all vital components in a successful patient-provider encounter. Although challenging, the simulated environment allowed students to be challenged and learn from mistakes with peer collaboration, instructor feedback, and self-reflection while ensuring patient safety. PERCEPTIONS OF CLINICAL REASONING 53 Chapter 4: Discussion This qualitative study aimed to understand student physical therapists' perceptions of clinical reasoning and how an SER activity influenced the acquisition of this complex skill. Understanding the student perspective allows educators to adapt learning activities to meet the needs of the students and the profession. First-year student physical therapists identified four central themes influencing the development of clinical reasoning, including understanding the why, the graduate learning experience, application of knowledge in practice, and growth. These findings may provide further guidance and understanding of how physical therapy programs and educators can better support students by implementing meaningful learning experiences that positively impact the growth of clinical reasoning. While there may be many implications, this study focused on the experiential learning activity of an SER. The Role of Clinical Reasoning in Physical Therapy Practice Clinical reasoning must be utilized effectively in a dynamic healthcare environment to ensure quality, patient-centered clinical decision-making (Furze et al., 2022; Gilliland & Wainwright, 2017; Higgs et al., 2019; Roitsch et al., 2021). Due to the increasing complexity of patient presentations and the healthcare environment, physical therapy clinicians must be able to implement clinical reasoning effectively and efficiently (Higgs et al., 2019). This complex skill is necessary to make in-the-moment clinical decisions by synthesizing collected data utilizing cognitive, psychomotor, and affective skills combined with the best evidence and clinical experience (Furze et al., 2022; Higgs et al., 2019; Huhn et al., 2019). However, before clinicians can utilize clinical reasoning successfully, they must understand its meaning and vital role in physical therapy practice. PERCEPTIONS OF CLINICAL REASONING 54 Defining Clinical Reasoning When discussing the role of clinical reasoning in physical therapy practice, student participants highlighted the critical role this skill plays in creating meaning for the unique patient presentation. Student participants described this concept as developing a deeper understanding through integrating multiple forms of data in the moment through critical thinking and problemsolving. Creating this understanding or meaning of the patient encounter was identified as necessary to justify the need for skilled physical therapy services. Although student participants recognized the need for clinical reasoning, they demonstrated difficulty verbally defining or describing this concept. A synthesis of descriptions of clinical reasoning by student participants indicates that it is a way of thinking through different clinical problems. It requires clinical judgment, experience, and evidence to interpret the collected data and create a meaningful physical therapy diagnosis and treatment plan that will facilitate the patient's optimal level of function. Other descriptions included supporting selected treatment techniques to address the overall goal of the physical therapy episode of care and providing the why behind the physical therapy plan of care. Higgs and colleagues (2019) provide a simple and complex description of clinical reasoning in healthcare professional practice. The simple definition emphasizes the critical thinking and decision-making necessary for autonomous clinical practice (Higgs et al., 2019). For the complex description, Higgs and colleagues (2019) highlight the multifaceted nature of clinical reasoning that allows practitioners to navigate uncertainty and complexity in the healthcare environment. There were consistencies and inconsistencies when comparing the definitions or meanings reported by the student participants to the widely referenced Higgs and colleagues' (2019) definition. Student participants highlighted the ability of clinical reasoning to PERCEPTIONS OF CLINICAL REASONING 55 create meaning for the unique patient encounter as it relates to the collected clinical data and current evidence consistent with the literature. The role of clinical judgment was missing in student participant descriptions of clinical reasoning, along with a limited emphasis on patientcentered clinical decision-making. First-year DPT student participants often have limited clinical experience utilizing clinical reasoning, which may contribute to the variability in definitions. The abstract and multifaceted nature of the metacognitive clinical reasoning process may also contribute to the differences in definitions. The need to synthesize multiple forms of data in-themoment through metacognition requires solid foundational knowledge, which is still being developed and refined at this point in the curriculum. The requirements of higher-order cognitive processes add to the difficulty in defining clinical reasoning by student participants and align with the differences in definitions within and across the health profession (Furze et al., 2022; Huhn et al., 2019; Young et al., 2018, 2019, 2020). Communication and Clinical Reasoning Although defining clinical reasoning was challenging, student participants consistently identified communication and adaptability as critical interpersonal skills necessary for implementing this complex skill in the clinical setting. Student participants elaborated on the importance of effective and efficient communication skills to aid in data collection and create a sense of trust between the patient and the provider. Figure 4 highlights the importance of bidirectional communication between the patient and clinician. Effective communication allows clinicians to gather more information relevant to the patient and their goals for physical therapy treatment. The added depth of knowledge gained through good communication facilitates clinical reasoning and decision-making, aiding in positive patient outcomes. Communication is vital in critically analyzing the unique patient presentation, facilitating patient engagement, and PERCEPTIONS OF CLINICAL REASONING 56 promoting positive functional outcomes (Ahlsen & Nilsen, 2022; Forbes & Nolan, 2018). Forbes and Nolan (2018) highlighted the importance of effective communication in patient-provider interaction as identified by the patient. Building rapport with patients improves the provider's ability to create an accurate diagnosis and treatment plan while increasing the patient's active participation to promote more successful outcomes (Forbes & Nolan, 2018). Adaptability and Clinical Reasoning Student participants also identified the importance of adaptability in utilizing clinical reasoning during patient encounters. Due to the dynamic healthcare environment, understanding and adjusting to contextual factors is a necessary skill often difficult for student clinicians to recognize early in their educational and clinical journey (Pelgrim et al., 2022). Cheung and Kulasegaram (2022) describe adaptive expertise as transferring knowledge to a specific context when addressing novel problems. Understanding that no two situations are the same in clinical practice is essential to modify clinical assessments, clinical judgment, and clinical reasoning to benefit the situation. Student participants highlighted the variability from textbook descriptions during actual or simulated patient encounters, thus emphasizing the need to be adaptable. Adaptability is challenging to master, especially for student clinicians, due to the complexity of physical therapy practice combined with their limited clinical experience and evolving knowledge base. With clinical experience and a solid foundational knowledge base, experienced clinicians can better adapt to the unique patient presentation using forward reasoning. This reasoning relies heavily on pattern recognition, or illness scripts, which speeds up the clinical reasoning process (Edwards et al., 2004). This pattern recognition contrasts with the hypothetico-deductive reasoning often employed by student clinicians (Edwards et al., 2004; Higgs et al., 2019). This PERCEPTIONS OF CLINICAL REASONING 57 form of reasoning starts with having several working hypotheses or diagnoses and confirming or disproving these through further data collection, such as observation and examination procedures (Edwards et al., 2004; Higgs et al., 2019). Working from generalized hypotheses to a specific diagnosis utilizes more procedural thinking, limiting the student's ability to adapt to unknown situations or patient presentations (Edwards et al., 2004; Furze et al., 2015; Higgs et al., 2019). This more procedural approach in clinical reasoning may limit the ability of the student clinician to adapt to complex or unfamiliar patient presentations, thus limiting their ability to reflect in action to make clinical decisions effectively. Even the most experienced clinicians will encounter times of uncertainty or unclear patient presentations, highlighting the need to be adaptable in clinical practice, which was identified by student participants (Ilgen et al., 2019). Experienced clinicians can recognize and embrace this uncertainty by keeping an open mind and effectively utilizing their skills, knowledge, and experience to address the unique situation (Ilgen et al., 2019). Student participants were early in their educational journey, thus making every case a new adventure and limiting their ability to identify patterns, or illness scripts, to be more efficient during patient encounters. The SER activity enhanced the student participants ability to recognize patient complexity, even with a seemingly straightforward diagnosis. The need to address co-morbidities and other contextual factors when determining the appropriate discharge plan and prescribing an assistive device did not cleanly follow the textbook regarding choices and rationale. Rather than choosing the assistive device by textbook standards, student participants had to adapt in the moment to select the assistive device that would be most beneficial to the patient for their given weight-bearing status. PERCEPTIONS OF CLINICAL REASONING 58 Learning Activities Facilitating Clinical Reasoning Development Student participants highlighted the positive impact of simulation-based activities. They acknowledged the challenge these realistic learning activities create, especially concerning their ability to adapt to the given situation, including appropriate assistive device selection, understanding patient descriptions such as calling a grab bar a handrail, and realizing that a patient did not know why they were taking some or all their medications. Activities that pushed them outside their comfort zone encouraged the student participants to apply the foundational concepts meaningfully. Communicating with a standardized patient in the SER activity required them to adjust their terminology to the level of the patient, which is also a requirement during clinical practice. The Mock Experience. The learning activities that influenced the interpersonal skills of communication and adaptability also impacted the development of clinical reasoning due to the need for these skills in the metacognitive process. Student participants highlighted the vital influence of the peer-to-peer simulation and SER learning activities experienced in Clinical Education I, mock, in developing clinical reasoning skills. The mock experience simulated the real-world environment while allowing the safe application of cognitive, psychomotor, and affective skills. The emphasis of mock is to provide clinical experience in one-on-one patient scenarios, including physical therapy initial evaluations and treatments. This course challenges students to apply foundational concepts and individually integrate coursework from current and prior semesters. Student participants described the positive influence of the guided experiences of the mock course in highlighting the variability between real-life and textbook patient presentations. This discrepancy emphasized the importance of being open-minded and adaptable during patient encounters. PERCEPTIONS OF CLINICAL REASONING 59 The simulation activities emphasis on a complete patient encounter required students to learn effective communication skills to obtain the necessary subjective and objective information to use clinical reasoning for in-the-moment clinical decision-making. Student participants identified the importance of having minimal patient information before the learning activity in facilitating their critical thinking and problem-solving development. They were required to wade through the uncharted waters independently, without continuous or structured instructor guidance. The simulation activities challenged students to work independently with facilitator guidance provided as needed, such as in moments of being "stuck." The autonomous physical therapy profession requires clinicians to make clinical decisions safely and effectively through critical thinking and clinical reasoning that will positively impact the patient. This autonomy means little supervision in clinical practice; therefore, instructors must walk that fine line between assisting or facilitating the learning process and allowing independent learning to develop the higher-order cognitive strategies necessary for clinical practice. Learning activities that present real-life scenarios and environments provide learners with a safety net when applying complex skills, such as clinical reasoning, with instructor support and decreased risk of causing patient harm through clinical decisions. Consistent with the literature, student participants identified the importance of the simulation activities provided in mock in allowing them to safely make decisions based on their clinical reasoning with instructor guidance and feedback (Sakemiller & Toth-Cohen, 2020). Pylman and Emery (2023) found that medical students' perceptions of effective feedback during simulation activities require that the input be in-the-moment and directly related to the specific goal of the activity or learning objective. Ensuring that feedback is constructive and that the learner and educator are receptive to feedback is vital for growth and learning (Bakke et al., PERCEPTIONS OF CLINICAL REASONING 60 2020; Shrivastava & Shrivastava, 2022). Student participants highlighted that the simulated environment of the escape room provided immediate feedback through successful or unsuccessful puzzle completion, peer collaboration, and intermittent instructor guidance directly linked to the clinical setting. Identifying the importance of instructor guidance and feedback highlights the need for intentionally structured pre-briefing and debriefing sessions combined with in-the-moment input during the activity to enhance learning (Shrivastava & Shrivastava, 2022). The structure of the SER provided meaningful structured and non-structured feedback to student participants. Transfer of Knowledge to Clinical Practice Furthering the discussion on the role of simulation activities in the development of clinical reasoning, student participants emphasized the ability of these activities to pull together foundational knowledge and psychomotor skills that they had developed in previous semesters or were developing concurrently. Student participants described this transition of didactic information to clinical practice as a positive influence in promoting independent problem-solving and critical thinking. The peer-to-peer simulation activities and the SER allowed the students in this study to interact with patient-like situations through peer role play or utilization of standardized patients. These interactions required them to ask the right questions and employ the correct psychomotor skills to develop accurate diagnoses and implement effective treatment strategies. These patient interactions emphasized the importance of trial and error when executing cognitive, psychomotor, and affective skills in clinical practice. Identifying the positive influence of simulation activities on students ability to apply knowledge and skill in clinical aligns with the evidence supporting the benefits of simulated healthcare environments (Frerejean et al., 2023; Marker et al., 2019). Real-time clinical decision-making requires in-the- PERCEPTIONS OF CLINICAL REASONING 61 moment synthesis of gathered data, experience, and knowledge. Learning activities highlighting the complexity of clinical reasoning in physical therapy practice is challenging for students inthe-moment but reflected upon as positive and necessary post-activity. Growth through Self-Reflection Student participants also identified self-reflection as a critical component in developing clinical reasoning. Although still early in their educational journey to becoming skilled physical therapy clinicians, student participants identified the personal and professional growth they had experienced over the initial three semesters of the program. Student participants reflected on the importance of being challenged during their performance, including their ability to apply psychomotor skills and foundational concepts. They were able to embrace being put in uncomfortable or unknown situations to apply critical thinking and problem-solving in the moment to make clinical judgments that reflect real-world conditions. Utilizing didactic content in a clinical setting is challenging due to the variability of the patient and the environment. Acknowledging areas of needed improvement while also identifying strengths through selfreflection is necessary to motivate learners to continue to gain knowledge, practice skills, and strive to be excellent clinicians. Many student participants acknowledged that they had no, or very limited, understanding of clinical reasoning and its role in physical therapy practice when they entered the program. They also reported difficulty connecting concepts in the first two semesters of the graduate program. With data collection completed following the SER activity, student participants had only about nine weeks of integrative clinical experience through the mock course, including the SER activity and peer-to-peer simulations. Collectively, nine weeks is a very short period when developing higher-order cognitive processes such as clinical reasoning. Student PERCEPTIONS OF CLINICAL REASONING 62 participants identified mock as the course that required them to pull everything together and increase the depth of their understanding of clinical reasoning and clinical decision-making, providing significant growth as student clinicians. They highlighted the challenge this course created, requiring them to develop their critical thinking and problem-solving skills through activities that pushed them outside their comfort zone. The peer-to-peer simulation-based learning activities and the SER activity provided student participants with the opportunity to experience different perspectives when addressing novel situations and facilitated the development of advanced cognitive processing through reflection and analysis (Chernikova et al., 2020; Tremblay et al., 2019). The Impact of Outside Learning Experiences Besides structured learning experiences aimed at clinical reasoning development, student participants identified other experiences during their graduate careers as positive influences. Such activities included interacting with community members during service activities and observing patient-provider interactions in a student-led pro-bono physical therapy clinic. Student participants described the positive impact of these experiences, including enhancing their clinical reasoning development and reminding them of the big picture of becoming a physical therapist. The Process of Clinical Reasoning Development Courses that require concept application, such as mock, are uncomfortable and challenging but allow for identifying knowledge gaps and creating errors in clinical decisionmaking and reasoning. These challenging courses stress the importance of being comfortable with making mistakes and learning from them. Simulation-based learning experiences require interweaving concepts, creating a deeper meaning and understanding of how these concepts relate to clinical practice. It also requires the learner to think on their feet, pushing them to do the PERCEPTIONS OF CLINICAL REASONING 63 activity rather than be a passive learner. Simulation learning activities force learners to apply knowledge and skills in various situations and scenarios while being observed by instructors and peers. The early implementation of an SER provided student participants with an immersive and unique learning experience that highlighted the variability and difficulty of the patient-provider encounter. Although student participants are early in their educational journey to becoming clinicians, they identified several vital skills necessary to provide skilled physical therapy services, including communication, adaptability, critical thinking, and problem-solving. The SER during the first week of the winter semester combined with 5-6 peer-to-peer low-simulation mock cases allowed student participants to develop their clinical reasoning through experience and recognizing the unpredictability of patient presentations. The results of these rich experiences highlight the need for challenging authentic experiences in developing metacognitive processes such as critical thinking and clinical reasoning. Implementing learning activities that specifically address clinical reasoning early within the physical therapy curriculum can be difficult due to the differences in learner experience and the variability of clinical reasoning (Higgs et al., 2019; Huhn et al., 2019). The variability in the conceptualization of clinical reasoning within healthcare disciplines combined with the many factors required for this complex skill create differences in the teaching, learning, and assessment aimed at clinical reasoning development (Higgs et al., 2019; Huhn et al., 2019). This highlights the need for challenging, meaningful, and authentic learning environments that provide instructor guidance and emphasize self-reflection when utilizing critical thinking, problem-solving, and clinical reasoning in clinical decision-making. Student participants highlighted small group and one-on-one learning activities as essential to developing clinical reasoning. The authentic PERCEPTIONS OF CLINICAL REASONING 64 environment created by mock, including the SER, allowed student participants to experience the clinical setting without the added pressure of direct patient contact. Compared to more passive learning activities such as laboratory demonstrations, written examinations, and bookbased projects, the experiential learning activities allowed student participants to practice cognitive, psychomotor, and affective skills in the moment, aiding clinical reasoning development. Student participants' perceptions of clinical reasoning in physical therapy practice are still in the early stages of development (for the study cohort), especially since they are in their first year of a three-year program. Although in its infancy, they identified the critical role clinical reasoning plays in physical therapy practice and highlighted key interpersonal components required to utilize this complex skill effectively. Educators must recognize the complexity of clinical reasoning and the need to address this skill early in the educational process through meaningful learning activities that are realistic and engaging to the learner. Challenging learners early with activities, such as the SER, within healthcare programs is necessary to develop higherorder cognitive processes, such as clinical reasoning. Ensuring that the learning activities meet the foundational knowledge level of the student and scaffolding authentic learning experiences to motivate and engage the learner are critical in developing the skills necessary to be successful novice clinicians. Clinical reasoning development requires much more than memorization; therefore, challenging learners through various instructional methods is necessary to apply foundational knowledge in novel situations. The Role of a Simulated Escape Room Activity on Clinical Reasoning Development The evolving needs of the healthcare environment and learners require educators to be creative and intentional in how they present and implement tools to facilitate the development of PERCEPTIONS OF CLINICAL REASONING 65 clinical reasoning (Chacon & Janssen, 2021). With increasing patient complexities and demands placed on the healthcare provider, clinicians must wear multiple hats to meet the needs of patients and the profession. This dynamic work environment adds to the difficulty in facilitating the development of clinical reasoning in the educational setting. The DPT curriculum emphasizes this complexity of clinical reasoning, as noted by healthcare programs' highly structured academic standards (CAPTE, 2020; Higgs et al., 2019). The DPT curriculum often intersperses this complex concept throughout and across courses due to the challenge of creating learning activities specific to clinical reasoning development (Christensen et al., 2017). Influence of Real-World Learning Experiences Clinical experiences or realistic learning activities aid in learner understanding of the complexity of clinical reasoning and its vital role in clinical practice (Gonzalez et al., 2021). Within the structure of the midwestern university studied, the clinical education series aims to provide students with simulated and real-life clinical experience beginning in their first year of the program. The realistic learning activities created in mock, such as the SER experience, emphasize clinical reasoning in multiple ways, including during the exercise, through postactivity guided self-reflections, and by integrating learned concepts into subsequent activities and courses. Consistent with the literature, student participants highlighted the critical role realistic experiences play in facilitating critical thinking and clinical reasoning compared to more passive or unrealistic learning activities (Wong & Kowitlawakul, 2020). Experiential Learning Student participants identified the importance of engaging or active learning activities simulating the authentic clinical environment, specifically the SER activity embedded within the mock course. They highlighted the positive impact this activity had on the growth and PERCEPTIONS OF CLINICAL REASONING 66 development of their clinical reasoning skills. The SER environment and peer collaboration allowed students to experience different problem-solving and critical thinking methods in the clinical setting, thus facilitating a deeper understanding of foundational concepts (Mullen & Seiler, 2019). Adding gamification to the learning experience enhanced teamwork and peer collaboration as the students had to work together to achieve a common goal, solve the puzzles, and "escape" the room (Mullen & Seiler, 2019; Zhang et al., 2018). Not only did they gain experience communicating with a "real" or standardized patient, but students also had to learn how to communicate effectively with their peers with the added element of the gaming experience. Student participants had to adapt to this new learning activity while maintaining professional behaviors during the patient-provider encounter, even when navigating the unknown and discussing differing viewpoints with colleagues. Adding to the complexity of the SER, student participants' decisions impacted their ability to complete the activity and the patient's well-being, making these clinical decisions meaningful to multiple stakeholders. Learners identified the importance of teamwork within the healthcare setting and the ability of the SER to facilitate this dynamic, enhancing the development of their critical thinking, problem-solving, and communication skills. This interaction created an environment that encouraged open-mindedness and a transition from textbook responses, facilitating knowledge translation to clinical practice (Hustad et al., 2019). Structured Self-Reflection for Growth. The SER environment allowed students to identify areas of clinical strengths and needed improvement through reflection in and on action. Student participants reported that although the escape room experience initially negatively impacted confidence in their physical therapy skillset, it provided a meaningful experience emphasizing the importance of continued learning and refining skills to be successful in clinical PERCEPTIONS OF CLINICAL REASONING 67 practice. The learning activity stressed the depth of knowledge, skill, and experience necessary in physical therapy practice. The SER activity allowed student participants to identify gaps in knowledge and skills. Although frustrating in the moment, it motivated students to focus on these areas of needed improvement to be more successful in future learning experiences and clinical practice. Reflecting in action, including observation of colleagues applying their knowledge and skills during the activity, allowed student participants to gauge their abilities and adapt as necessary to meet their personal and professional goals. Student participants reported feeling awkward during the SER activity and having difficulty in areas they did not expect, which aided their growth as student clinicians. The placement of the SER learning activity allowed student participants to experience performing a non-complicated orthopedic initial evaluation and demonstrate that they did possess the skills required to do this task even though they were in the program's first year. It aimed to integrate the skills and knowledge they gained in their first and second semesters within the graduate program. Student participants highlighted the eye-opening experience that this activity provided primarily related to the significant amount of critical thinking and problemsolving required during patient encounters. Within the graduate program, the SER activity was the first structured learning experience where students were required to apply clinical reasoning in an authentic clinical situation. The activity pushed the student participants to transfer didactic knowledge and skills to clinical practice. This learning activity challenged student participants to adapt and maintain professionalism in uncomfortable situations. Although the SER activity challenged student participants in a clinical practice setting, it allowed them to recognize they had the necessary tools to complete a low-complexity orthopedic physical therapy initial evaluation. Student participants reported feeling overwhelmed with the PERCEPTIONS OF CLINICAL REASONING 68 amount and depth of information needed to make informed clinical decisions. They appreciated the guidance provided by the puzzles in assisting them in identifying the required information to complete the task. The puzzles and their associated lockboxes within the SER emulated the continuous problem-solving process required during the physical therapy patient encounter. The activity did not end with completing one puzzle, but rather another problem, or puzzle, required their attention to continue with the learning activity. The puzzles integrated information throughout the initial evaluation process; therefore, student participants had to keep track of all gathered information as it may be helpful in subsequent puzzles. Student participants reported feeling surprised by their awkwardness during the SER activity. Some acknowledged that they muddled through the experience and were not as efficient or effective in their cognitive, psychomotor, or communicative skills as they thought they would be. This limited efficiency highlights the need to be put in novel situations, including the patientprovider experience, early in the curriculum to allow practice and refinement of skills to facilitate success for future physical therapy encounters. Although some student participants reported feeling overwhelmed by the activity, others described the SER activity as providing a boost of confidence. The added confidence related to the successful completion of puzzles during the exercise and successfully escaping the room improved their confidence for the rest of the semester, including the subsequent peer-to-peer low simulation mock cases. Although stressful and challenging in the moment, the SER provided a framework for the rest of the semester, including highlighting the importance of preparation and self-reflection. The SER activity forced student participants to review previously learned concepts and skills and required them to connect the dots or align concepts from multiple courses. They were required to put together foundational skills such as safe patient handling, range of motion and PERCEPTIONS OF CLINICAL REASONING 69 strength assessment, and treatment techniques, such as gait training, in the moment within an authentic and challenging environment. It required the student participants to adapt and implement learned skills in novel ways to meet the needs of the patient and the situation. This activity highlighted the need for in-the-moment adaptability while maintaining professionalism, even in challenging situations. Kolb's Experiential Learning Cycle The stages of Kolb's learning cycle include concrete learning, reflective observation, abstract conceptualization, and active experimentation (Kolb & Kolb, 2017), which align with the themes identified as essential components of clinical reasoning development by student participants (Figure 5). Kolb's learning cycle emphasizes the need for experiential learning activities to facilitate the learner's ability to utilize clinical reasoning for a given clinical situation (Poore et al., 2014). When asked to identify learning activities or experiences that enhanced or facilitated their clinical reasoning development, student participants recognized the importance of applying knowledge in a realistic setting in developing their clinical reasoning. Student participants highlighted the influential role of the SER activity in developing complex clinical reasoning by creating a safe and authentic learning environment to apply foundational concepts and provide opportunities to practice skills. Concrete Experience. The first stage or step of Kolb's Experiential Learning Cycle, concrete learning, is when students are fully immersed in a learning activity or experience (Fewster-Thuente & Batteson, 2018). Consistent with the application of knowledge in practice theme found in this study, learning experiences that reflect a realistic clinical environment and situation create a more meaningful learning experience (Bizama et al., 2022). Simulating realworld conditions in the healthcare educational setting allows learners to take on professional PERCEPTIONS OF CLINICAL REASONING 70 roles in a controlled environment, including in-the-moment clinical decision-making through critical thinking and problem-solving (Bizama et al., 2022). The initial curricular focus of the studied DPT program is on creating a solid foundational knowledge base necessary for patientcentered care, thus limiting clinical experience for first-year student participants. When learning foundational concepts, understanding textbook patient presentations and methods for diagnosis and treatment is essential to provide the base for students to build upon with practice and experience (Timmerberg et al., 2022). Subsequent learning activities must incorporate active learning experiences where learners can apply foundational concepts to unique situations to develop critical thinking and problem-solving skills, thereby enhancing clinical reasoning (Chacon & Janssen, 2021). Being able to understand and acknowledge individual patient presentations when addressing clinical problems allows students to be able to adapt to the given situation. The SER activity highlighted this variability between textbook and patient presentations, aiding the student participants ability to adapt their critical thinking and problemsolving skills through practice and reflection. Adaptability was an identified essential component of student participants for clinical reasoning development, thus making the SER activity meaningful in addressing this complex skill. Reflective Observation. The second stage of Kolb's Experiential Learning Cycle, reflective observation, addresses the importance of learner-identified knowledge gaps through reflection on the concrete experience, promoting deeper learning (Fewster-Thuente & Batteson, 2018). This stage reflects the growth theme reported by student participants as playing a significant role in developing their clinical reasoning through self-reflection and being pushed outside their comfort zone. Guided self-reflection activities assist learners in addressing strengths and areas of needed improvement by identifying missing concepts or areas they must focus on PERCEPTIONS OF CLINICAL REASONING 71 when moving forward in their educational journey. The SER had structured reflection activities, including a group pre-briefing and debriefing session. Student participants were also required to complete a post-activity individual self-reflection aimed at reflection on action. Reflection in and on action during the SER experience allowed student participants to grow and develop clinical reasoning in multiple ways. Abstract Conceptualization. In Kolb's third stage of the Experiential Learning Cycle, abstract conceptualization, the learner takes the new understanding or knowledge gleaned from reflective observation and begins implementing this into action or practice (Fewster-Thuente & Batteson, 2018). Aligning with the theme of understanding the why in this study, abstract conceptualization requires the learner to integrate new knowledge or skill within existing schemas to bridge the gap in understanding the significance of clinical reasoning in clinical practice (Fewster-Thuente & Batteson, 2018; Poore et al., 2014). The SER facilitated this stage of Kolb's learning cycle, allowing learners to practice and build upon existing knowledge and skills through planning and implementation in future learning activities. It allowed the learners to practice real-time critical thinking and problem-solving. An example of this real-time abstract conceptualization during the SER is when students were required to choose the correct assistive device for the patient and teach the patient how to use this device in preparation for discharge from the emergency department. Based on their knowledge of assistive devices for given diagnoses, the textbook device did not adequately meet the patient's needs. Student participants did not receive the correct puzzle pieces when choosing the textbook device, creating discrepancies in what they knew and what was required. This activity component required student participants to interact with their colleagues and faculty facilitators to discuss the reasoning behind the need for an alternative assistive device related to patient safety and the PERCEPTIONS OF CLINICAL REASONING 72 ability to utilize it successfully. This in-the-moment clinical reasoning created a disconnect between what they knew and what they needed to know. It required problem-solving and critical thinking in an authentic environment, pushing the student participants outside their comfort zone. Student participants described this challenge of their foundational knowledge as a necessary evil to facilitate growth and motivated them to address their areas of weakness. Active Experimentation. In Kolb's final stage of the Experiential Learning Cycle, active experimentation, the learner applies and evaluates the new knowledge, skill, or understanding (Fewster-Thuente & Batteson, 2018). The SER activity, along with the theme of the graduate learning experience, aligned with this stage of Kolbs cycle through learner implementation of newly gained knowledge and skills. The active learning environment of the SER created an experience that allowed students to be hands-on in the clinical setting to develop their practical approach to problem-solving. For example, student participants were required to adapt their psychomotor skills of range of motion and manual muscle testing in the moment due to the patient's inability to achieve the standardized testing position. They had to obtain the necessary information to ensure the patient was appropriate for gait and functional transfer training but had to modify how they attained the measurements. Although challenged to consider alternative ways of obtaining objective measures in previous courses, this activity required student participants to implement those modifications, aiding their cognitive and psychomotor skill development. Student participants identified the connection between the learned foundational concepts and the practical application of those concepts as a critical component in facilitating their clinical reasoning development. The SER required adaptability to the unique situation, fostering a deeper understanding of foundational knowledge. PERCEPTIONS OF CLINICAL REASONING 73 Kolb's experiential learning cycle stresses the essential role of experience in facilitating the development of the learner's understanding, problem-solving, and critical thinking (Poore et al., 2014). The SER activity provided an application of experiential learning, allowing the learner to actively participate in developing their knowledge and skill as a physical therapy clinician. The authenticity of this activity created a safe environment where student participants could implement feedback and reflection with decreased risk of harm to the patient. Student participants acknowledged the benefit of the SER activity in preparing them for real-life situations without worrying about harming patients or peers during the learning process. The added gamification element allows for greater applicability of the learning experience to clinical practice regarding managing time and the dynamic healthcare environment (Graafland et al., 2012). The SER learning activity underscored all stages of Kolb's learning cycle, including preparing for the activity, the experience itself, guided self-reflection, and implementing lessons learned in subsequent learning activities. Motivation for Learning In the dynamic realm of healthcare, individuals must be motivated to continuously learn and adapt, which requires active learning and constant self-reflection (Gilliland & Wainwright, 2017). Connecting learning experiences to the real-life environment is necessary to transition from student to clinician. As the results of this study indicate, the complexity of clinical reasoning requires a multifaceted approach within the healthcare education setting. Students can identify the role that clinical reasoning plays in physical therapy practice, but developing their definition of clinical reasoning is difficult due to their limited experience and current knowledge level. Creating experiential learning opportunities, such as an SER activity, aids in developing clinical reasoning through applying foundational knowledge and skill practice in a safe but PERCEPTIONS OF CLINICAL REASONING 74 realistic environment. When preparing to utilize clinical reasoning in practice, students identified the need to understand clinical reasoning, experience real clinical situations, reflect on their personal and professional growth, including strengths and areas of needed improvement, and embrace the overall experience of the graduate program. Although distinct themes emerged, interrelationships between these themes were noted (Figure 3). When developing clinical reasoning, facilitating learner understanding of the meaning of this complex skill and its role in physical therapy clinical practice is important to scaffold learning activities to meet the needs of the student clinician throughout their educational journey. Gaining this understanding requires applying foundational knowledge in a realistic healthcare setting. During real-world application, the learner must also be able to self-reflect during and after the experience to facilitate clinical reasoning development in physical therapy practice. Real-world activities facilitate learner understanding of clinical reasoning and its role in physical therapy practice. Applying knowledge in an authentic clinical practice environment was linked to a positive learning experience and facilitated by interweaving concepts across the curriculum to aid in knowledge retention. Instructor feedback and peer collaboration allowed students to gain experience from different viewpoints and grow into skilled clinicians. Whether it be adapting to the specific patient presentation to understand the underlying factors requiring physical therapy services or the ability of the students to adapt to the rigors of a graduate healthcare program, being able to develop and utilize clinical reasoning was identified as complex and challenging. The ability to practice within real-world learning environments that combine concepts from multiple courses and semesters challenged the learners critical thinking and problem-solving in the moment, thereby facilitating the development of clinical reasoning. PERCEPTIONS OF CLINICAL REASONING 75 Limitations and Bias Study limitations include using a single DPT program and cohort, thereby limiting the generalizability of the qualitative descriptive analysis. Potential researcher bias was also noted as the primary researcher also served as the students faculty member in multiple courses and played an influential part in designing and implementing the SER activity. Further areas of potential bias include interviewer bias, as the primary investigator completed the entire interview process for all participants. Other potential biases include the primary researcher's responsibility for initial coding, creating consistent theme identification but limiting different interpretations of the collected data. Methods to limit or address potential researcher bias included thick verbatim student descriptions and random audits of verbatim transcription and initial coding by coinvestigators. Furthermore, the primary researcher performed field journaling during and after the individual interviews and data analysis to identify and bracket any bias during these processes. Limitations in study results also include that no demographic data was collected for the study participants. Further study limitations include that the data was collected from DPT students at a single university at one point; thus, the study findings may be limited to the students, instructors, and curriculum. The curriculum structure and experience in simulation activities of the first-year physical therapy students at the university in this study may differ from the experiences of physical therapy students at other institutions. There was also a lag of about nine weeks from when the students completed the first SER activity and the semi-structured interviews. This lag was related to receiving IRB approval to conduct this study and coordinating the approval between the studied University and the University where the primary investigator is completing the advanced degree. During this time, students continued acquiring new knowledge PERCEPTIONS OF CLINICAL REASONING 76 and skills, which enhanced their clinical reasoning development through the progression of coursework, including peer-to-peer simulated physical therapy evaluations in the clinical education course. This added time could have created recall bias in the study participants and means that the results of the collected data were not specific to the SER but also related to the integrated clinical education experiences. Although the influence of the mock experience was influential in student development of clinical reasoning, this study aimed to address the impact of the SER. Future Research For future research, following the development of students' clinical reasoning skills from entering the healthcare education program through graduation and their first year of clinical practice would enable the researchers to identify learning activities and experiences that enhanced this complex and essential skill. Including student interviews related to perceptions of clinical reasoning before the SER activity and immediately following the learning activity would emphasize the role of the specific exercise and further the evidence to support this learning experience. Expanding upon this research to include the timing of the simulation activities and the influence of this timing on the development of metacognitive processes is also necessary to best place these activities for optimal learning. Future research, including validated quantitative measures of clinical reasoning, may also provide further opportunities to gain a deeper understanding and analyze the impact of a SER activity on students' ability to understand and utilize clinical reasoning in practice. Gathering data immediately following an SER activity to gain specific insights into the activitys impact on clinical reasoning development is also an area of further research. PERCEPTIONS OF CLINICAL REASONING 77 Conclusion This study examined the impact of a simulated educational escape room on physical therapy students' perceived development of clinical reasoning. Due to the abstract nature of clinical reasoning, defining and describing its critical role in physical therapy practice is difficult for first-year DPT students. Limited clinical experience and developing foundational knowledge create difficulty adapting critical thinking and problem-solving skills in novel situations. Educators must create authentic learning environments that promote meaningful learning experiences when addressing the higher-order cognitive process of clinical reasoning. Promoting early integration of active learning experiences that facilitate a complete patient encounter in a realistic setting is crucial in developing this complex skill. Through advancements in technology, simulation activities, including a simulated escape room experience, provide a one-on-one or small group learning environment that can enhance the professional role of the student clinician. Careful integration of reflection in and on action through instructor guidance is necessary during the simulated learning activity to allow learners to identify and understand knowledge gaps and promote further development of cognitive, psychomotor, and affective skills required for professional practice. A simulated escape room learning activity can replicate the dynamic healthcare environment and provide an additional instructional method that addresses clinical reasoning development in DPT students. PERCEPTIONS OF CLINICAL REASONING 78 References Ahlsen, B., & Nilsen, A. B. (2022). Getting in touch: Communication in physical therapy practice and the multiple functions of language. Frontiers in Rehabilitation Sciences, 3, Article 882099. https://doi.org.10.3389/fresc.2022.882099 American Physical Therapy Association. (2006). Physical therapist clinical performance instrument. Retrieved December 08, 2022, from http://www.apta.org/PTCPI/ Anderson, M., Lioce, L., M. Robertson, J., O. 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Exploring perceptions and barriers in developing critical thinking and clinical reasoning of nursing students: A qualitative study. Nurse Education Today, 95, Article 104600. https://doi.org/10.1016/j.nedt.2020.104600 Young, M. E., Thomas, A., Lubarsky, S., Gordon, D., Gruppen, L. D., Rencic, J., Ballard, T., Holmboe, E., Da Silva, A., Ratcliffe, T., Schuwirth, L., Dory, V., & Durning, S. J. (2020). Mapping clinical reasoning literature across the health professions: A scoping PERCEPTIONS OF CLINICAL REASONING 91 review. BMC Medical Education, 20(1), Article 107. https://doi.org/10.1186/s12909-02002012-9 Young, M., Thomas, A., Gordon, D., Gruppen, L., Lubarsky, S., Rencic, J., Ballard, T., Holmboe, E., Da Silva, A., Ratcliffe, T., Schuwirth, L., & Durning, S. J. (2019). The terminology of clinical reasoning in health professions education: Implications and considerations. 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Cureus, 10(3), Article 2256. https://doi.org/10.7759/cureus.2256 PERCEPTIONS OF CLINICAL REASONING 92 Table 1 Simulated Escape Room Design Puzzle Puzzle #1 Yellow Blooms Taxonomy Educational Domain Focus Cognitive Critical o Evaluate thinking o Analyze Problem Affective solving o Organization Reflective o Valuing Assessment Psychomotor o Mechanism Educational Topic Subjective data gathering Clinical Task Puzzle Task Learning Objective(s) Gather data related to: Home situation Medications Past medical history Complete a Demonstrate understanding crossword of basic clinical reasoning, puzzle to find problem-solving, and corresponding evidence-based clinical numbers decision-making processes. (highlighted Demonstrate an boxes) for a understanding of the four-digit importance of involving the code to open patient in their rehabilitation lockbox #1 program using an ICF framework. Demonstrate effective interaction skills with student-patients and other (mock) health professionals in the verbal, non-verbal, and written realms of communication. Demonstrate professional flexibility and sound clinical judgment. PERCEPTIONS OF CLINICAL REASONING Puzzle Puzzle #2 Red Puzzle #3 Green 93 Blooms Taxonomy Educational Domain Focus Cognitive Critical o Evaluate thinking o Analyze Problem Affective solving o Organization Reflective o Valuing Assessment Psychomotor o Adaptation o Complex response o Mechanism Educational Topic Objective data gathering Clinical Task Puzzle Task Learning Objective(s) Gather numerical data related to: Verify patient's DOB Pain level Vitals ROM Strength Obtain objective numerical measures to complete the boxes and reveal a fourdigit code to open lockbox #2 Objective data gathering Gather descriptive data related to: Observation Palpation Complete a cryptogram to reveal a fourdigit code to open lockbox #3 Demonstrate accurate and skillful performance of basic general and musculoskeletal examination/evaluative procedures related to the given student-patient diagnosis/function. Demonstrate accurate interpretation of examination results (evaluation). Demonstrate professional flexibility and sound clinical judgment. Demonstrate accurate and skillful performance of basic general and musculoskeletal examination/evaluative procedures related to the given student-patient diagnosis/function. Demonstrate accurate interpretation of examination results (evaluation). Demonstrate professional flexibility and sound clinical judgment. Cognitive o Evaluate o Analyze Affective o Organization o Valuing Psychomotor o Adaptation o Complex response o Mechanism Critical thinking Problemsolving Reflective Assessment PERCEPTIONS OF CLINICAL REASONING Puzzle Puzzle #4 Blue Blooms Taxonomy Educational Domain Focus Cognitive Critical o Create thinking o Evaluate Problemo Analyze solving Affective Reflective o Organization Assessment o Valuing Psychomotor o Adaptation o Complex response o Mechanism 94 Educational Topic Safety and intervention implementati on Clinical Task Puzzle Task Learning Objective(s) Implement safe intervention techniques: Safety measures to stand/ambul ate Choose the correct assistive device and gait pattern Provide correct gait instructions Obtain puzzle Demonstrate effective pieces intervention planning through the (development of plan of correct care) and implementation. selection of Demonstrate professional safety features flexibility and sound clinical (i.e., gait judgment. belt), assistive device, and gait training procedures and complete the puzzle to reveal a fourdigit code to open lockbox #4 PERCEPTIONS OF CLINICAL REASONING Puzzle Puzzle #5 Black Blooms Taxonomy Educational Domain Focus Cognitive Critical o Create thinking o Evaluate Problemo Analyze solving Affective Reflective o Organization Assessment o Valuing Psychomotor o Adaptation o Complex response o Mechanism 95 Educational Topic Professional behaviors/qu alities Clinical Task Puzzle Task Learning Objective(s) Maintain professional behaviors/qualiti es through: Demonstrate professionali sm Discuss patient background Discuss patient goals SPTs introduce themselves to the standardized patient Maintain a pleasant demeanor Complete a Demonstrate an appreciation word search of the importance of from collected professional attributes and professional behaviors (as identified in qualities cards the Professional Behaviors provided by Assessment) in the on-going the development of competence standardized for physical therapists. patient (once qualities demonstrated by the SPTs) to reveal a four-digit code to open lockbox #5 Note. Description of the five puzzles of the simulated escape room (SER) activity, including the educational focus, educational topic, clinical task, puzzle task, and learning objectives. Each puzzle corresponded to different components of the physical therapy evaluation, including examination activities, interpretation of collected data, and implantation of intervention techniques. Each puzzle corresponded to a specific lockbox, which included Scrabble pieces to be collected. The final puzzle required the student groups to create a word or phrase from the collected Scrabble pieces, which was the overarching theme of the SER. DOB = date of birth. ROM = range of motion. SPT = student physical therapist. ICF = International Classification of Functioning, Disability, and Health PERCEPTIONS OF CLINICAL REASONING 96 Table 2 Understanding the Why Code Create Meaning Sub-Code Participant Quote Participant interpreting that information into something 1 that is meaningful for a diagnosis I guess [clinical reasoning] means why am I 12 doing this certain exercise or why am I treating a patient. So, in order to really cover your bases and make 13 sure that youre actually getting to the root of the problem, I think you need to reason through the body. just kind of knowing how to make those 15 connections and decisions based on what you find. being able to think through what could be 4 causing those issues and then how to approach treatment Having a purpose or understanding why youre 2 doing something and deciding the best thing to do in that moment for the specific patient. Necessary Communication being able to communicate effectively in 9 Skills asking questions that are working towards potential diagnoses. So, one of the main skills I would say that I think 4 is necessary for clinical reasoning is that of communication. Being able to communicate with your patients and not only just be able to tell them information. But being able to interpret what theyre saying and tell them information in a way that they can understand. And communication skills. Making sure they 15 understand what youre doing and why youre doing it. Adaptability So, being able to adapt and adapt quickly without, 16 you know, like having, I dont want to say cause chaos, but like you know like you dont, you want to be as smooth of a transition as possible if you need to adapt. So being able and willing to adapt but also be confident with your choices. Definitely being adaptive to the patient. 12 Multitasking too. PERCEPTIONS OF CLINICAL REASONING Code Sub-Code Participant Quote So, I guess like self-reflection and an understanding that, like, were not all perfect and that the first thing that we do isnt going to be the right thing and we might have to go back and do it again. So, its important to be able to adapt what youre doing towards that specific patient, especially if somethings not going right or somethings not going how you though it would. 97 Participant 14 2 PERCEPTIONS OF CLINICAL REASONING 98 Table 3 The Graduate Learning Experience Code Adaptation to Graduate Program Instructor Guidance Sub-Code Participant Quote Participant and I found out that writing by hand, I keep 9 information a lot better. So, when Im running back through lectures and studying, I write out the key information. Ive found out that by doing that, I can deduce a lot of information on exams or in practicals if Im given something. I can kind of break down the answer based on knowing the big picture information and not always the smallest little details. Yeah, that was a big learning curve for sure. I had 13 to completely change how I studied, what I studied, and the order that I studied it in. And I just, I felt behind in that aspect [anatomy], 6 but it taught me how to study and how to ask for help which was nice. Like I actually went to tutoring and I like met people that studied similarly to me and thats how we became friends, and I was able to boost my confidence in asking professors questions because I was always too anxious to do that [in undergrad]. But Ive learned how to like, shrink like what the 14 time frame, I guess. So, like I cant write it in a notebook and then write it on a flash card and then study. So, like I dont have time for that. So I guess I figured out like the most efficient way for me to study. Making time to meet with professors one-on-one 7 sometimes is a better way [to learn]. Feedback from professors, I feel like thats the 5 biggest [learning experience]. When I go into office hours, I feel like I learn the most, especially when Im struggling with the concept. Maybe guiding questions from my professors have 6 helped me when I get really stuck and they give me one key piece of information. Definitely having instructors that answer questions 3 with questions is really helpful even though its frustrating. Sometimes you just want the answer but making me think through what PERCEPTIONS OF CLINICAL REASONING Code Interweaving of Concepts Sub-Code Participant Quote else could be a possibility is helpful. So having guidance, I guess, in controlled situations. I feel like I can understand concepts and then, this semester specifically, since were doing a lot of region stuff, Im able to connect all my classes. Mock, and in all of our labs, all of the pathologies that we talk about are coming up l three or four times and so, were building on the knowledge and essentially critically reasoning in three or four different ways. I like that [all classes] kind of flow together. We do body region by body region. 99 Participant 6 3 17 PERCEPTIONS OF CLINICAL REASONING 100 Table 4 Application of Knowledge in Practice Code Clinical Education I Mock Simulation Sub-Code Participant Quote Participant I definitely know I would not be prepared for 16 any sort of clinical if it wasnt for mock. Its a lot of prep and a lot of hard work, but I feel like if I stepped into the clinic without any sort of mock scenario I would feel lost. I always go in thinking Im going to do one 2 thing and then its never what I think it is. So, you have to think on your feet. But [mock] definitely helped in being able to 9 try to think about all the potential diagnosis. Even though sometimes I do kind of get locked in on one thing, being able to take all the different diagnoses and break them down. then in mock, Im able to apply 6 [concepts], which has been very helpful because Im a very hands-on learning. So being able to apply everything has helped me study for all my other classes. Those simulations make me revisit and pull 13 [concepts] together. [Simulation experiences] remind me of all the 10 things that Im missing and or lacking. Simulation causes you to have to think on your 9 feet... It makes you apply [your knowledge] to whatever information youre getting from the patient and it can vary a lot depending on where in the body the pain is located.. But [simulation] is actually having to apply 11 [knowledge] and you realize how indepth the protocols are. It was just very eye-opening to me, and I was like not prepared whatsoever for it. Simulation, me being a patient and me being a 12 PT, has really benefited me. Using the knowledge Ive gained and then applying it to actual class. PERCEPTIONS OF CLINICAL REASONING Code Sub-Code Escape Room Adapting to the Situation 101 Participant Quote Participant [Simulation] gives us the opportunity to 14 perform [skills] under pressure with peoples eyes on us. For me the patient interaction, thats what 14 really stuck to me because we all had the skills necessary to complete the puzzle. But when we walked in maybe we did introduce ourselves, but we literally had a 5 second conversation [with the standardized patient] then turned our back to the patient and was just over the puzzle. [The escape room] was the first experience I 2 had where I had to start critically thinking. Because everything else we had before was very like, ok do this, very standard. So, it was the first experience I had that wasnt like that so it kind of just made me realize how much problem-solving and thinking [physical therapy] really is because I felt so tired after. First off, it was kind of scary to just like go in 10 [the escape room] and see a patient with like, you could see the bruises, they acted very weakso it was kind of intimidating in that sense. I think [the escape room],kind of made it more 11 open and more apparent as to how every patient doesnt present the same. You have to be able to take what we learn, but 16 we have to be able to adapt, and I feel like [the escape room] set us up perfectly for what we needed going forward, because not everything is going to be so cut and dry. So, [the escape room] made you critically 8 think how can you do this but still be a valid assessment. but I do feel like [the escape room] was a 12 good learning experience, like I said, because we have to adapt, and we have to know what to do on the fly. We have to understand what [patients] limitations are, what they can and cant do, how to PERCEPTIONS OF CLINICAL REASONING Code Sub-Code Confidence Teamwork Participant Quote respond, how to react to the patient, interact with them too. So,,it was a good overall experience, but I definitely didnt know how to do clinical reasoning at that certain time. [The escape room] was enlightening because there were so many different things that were easily missed because we were focused on the big outcomes or the really big functional things that we wanted to do. And understanding the things that we learned in our previous courses werent necessarily always the right choice for the patient presented to us. Even though I was not confident at all and it was a shot to the confidence, I think like realizing like I got through [the escape room] and like, OK, theres gonna be hard stuff, but like you can like, Im only going to get better from there. The escape room in general is most memorable. I remember feeling very good when I was able to do a gait pattern with a walker, I felt pretty good about that one so it was a little win. it was also, like, such a good feeling when you got like the little riddles done. Like, I dont know, I just felt it was a proud feeling, like when you open the next lock box and youre just like excited. I was glad that I had a group of people because I felt less nervous, even though I was extremely nervous going into [the escape room]. [The escape room] was definitely scary, but I felt like it was kind of fun, honestly. To be able to work with my classmates on kind of using what we learned last semester to solve the puzzle. So, I thought it was pretty fun. It was good to do [the escape room] together, I really like that. Its the puzzles, they were the hardest part because I wanted to talk to the patient, but I also didnt 102 Participant 10 2 1 16 12 15 10 PERCEPTIONS OF CLINICAL REASONING Code Sub-Code Participant Quote want to be the only one to talk to the patient and then nobody else got the patient-PT interaction. But I thought we worked well together as the team up there. Im not very good at puzzles, so I let them all figure out the, the riddles and Ill do the hands-on stuff. But I thought we all, we all delegated well 103 Participant 14 PERCEPTIONS OF CLINICAL REASONING 104 Table 5 Growth Code Embracing Being Uncomfortable Importance of Collaboration Self-Reflection Sub-Code Participant Quote Every time I feel challenged, I know its because Im learning to be able to pick apart very subtle difference in the future. Better get comfortable with being uncomfortable. So sometimes, you have to go outside your comfort zone a little bit if, you know, and have that kind of prior evidence from other places that might not exactly support what youre doing but if its working for the patient and theyre having better outcomes then your clinical reasoning is on point. like being able to go through this with other people as well. When we talk to each other and when we study together, being able to bounce ideas off [each other]. I feel like thats, even though it's just studying for say like an exam, it can translate to the real world So, beginning with our anatomy class, the way that it was set up, we had mostly selfguided laboratory experience. But that kind of created its own like crash course in having to clinically reason because you had to figure out what you were doing, and you had to work with your classmates because you couldnt possibly take in all of the information or learn it all by yourself. A lot of [learning] has been studying with students actually. In undergrad I never group studiedSo being able to get multiple perspectives has also helped me [learn] a lot. not losing sight of the end goal and not getting so overwhelmed by these things right now because it is hard, but at the end of the day I know that I know a lot more than I give myself credit for. Participant 10 1 7 16 3 11 7 PERCEPTIONS OF CLINICAL REASONING Code Sub-Code 105 Participant Quote Participant So I think [mock case] was pretty memorable 12 because I felt like I am growing, I am gaining the confidence and getting prepared to, you know, actually do PT one day.. I feel like Ive improved a lot, which is 10 expected and hopeful but I also feel like sometimes I doubt myself a little bit and Im not sure how to not [doubt myself]. Even with like previous experience like, you 17 know, coming in as like a CNA and all that stuff I was like, oh yeah, this wont be [hard], Ive done this patient care stuff [before]. And Im like, no, theres so much more to it than what Ive done before. I still need to work on myself a lot. since Ive graduated undergrad Ive taken 6 less time to think through things, Im doing it more effectively and more efficiently. I get to the correct answer or I get to solving the problem a lot sooner and I dont have to go through all these different webs to get there. PERCEPTIONS OF CLINICAL REASONING 106 Figure 1 Clinical Education Series Structure Year 1 Summer I: oncampus didactic coursework Summer II: oncampus didactic coursework Fall: on-campus didactic coursework Winter: on-campus didactic coursework including Clinical Education I or "mock" Year 2 Summer I: Clinical Education II - offcampus experience Summer II: on-campus didactic coursework Fall: on-campus didactic coursework including Clinical Education III or "mock" Winter: on-campus didactic coursework Year 3 Summer I: on-campus didactic coursework Summer II: on-campus didactic coursework Fall: Clinical Education IV - offcampus experience Winter: Clinical Education V - offcampus experience Note. The clinical education curriculum consists of five courses, with two (Clinical Education I and III) integrated on-campus semester-length clinical experiences or mock courses. In these mock courses, students prepare for off-campus clinical experiences by participating in case simulations designed to integrate knowledge and skills from various academic courses and advance clinical reasoning processes. Clinical Education II, IV, and V are full-time clinical experiences. PERCEPTIONS OF CLINICAL REASONING 107 Figure 2 Clinical Education I Mock Course Design Week 1: Group lowcomplexity, high-level simulation simulated escape room Week 3-6: Peer-topeer, low-level simulation (one case per week) Week 7-14: Peer-topeer, low-level simulation (two cases per week) Week 15: Group high-complexity, high-level simulation - simulated escape room Note. Clinical Education I, or mock, emphasizes clinical problem-solving, clinical reasoning, and clinical decision-making through low- and high-simulation activities over the 16-week semester. Through patient and PT role-playing (peer-to-peer, low-level simulation activities) and simulated escape room (SER) experiences (group high-level simulation with standardized patients), students apply theoretical, scientific, and technical knowledge and skills gained throughout the curriculum for identifying and managing specific patient problems/cases encountered in the clinical setting. This course primarily focuses on managing patients with musculoskeletal dysfunction and various orthopedic or rheumatologic disorders. Patients will also present with secondary diagnoses and comorbidities involving other systems. Management includes the full spectrum of care a physical therapist provides, including examination, evaluation, and intervention. PERCEPTIONS OF CLINICAL REASONING 108 Figure 3 Students Perceptions of Clinical Reasoning Development Central Theme Model Application of Knowledge in Practice Graduate Learning Experience Growth Understanding the Why Note. The central themes identified by participants as influencing their development of clinical reasoning in physical therapy practice. The arrows represent the interrelationship between these themes. Students must understand clinical reasoning and its importance in physical therapy practice to begin to develop this complex skill. Facilitation of clinical reasoning development requires challenging learning experiences where the learner must apply foundational knowledge in a realistic environment. Learners must practice real-world application of clinical reasoning in various situations to grow as skilled physical therapy clinicians. PERCEPTIONS OF CLINICAL REASONING 109 Figure 4 Influence of Effective Communication in Clinical Reasoning Patient A: Good Patient-Provider Communication Patient B: Poor Patient-Provider Communcation Illicits greater key factors Illicits fewer key factors Increases reasoning considerations Limited reseasoning considerations Enhanced patient-provider relationship Poorer patientprovider relationship More successful patient outcomes Less successful patient outcomes Note. Effective communication aids in the clinical reasoning process by eliciting a greater depth of information obtained during the patient encounter. This greater depth of information, or a greater number of critical factors, aids in the clinical reasoning process of the clinician. Effective communication also positively influences the patient-provider relationship. A positive patientprovider relationship combined with a greater depth of understanding in the clinical decisionmaking process creates the opportunity for successful patient-centered outcomes. PERCEPTIONS OF CLINICAL REASONING 110 Figure 5 Comparison of Kolb's Experiential Learning Cycle and Central Themes Note. Comparison of phases of Kolb's Experiential Learning Cycle (Kolb & Kolb, 2017) on the readers left to the themes found in this study related to clinical reasoning development during a simulated escape room (SER) experience on the readers right. The SER experience required the student participants to apply knowledge in a clinical setting or provide a concrete experience of Kolb's Experiential Learning Cycle. Reflection in and on the action of the SER activity, or reflective observation, was identified by the theme of growth. Being able to better understand what clinical reasoning is and its vital role during physical therapy encounters was reflective of the abstract conceptualization component of Kolb's Experiential Learning Cycle. Student participants could modify or adapt their knowledge and skill in the moment during the SER activity and within subsequent learning activities in the program, emulating the active experimentation stage. PERCEPTIONS OF CLINICAL REASONING 111 Appendix A Email Template (Date) Re: Simulated Escape Room Influence on Student Physical Therapists Perceptions of Clinical Reasoning Dear: CMU DPT Class of 2025 I am writing to inform you of an opportunity to participate in a voluntary research study regarding the perceived impact of a simulated escape room activity on the development of clinical reasoning skills in student physical therapists. This study is being conducted by Jessica Sullivan PT, DPT at Central Michigan University as part of the requirements for the Doctor of Health Science Program at the University of Indianapolis. What is the purpose of this study? Participation includes a 60-minute individual audio-recorded interview either in person or virtual as well as an additional follow-up via email with a summary of the interview as perceived by the primary investigator. Participating in this study would provide 1 volunteer hour/point toward PTH 666 Seminar II and/or PTSO. Attached you will find the informed consent form for participation which provides a more detailed description of the research study. Who can participate in this study? Eligibility for this study includes the following: Actively enrolled in PTH 633 Clinical Education I Completed 1 simulated escape room activity in person Completed all assignments related to the simulated escape room activity At least 18 years of age or older Fluent in English At no time should a potential participant feel obligated to participate in this study. Participation or non-participation in this study will not directly or indirectly impact successful completion of PTH 633 Clinical Education I. This study is voluntary, and participants have the ability to withdraw at any time. Information obtained by the primary investigator (J.S.) will be deidentified and stored securely utilizing University-supported software. Sharing of de-identified individual data to study co-investigators will only be done as necessary for random external PERCEPTIONS OF CLINICAL REASONING 112 audits to ensure data analysis accuracy and all necessary measures to protect participant privacy will be followed. The aim of this study is to gain insight into a student physical therapists perception of clinical reasoning development and how a simulated escape room impacted that perception. This is to better adapt instructional methods in the future to best address the needs of the students. If you are interested in participating in this study or would like additional information, please contact the primary investigator, Jessica Sullivan PT, DPT, either by email (sulli3jl@cmich.edu), phone (989-774-1447), or in person (HPB 1241). An in-person follow-up to this email also be provided to answer any questions or concerns you may have and will take place during PTH 633 lecture on XX/XX/2023. Thank you for your consideration, and once again, please do not hesitate to contact us if you are interested in learning more about this Institutional Review Board-approved project (pending). Jessica L. Sullivan PT, DPT Principal Investigator Lecture I Director of Physical Therapy Services Carls Center for Clinical Care and Education Central Michigan University PERCEPTIONS OF CLINICAL REASONING Appendix B Consent Form 113 PERCEPTIONS OF CLINICAL REASONING 114 PERCEPTIONS OF CLINICAL REASONING 115 PERCEPTIONS OF CLINICAL REASONING 116 PERCEPTIONS OF CLINICAL REASONING 117 PERCEPTIONS OF CLINICAL REASONING 118 Appendix C Eligibility Screen Eligibility Criteria Actively Enrolled in PTH 633 Clinical Education I Complete (in-person) 1 simulated escape room activity Completed all assignments related to the simulated escape room activity 18 years of age or older Fluent in English Met Not Met PERCEPTIONS OF CLINICAL REASONING 119 Appendix D Simulated Escape Room Influence on Student Physical Therapists Perceptions of Clinical Reasoning: Interview Guide Introductory Paragraph Good morning/afternoon/evening! First, thank you for agreeing to participate in this interview as part of a research study entitled Simulated Escape Room Influence on Student Physical Therapists Perceptions of Clinical Reasoning, which meets the required dissertation component for completion of the Doctor of Health Science degree from the University of Indianapolis. This study aims to better appreciate physical therapy students' understanding of clinical reasoning, what components make up the clinical reasoning process as perceived by the student, and the impact that a simulated escape room has on your perception of the development of these clinical reasoning skills. Any information shared will be de-identified and stored securely to maintain confidentiality to the highest degree. Data collected will be used to gain insight into your thoughts on how a simulated educational escape room influenced the development of your clinical reasoning skills. You will also have an opportunity to share anything else you would like on the subject. This interview is expected to take 45-60 minutes. I will audio-record our interview today to ensure that I capture your thoughts and feelings as accurately as possible. I will also be taking notes throughout the interview. Participation in this interview is voluntary and you may stop the interview or choose not to answer a question at any time. Do you have any questions about how this interview will be conducted? Is it okay with you if I begin the recording now? PERCEPTIONS OF CLINICAL REASONING 120 Domains and Interview Questions Domain 1 - Definition of Clinical Reasoning 1. What does clinical reasoning mean to you? a. What are the necessary components in the evaluation process to guide you to your physical therapy diagnosis and prognosis? (Cueing question if unable to answer the initial question) b. How do you utilize critical thinking during the physical therapy evaluation to develop an individualized physical therapy diagnosis, prognosis, and/or goals? (Cueing question if unable to answer the initial question) c. How do you define clinical reasoning? d. Why is clinical reasoning necessary in physical therapy practice? e. What have you experienced thus far in your educational journey related to the development and use of clinical reasoning? 2. What skills are necessary to be able to use clinical reasoning in physical therapy practice? 3. How do you think your critical thinking and problem-solving skills have evolved over the past year? a. What factors do you believe helped in the development of your critical thinking and problem-solving skills? b. Are there any factors that you believe challenged your critical reasoning and problemsolving skills? Domain 2- Educational Methods 4. Will you please describe the learning experiences you have had thus far during the physical therapy curriculum? PERCEPTIONS OF CLINICAL REASONING 121 a. How would you describe the meaning of these learning experiences? i. For example, what experiences have been most meaningful in your journey compared to those that have been least meaningful? b. What modes or methods of instruction have been most beneficial towards your development of clinical reasoning skills? c. What modes or methods of instruction or content delivery have been least helpful in the growth of your clinical reasoning skills? 5. Will you please describe in your own words the simulation experiences you have participated in during the educational program thus far? a. How do you think these simulation experiences have facilitated your growth as a student clinician? i. What aspects of the simulation experience provided the greatest growth in your critical thinking and problem-solving skills? b. How do you think these simulation experiences have limited your growth as a student clinician? c. Thinking back to your description of clinical reasoning, will you describe how simulation experiences may impact this aspect of learning? i. If you do not feel that simulation experiences have directly impacted your development of clinical reasoning skills, what methods or modes of instruction may be more beneficial based on your experience? d. What was the most memorable aspect(s) of the simulation educational experiences? 6. How would you describe your experience in the simulated escape room activity? a. How would you change it, and why? PERCEPTIONS OF CLINICAL REASONING 122 b. How do you think this activity influenced your growth as a student clinician? i. Do you feel this experience addressed your ability to utilize clinical reasoning skills during a direct patient encounter? If so, how do you feel this experience addressed your clinical reasoning skills? c. Did this activity create any changes in your views of clinical practice in physical therapy? If so, how did your views change and why? d. Will you describe any aspects of the escape room simulation activity that would have made the experience more beneficial to your growth as a student clinician? 7. Is there anything else you would like to share with me regarding the development and utilization of your clinical reasoning skills? Encouraging words/phrases to facilitate continued interviewee engagement include: Can you elaborate on that? Can you tell me more about ____? Go on ...
- Creator:
- Sullivan, Jessica
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- Dissertation
16. Black American Perceptions of Trauma and Sense of Well-Being
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- ... Black American Perceptions of Trauma and Sense of Well-Being Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Chioma Patterson Lindo, BS/MS OT, OTR/L Copyright December 5th, 2023 By: Chioma Patterson Lindo, BS/MS OT, OTR/L All rights reserved Approved by: Laura Santurri, Ph.D., MPH, CPH, aPHR Committee Chair ______________________________ Lisa Borrero, Ph.D., FAGHE Committee Member ______________________________ H. Jean Wright II, Psy.D. Committee Member ______________________________ Accepted by: Lisa Borrero, Ph.D., FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, Ph.D. Dean, College of Health Sciences University of Indianapolis ______________________________ BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 1 Black American Perceptions of Trauma and Sense of Well-Being Chioma Lindo Department of Interprofessional Health & Aging Studies, University of Indianapolis Author Note I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Chioma Lindo, University of Indianapolis, 1400 E. Hanna Avenue, Indianapolis, IN 46227. Email: lindoc@uindy.edu BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 2 Abstract Background: Black Americans have a higher reported trauma exposure than other groups in the U.S. Although the causes of and impact of trauma are well-cited, little is known about how Black Americans examine and draw conclusions about trauma and its perceived effect on their wellbeing. Purpose: This qualitative study used interpretative phenomenological analysis to explore how middle-aged Black American adults described traumatic adverse experiences. The study also explored the resulting dysfunction and its physical, psychological, and spiritual implications. Method: The researcher recruited participants from across the U.S. using online recruitment strategies. The purposive sampling consisted of middle-aged Black Americans 40 - 60 years of age who had endured at least one traumatic event. A prescreening survey was used to determine eligibility, and data was collected through semi-structured interviews to develop a deeper understanding of the participants' experiences. Results: Four main themes emerged from the data, including faith as a contextual factor, the longevity of trauma, the emergence of well-being, and the influence of support systems. The connection between the passage of time and the emergence of well-being was evident and required reflection and active addressing of trauma. Discussion: There were anticipated and unforeseen experiences described as contributing to trauma, such as sexual abuse and reckoning with unexpected paternal lineage, respectively. Environmental and personal factors played a pivotal role in shaping the experience of trauma. This study underscores the enduring impact of traumatic adverse experiences on well-being and discerns opportunities to create timely and targeted interventions to disrupt the trauma cycle. Keywords: trauma, psychological trauma, well-being, psychological functioning, health, spirituality, Black American, African American BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 3 Acknowledgements Completing this research has been a challenging and rewarding journey. I would like to express my deep gratitude to all those who played a pivotal role in both the commencement and culmination of this significant chapter in my academic journey. I offer my sincere thanks to God for His unwavering presence and blessings. I want to extend my heartfelt appreciation to my family, with special thanks to my husband, Troy Lindo, and our children, Jones and Zuri Lindo, who supported me unwaveringly and served as my most enthusiastic cheerleaders. I am profoundly grateful to my extended family: my mother, Lois Patterson, my sister, Adaoma Patterson, and my late father, Horace Patterson. They serve as inspiring examples of championing marginalized groups and relentlessly pursuing one's dreams. To the Lindo family, I offer my sincere thanks for exemplifying the fruits of higher education. You have been a source of inspiration throughout this journey. I am also indebted to Dr. Terrance Anderson for igniting my pursuit of a doctorate and to Dr. Shanese Higgins for clearing the path that allowed me to successfully complete this endeavor. My gratitude extends to many others who provided invaluable support, including Dr. Mamie Lindo, Dr. Rachelle Janning, Dr. Danielle McPeck, Evelyn Gordon, Michele Jackson, my colleagues in the OTD class of 2024, 2025, and 2026, Pam Wilson, and Mary Kay Cobb. To all of you, I offer a heartfelt acknowledgment. I want to express my profound appreciation to my committee members, Dr. Laura Santurri, Dr. Lisa Borrero, and Dr. H. Jean Wright II. I could not have asked for a more supportive, passionate, and exceptionally brilliant group of individuals. Your unwavering patience with me was remarkable, and I am forever grateful for your guidance and support. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 4 Lastly, to the incredible women who participated in my study, I am deeply grateful. Your willingness to share your stories provided a culturally specific lens to understand Black women and girls. May the stories you shared bring hope to others who have experienced trauma, inspire others to share their stories, and contribute to the emaciating of trauma. Thank you, Chioma Lindo BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 5 Table of Contents Title Page . ...................................................................................................................................... 1 Abstract ........................................................................................................................................... 2 Acknowledgements ......................................................................................................................... 3 Table of Contents ............................................................................................................................ 5 Chapter 1: Introduction .................................................................................................................. 8 Research Problem ............................................................................................................... 9 Purpose Statement ............................................................................................................... 9 Research Questions ................................................................................................. 9 Significance of the Study .................................................................................................. 10 Definition of Terms........................................................................................................... 11 Chapter 2: Literature Review ........................................................................................................ 11 Trauma .............................................................................................................................. 11 Responses to Trauma ............................................................................................ 12 Trauma and the Black American Adult ............................................................................ 13 Governmental Agencies and Trauma.................................................................... 13 Interpersonal Trauma and Loss ............................................................................. 14 Discrimination and Trauma .................................................................................. 14 Consequences of Trauma and the Black American .............................................. 15 Well-Being ........................................................................................................................ 16 Trauma and Well-Being ........................................................................................ 17 Categories of Research Analysis ...................................................................................... 20 Chapter 3: Method ........................................................................................................................ 21 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 6 Study Design ..................................................................................................................... 21 Participants ........................................................................................................................ 22 Procedures ......................................................................................................................... 23 Sampling and Recruitment .................................................................................... 23 Informed Consent.................................................................................................. 24 Data Collection ................................................................................................................. 25 Data Management and Analysis ........................................................................... 26 Rigor/Trustworthiness....................................................................................................... 28 Ethical Considerations ...................................................................................................... 30 Chapter 4: Results ......................................................................................................................... 30 Faith as a Contextual Factor ............................................................................................. 32 Longevity .......................................................................................................................... 33 Emergence......................................................................................................................... 37 Chapter 5: Discussion and Conclusion ......................................................................................... 41 Expected Trauma Experiences .......................................................................................... 41 Mitigating and Aggravating Factors ................................................................................. 44 Unexpected Trauma Experiences ..................................................................................... 47 The Broader Narrative ...................................................................................................... 48 Themes .............................................................................................................................. 48 Faith as a Contextual Factor ................................................................................. 48 Longevity of Trauma ............................................................................................ 49 Emergence of Well-Being and Support ................................................................ 50 Study Limitations .............................................................................................................. 50 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 7 Implications for Future Research ...................................................................................... 51 Conclusion ........................................................................................................................ 53 References ..................................................................................................................................... 55 Table 1 .......................................................................................................................................... 78 Appendices .....................................................................................Error! Bookmark not defined. Appendix A: Supporting Organization Recruitment ........................................................ 80 Appendix B: Recruitment Flyer ........................................................................................ 81 Appendix C: Study Eligibility Form ................................................................................. 82 Appendix D: Study Information ....................................................................................... 87 Appendix E: Interview Confirmation ............................................................................... 90 Appendix F: Interview Guide ........................................................................................... 91 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 8 Black American Perception of Trauma and Sense of Well-Being More than half of those living in the U.S. have suffered at least one traumatic event (Carter, 2019). Trauma is defined as one or multiple experiences that adversely affect the individual's physical, emotional, and mental health, including overwhelming a person's ability to cope (Bloom & Farragher, 2013; Kirkinis et al., 2018). Individuals exposed to trauma are at higher risk for psychological symptoms and disorders such as post-traumatic stress disorder (PTSD) and depression (Carter et al., 2020; Powers et al., 2020) and chronic health conditions (e.g., ischemic heart disease) (Carter et al., 2020). The negative impact of trauma is uniquely observed in the Black American community, with higher reports of trauma exposure than their Caucasian counterparts (Hampton-Anderson et al., 2021) and increased psychological disorders, particularly PTSD (Carter et al., 2020; Gluck et al., 2021). The experiences of Black Americans that contribute to trauma and its impact are wellestablished and include, but are not limited to, racial discrimination (Fani et al., 2021; Kirkinis et al., 2018), adverse childhood experiences (Hampton-Anderson et al., 2021; Volgenau et al., 2022), and violence (Mental Health America, 2022; Mushonga et al., 2021). The research reveals the parasitic relationship between trauma and health (Gluck et al., 2021; Range et al., 2018; Hampton-Anderson et al., 2021; Powers et al., 2020; Stenson et al., 2021). Just as a parasite lives off another and may cause harm (Merriam-Webster, n.d.), the presence of one's adverse experience(s) can impact health, causing harm to the individual. It may alter or destroy an individual's physical, physiological, and psychological state (Hampton-Anderson et al., 2021; Mental Health America, 2022). However, little is known about how Black Americans examine and draw conclusions about their adverse experiences and if they perceive the kind of events that constitute trauma in the same way researchers do. A term often used interchangeably with health BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 9 is well-being. Although a nebulous concept, the literature offers overlapping descriptions of well-being, including positive mood and emotion, the absence of psychological symptomologies such as depression or anxiety, satisfaction with life, and the ability to function (Centers for Disease Control and Prevention, 2018). If there is to be serious discourse about well-being in the Black American community, a culturally-based view of trauma and how it shapes health and one's sense of well-being must be understood. Research Problem An in-depth understanding of how Black Americans conceptualize trauma and its influence on their well-being is essential to better curate and create experiences to meet the population's needs. Many existing studies identify trauma using quantitative assessments, such as the Adverse Childhood Experiences Assessment and the Traumatic Events Inventory. These assessments do not capture the lived experiences in any depth. By the nature of their structure, the assessments do not allow a respondent to appraise the experiences and describe how the experiences impact them. Understanding the lived experience further elucidates the broader themes and relationships between populations' trauma and well-being. Purpose Statement This study explored Black Americans' perception of trauma and its influence on their sense of well-being. Specifically, this researcher sought to explore how Black American adults describe experiences as causing trauma and how these experiences shaped their sense of wellbeing. Research Questions How do Black American adults characterize trauma? In what ways do the experiences of trauma shape their sense of well-being? BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 10 o How do Black Americans describe the association between trauma and their mental health? o How do Black Americans describe the association between trauma and their level of life satisfaction? o How do Black Americans describe the association between trauma and physical health? o How does trauma shape the spiritual well-being of Black Americans? Significance of the Study The opportunity for individuals to reflect on and talk through the experiences adversely affecting them offers contextual nuance that quantitative studies alone cannot provide. Studies like this are particularly relevant as Black Americans are more likely to experience trauma at a higher rate than the general population (Hampton-Anderson et al., 2021; Motley & Banks, 2018) and face unique historical and intergenerational factors. Furthermore, Black Americans are less likely to have their trauma addressed due to such factors as access to services (Rich et al., 2020), stigma (Kanor et al., 2017), and healthcare providers' lack of knowledge (LanghinrichsenRohling et al., 2017; Metzger et al., 2021; Pletcher et al., 2016). Therefore, the qualitative approach to this study was essential. These opportunities for expression contribute to normalizing the conversation about trauma. The value of the population's frame of reference, which may be underappreciated, helps healthcare providers, policymakers, and the community create more culturally appropriate plans when considering best practices and program development. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 11 Definition of Terms Adverse Experiences: a broad term that refers to a wide range of circumstances or events that pose a serious threat to a childs physical or psychological well-being (Bartlett & Sacks, 2019). Trauma: defined as one or multiple experiences that adversely affect the individual's physical, emotional, and mental health, including overwhelming a person's ability to cope (Bloom & Farragher, 2013; Kirkinis et al., 2018) Well-being: for the purpose of this study, well-being is defined as how people feel, function, and evaluate their lives (Centers for Disease Control and Prevention, 2018; New Economic Foundation, 2012) Literature Review Trauma The definition of trauma noted by Bloom and Farragher (2013) and Kirkinis et al. (2018) is further outlined by The International Classification of Diseases of the World Health Organization (ICD-11) (2018) and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (American Psychiatric Association, 2013). They specify the experiences that may adversely affect an individual, which could result in trauma, including actual or threatened serious injury, actual or threatened sexual violence, or the threat of death (DSM-5, 2013; ICD-11, 2018). Trauma is related to stress in that it serves as a more acute form of stress that may overwhelm the coping mechanisms typical for the individual (Kirkinis et al., 2018). Coping mechanisms are the conscious thoughts and behaviors used to manage stressful situations (National Library of Medicine, 2023). The National Council for Behavioral Health (n.d.) reports that exposure may come in the form of an overwhelming or disturbing event such as war, BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 12 disasters, sudden loss, serious illness, and violence, as well as medical intervention and as a result of historical factors. Historical trauma is the cumulative damage of multiple generations of a specific population and is typically associated with their oppression (Brave Heart, 2003, p. 7; Fortuna et al., 2022). Closely associated with historical trauma is intergenerational trauma. Intergenerational trauma is the damage to an individual, group, or family and its psychological effect on future generations (Fortuna et al., 2022). Trauma exposure as related to factors like intergenerational trauma and discrimination are less likely to be listed in the general descriptions of trauma but are essential to recognize, especially as it pertains to the Black American community (Kirkinis et al., 2018; Ortega-Williams et al., 2021; Range et al., 2017; Roberson & Carter, 2022; Williams-Washington & Mills, 2018). Responses to Trauma Traumatic experiences can have immediate and long-term effects with far-reaching consequences (Miller & Brock, 2017). Fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities associated with the trauma are normal reactions following an adverse event and may be immediate or delayed (Center for Substance Abuse Treatment, 2014). The traumatization can compromise psychological, metabolic, neurological, endocrine, and immune functions (Jones, n.d.; Hampton-Anderson et al., 2021; Stenson et al., 2021). Individuals' ability to overcome adverse experiences is based on an individual's life experience, responsiveness, availability of support from others, and coping styles and life skills (Center for Substance Abuse Treatment, 2014). The inability to move beyond the trauma experience may result in dysfunction, specifically when an individual lacks the factors mentioned above, such as healthy coping skills, support, or time between traumas. Dysfunction may present itself as persistent mental health BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 13 problems such as post-traumatic stress disorder (PTSD), complex post-traumatic stress disorder, major depressive disorders, anxiety disorders, psychosis (McGreevy & Boland, 2020; O'Hare et al., 2017), or obsessive-compulsive spectrum disorders symptoms (Miller & Brock, 2017). Additionally, the risk of engaging in harmful behaviors increases with trauma exposure. These behaviors may manifest in various ways, including smoking, alcohol and substance abuse, sexual risk-taking (Marks et al., 2021), hoarding, and excoriation (Miller & Brock, 2017). Trauma and the Black American Adult Governmental Agencies and Trauma Black Americans have an amalgamation of experiences that may contribute to trauma. Despite making up approximately 14% of the population (Statista, 2021a), Black Americans account for 38.3% of the prison population (Federal Bureau of Prisons, 2020). Incarcerated men are more likely to have experienced trauma in childhood or adulthood, with over one-quarter being abandoned in childhood or adolescence, physically and sexually abused, witnessing interpersonal violence, and over half experiencing physical trauma in childhood (Wolff & Shi, 2012). Contact with the criminal justice system also stems from the overrepresentation of inschool suspensions and expulsions (Okonofua & Eberhardt, 2015). There is a connection between suspension and expulsion, increased drop-out rates, and interactions with the criminal justice system (Lyell, 2019; Simmons, 2016). Trauma continues in prison, with some men being victims of physical violence (Wolff & Shi, 2012). Trauma affects not only those imprisoned but also their children. Enduring trauma is the main feature for children of an incarcerated parent because it persists over time (Arditti & Savla, 2015). A study by Arditti & Savla (2015) found that children who have an incarcerated parent and live in a single-parent household had elevated trauma symptomology and were independent of other factors such as socioeconomic status. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 14 Evidence supports that trauma also exists for families involved in the child welfare system. The imbalanced representation of Black children in the welfare system occurs at multiple Child Protective Service (CPS) decision points, investigation, assessment of abuse and neglect, ongoing CPS involvement, foster care, and length of time in foster care (Knotts & Giwa, 2012; Kokaliari et al., 2019; National Conference of State Legislatures, 2021). The removal, or threat of removal, is deemed a traumatizing experience for both parent and child (Blakey & Glaude, 2021). Interpersonal Trauma and Loss Black Americans also disproportionally experience interpersonal trauma (Blakey & Grocher, 2020), particularly Black women. Harrell (2011) found that nearly 50% of Black American women were victims of rape, sexual assault, aggravated assault, and robberies, and intimate partner violence was experienced by 25% to 31% of the women. Disproportionality for Black Americans occurs in both life and death, with the mortality for all causes of death being 24% higher for Black Americans than White Americans (Benjamins et al., 2021). Infant mortality rates are 2.3 times greater for Black Americans than White Americans (Ely & Driscoll, 2020). Perinatal loss exposes women to a risk of experiencing PTSD seven times greater than those who delivered a healthy baby (Gold et al., 2016). Families, including siblings, of children who passed away in childhood, are more susceptible to developing a pathological response to grief (Institute of Medicine, 2003; Morris et al., 2019). Discrimination and Trauma When asked, Black Americans report work and pay inequalities, use of racial slurs directed at them, and police misconduct more than 50% of the time (Harvard Public Health, 2018; Holliday et al., 2020). While less in percentage but still significant is that 22% of Blacks BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 15 avoid seeking medical care out of concern that they will face discrimination (Harvard Public Health, 2018). Numerous studies point to physicians' problematic and differential treatment of marginalized groups (Hoberman, 2012; Kerr, 2017; Noonan et al., 2016). Microaggression plays a role in the avoidance of seeking healthcare. According to Cruz et al. (2019), "microaggressions are broadly defined as behaviors that ambiguously disempower racial minorities (p. 1)." The study found a positive correlation between microaggressions and perceived discrimination. Moreover, they found that microaggressions may significantly and negatively influence one's quality of life. These findings are consistent with previous research in this area. The case for regular exposure to discrimination or microaggression producing symptoms similar to severe trauma has a growing body of evidence (Nadal, 2018). Even during events that have the propensity to induce a trauma response, such as a natural disaster, there are additional burdens to the Black experience. As natural hazard damages accrue, Black Americans tend to lose wealth while white Americans tend to accrue wealth, all else being equal (Howell & Elliott, 2018). It is suggested that discrimination and unfair treatment as chronic stressors may lead to a heightened stress response, negative emotional state, poor health-related behaviors, and decreased psychological responsivity (Holliday et al., 2020). The response to discrimination as a chronic stressor poses an increased risk for mental and physical problems such as PTSD (Holliday et 1l., 2020). Another argument is that discrimination is chronic trauma (Holliday et al., 2020). Consequences of Trauma and the Black American The repercussions of trauma, as noted earlier, are profound. Cardiovascular disease, cerebrovascular disease, diabetes mellitus, cancer, autoimmune disorders (Glauck et al., 2021), and accelerated biological aging (Stenson et al., 2021) are the physical manifestations of some who experience trauma, particularly those whose trauma experiences begin in childhood BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 16 (Forkey, 2018; Gluck et al., 2021). Coincidentally, Black Americans have the highest incidence of cardiovascular disease in the U.S. and are more likely to die due to heart disease (American College of Cardiology, 2018). They also have the second-highest incidence of developing diabetes (American Diabetes Association, 2022) and experiencing a cerebrovascular accident (National Center for Health Statistics, 2018). Another obvious byproduct of trauma is PTSD. PTSD is most prevalent among females and Black Americans, 8% (National Center for PTSD, 2022) and 8.7% (Roberts et al., 2011). It is important to note that these numbers vary depending on the sampling methods (Sibrava et al., 2019). The comorbidities of PTSD include depression, substance abuse, and suicide (Gluck et al., 2021). Depression, which may occur even in the absence of PTSD, tends to be more persistent in those depressed individuals who are Black American (American Psychiatric Association, 2017; Bailey et al., 2019; Richards, 2021). The lifetime prevalence of major depression is higher for Black Americans following trauma exposure than for the general population (Power et al., 2020). Of the Black Americans suffering from substance abuse disorder, 85% have not sought or received treatment (Substance Abuse and Mental Health Services Administration, 2019). Suicidal ideation, too, has demonstrated an upward trend amongst the Black American population (Substance Abuse and Mental Health Services Administration, 2019). Contributing factors to suicidal ideation and suicide attempts include discrimination (Oh et al., 2020) and police violence (Kyriopoulos et al., 2022). Well-Being There appears to be no consensus on the definition of well-being (Centers for Disease Control and Prevention, 2018; Mansfield et al., 2020; Rohde et al., 2020). Well-recognized dictionaries such as Merriam-Webster (n.d.) and Oxford Learners Dictionary (n.d.) include BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 17 health and positive emotions in their definition of well-being. A more historical and in-depth analysis of well-being comes from two perspectives: hedonic and eudaimonic well-being (Alkozei et al., 2018; Di Fabio & Palazzeschi, 2015; Mansfield et al., 2020). Hedonic well-being, also called subjective well-being, emphasizes happiness, having a quality of life, attaining positive affect, and minimizing low and unpleasant affect (Alkozei et al., 2018; Di Fabio & Palazzeschi, 2015; Mansfield et al., 2020). Eudaimonic well-being, also known as psychological well-being (Di Fabio & Palazzeschi, 2015), focuses on optimal human potential, positive psychological functioning, and human flourishing. An individual will have psychological resources, develop meaningful relationships, and have meaning and purpose (Di Fabio & Palazzeschi, 2015; Mansfield et al., 2020; Ruyter et al., n.d.). Psychological resources include personal mastery, agency, and self-sufficiency (Bookwala & Fekete, 2009). Vital elements of well-being are positive emotions, such as contentment and happiness, and psychological resources (CDC, 2018). Hobfoll (2002) defines psychological resources as entities that hold value in their own right for individuals. Psychological resources include personal mastery, agency, and self-sufficiency (Bookwala & Fekete, 2009). The present study will consider and incorporate both hedonic and eudaimonic descriptions of well-being as the research questions reflect both descriptions. Trauma and Well-Being Trauma both shapes and is shaped by well-being. As expected, trauma increases the likelihood of experiencing psychological symptoms, less life satisfaction, and functional impairment. The more adverse experiences one has, the lower the levels of life satisfaction are reported, and the more likely one would engage in unhealthy behaviors (Mendez et al., 2018). The functional impairment that may arise as a consequence of one's response to trauma and the BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 18 disorders that develop include decreased productivity in the workplace, absenteeism from work, and diminished ability with household and financial management (Psychiatric & Neurology Resource Center, 2017). Also noted are sleep disturbance, fatigue, and psychomotor changes (Tanner et al., 2019). The mentioned impairment list is by no means meant to be exhaustive. A systematic review of studies conducted by Jellestad et al. (2021) found a significant impact on daily functioning, as classified by the International Classification of Functioning, Disability, and Health (ICF), of those who have PTSD. Childhood trauma and its' effect on one's ability to thrive and function positively in adulthood (Volgenau et al., 2022) is an example of the interplay between trauma and well-being. Wade Jr. et al. (2015) found that more experiences of abuse, neglect, and family dysfunction increased the risk of poor health outcomes, such as risk-taking behaviors. Volgenau et al. (2022) found that trauma in the form of emotional neglect was closely associated with low-reported feelings of well-being in adulthood. They also found that the more experiences of trauma in the form of maltreatment in childhood, the greater the report of poor well-being in adulthood. Chronic discrimination, too, has been reported to decrease well-being and health outcomes and a lower rate of life satisfaction (Armstrong et al., 2019). At the same time, some factors mediate the harmful effects of trauma and, therefore, shape well-being. It is suggested that forgiveness has a buffering effect and facilitates physical and emotional well-being (Balkin et al., 2021). In light of recent events related to violence perpetrated against Black Americans at the hands of police and white extremists, the role of forgiveness has emerged (Balkin et al., 2021). When trauma occurs as a result of an interaction between individuals, the ability of the victim to address ill will toward the offender can decrease emotional distress, such as anger. The association between forgiveness and well-being includes BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 19 decreased anger, anxiety, rumination about the event and revenge, improved physical health, self-esteem, environmental mastery, and the ability to find meaning after the trauma (Balkin et al., 2021). Studies suggest that religious beliefs and practices are linked to well-being (Koenig, 2002). Accompanying higher levels of spiritual well-being, both religious and existential is higher levels of mental and physical health and quality of life, which may mediate the effects of trauma (Lamis et al., 2014; Stevens-Watkins et al., 2018). Existential well-being refers to feelings of purpose, significance, and meaningful goals (Florez et al., 2018). Religious wellbeing is having religious practices and beliefs and pursuing a relationship with a higher power (Florez et al., 2018). Emotional abuse in childhood was negatively related to existential wellbeing, and existential well-being was positively related to self-esteem (Lamis et al., 2014). Affirming spiritual well-being, particularly for Black Americans, is also associated with lower symptoms of PTSD, a trauma-related disorder (Florez et al., 2018). Cultural beliefs and practices are also buffering agents against trauma in the Black American community and positively impact well-being (Henderson et al., 2021). In the face of trauma, utilization of a problem-solving approach, persistently targeting mastery (Myers et al., 2015), and having social support reduced depressive symptoms and contributed to well-being (Novacek et al., 2020). The employment of problem-focused coping, also known as active coping, leads to greater levels of life satisfaction (Mendez et al., 2018). Mastery, defined as "the extent to which one regards one's life chance as being under their control..." is described as a mitigating and protective factor for Black Americans (Mouzon & McLean, 2017, p. 37). A direct mediating factor against trauma is resilience. Resilience is "the process of overcoming the negative effects of risk exposure, coping successfully with traumatic BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 20 experiences, and avoiding the negative trajectories associated with risks" (Fergus & Zimmerman, 2005, p. 399). Byers et al. (2021) found that the more psychological resilience a Black nurse had, the less racism-related stress was present. Black women, in particular, are often viewed as resilient (Mushonga et al., 2021). Mushonga et al. 2021 found that Black women who experienced interpersonal violence reported resilience through utilizing internal and external resources, facilitating the emergence of meaning-making. The studies also demonstrate young Black mens resilience, defined as an effective adjustment to hardship (Bauer et al., 2020). Selfreliance, family, religious affiliation, and cultural identity have been associated with young Black men's resilience (Bauer et al., 2020). That same resilience is found in Black American youth using familial and cultural strengths (Metzger et al., 2021). Other mediating agents within the Black American community, both positive and negative, include coping style, number of trauma experiences (Cavanagh & Obasi, 2020), community program involvement (Meredith et al., 2022), and engagement in therapy (Jorden, 2022). Utilizing group therapy, Black American children and adolescents have experienced trauma healing through resiliency (Manyam et al., 2021). Additionally, Metzger et al. 2021) posits that the combination of Cognitive-Behavioral Therapy and racial socialization is a way to help young people process and cope with trauma related to racial experiences, manage other race-related stress, and enhance engagement to promote positive outcomes. Beyond childhood and adolescence, Kimber et al. (2022) detail specific treatment approaches that work well for and benefit Black women. Categories of Research Analysis The studies on trauma and the Black American community frequently used quantitative methods to collect data- standardized scales, standardized interviews, and secondary data analysis, and less noticeably utilized qualitative methods. All studies addressed subgroups within BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 21 the Black American population, such as women with a substance abuse history (Blakey & Grocher, 2020) and children of incarcerated parents (Arditti & Savla, 2015), but not the broader experience of trauma as it relates to well-being. At least one qualitative study spoke to the lived experiences of Black Americans. Lee and Robinson's study (2019) provided an in-depth narrative of the nature of mental health and its consequences. It used a semi-structured interview format to construct what it meant to be exposed to police violence and police killings. A minority of participants reported positive interactions with police, and when positive interactions were noted, they were noted as being exceptional (Lee & Robinson, 2019). From the narratives, police violence emerged as a traumatic stressor that progressed from witnessing violence by the police to experiencing violence by the police as they aged (Lee & Robinson, 2019). Another study included trauma but only as a prerequisite for participation and not the focus of the qualitative data collection. A qualitative method was used to explore the relationship between individuals who experienced trauma, their relationship with counselors, and the effects on their treatment (Blakey & Grocher, 2020). More qualitative studies are needed to amplify the voices of those with a higher propensity to experience trauma, to which this study aspires. Method Study Design This research study employed interpretative phenomenological analysis (IPA), a methodology used to explore how individuals made sense of their life experiences (Smith et al., 2022). Specifically, IPA, conducted in a structured format, facilitated the process of individuals making sense of significant experiences (Smith et al., 2022). The primary aim of this study was to understand how participants perceived their experiences with trauma and how they believed these experiences were linked to their emotional and physical well-being, life satisfaction, and BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 22 spiritual life. To be more specific, this study delved into the associations participants established between traumatic experiences and their overall state of well-being. Approval from the Institutional Review Board at the University of Indianapolis was obtained before the commencement of study activities. Participants Black Americans aged 40 to 60 who resided in the continental United States or territories were recruited for this study. This population was chosen for investigation due to health declines associated with trauma at this age (Infurna et al., 2015). Black Americans aged 40 to 60 had unique experiences distinct from earlier and later phases of life (Infurna et al., 2020). Furthermore, there was a relative scarcity of research on midlife individuals compared to other age groups, although this was changing (Infurna et al., 2020). It could be assumed that this group had experienced enough life to potentially encounter trauma and experience its long-term effects on their physical, mental, and spiritual well-being. However, they also had enough life ahead of them to recognize trauma's impact and address it. Additionally, participants needed to identify having encountered trauma, defined as one or more experiences that substantially and adversely impacted their physical, emotional, and mental health. Examples of traumatic events were provided for reference. Finally, participants had to speak and understand English and identify as Black, Black American, African American, or of mixed heritage, that included Black, Black American, or African American. The exclusion criteria for this study included individuals with professional training in trauma. This study aimed to gather insight from non-professionals rather than those with specialized knowledge of trauma and its impact on ones life. The number of participants in published IPA studies has ranged from one to fifteen (Pietkiewicz & Smith, 2014). For this, a target of eight to ten participants was set to facilitate the BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 23 examination of similarities and differences without overwhelming data collection (Turpin et al., 1997). In the end, this researcher interviewed a total of six participants. Procedures Sampling and Recruitment The researcher employed maximum variation sampling to capture and fully explore central themes across the cohort, as homogeneity of perspectives could not be assumed. Maximum variation allowed the researcher to capture various perspectives regarding trauma and its influence (Patton, 1990). The research, therefore, did not specify when the initial adverse experience had to have occurred. The researcher contacted national organizations and recruited through online platforms such as Facebook and LinkedIn. The organizations that were targeted included the YMCA and the National Urban League. The organizations and platforms identified provided the study researcher access to a broad group within the population of interest. For example, Black Americans were among the top users of Facebook (Meta, 2015; Tech Explore, 2021). The researcher contacted the organizations via email, introducing the researcher, the purpose and significance of the study, and a request for the organization to digitally share the study description with the organization's participants or on their webpage. The email emphasized the study's goal of amplifying the voices of the Black community (see Appendix A). While no organization formally agreed to participate, several individuals requested the flyer to share (see Appendix B). The digital recruitment flyer was shared online and included information about the study's purpose, privacy, a confidentiality statement, and participant eligibility with an embedded link for interested parties to verify eligibility. The flyer also underscored the researcher's appreciation for potential participants helping to amplify Black voices. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 24 The eligibility survey asked about one's age range, residency in the United States, whether they had experienced one or more traumatic experiences, and interest in participating (see Appendix C). Examples of traumatic experiences were listed as a reference. Those who met the eligibility criteria could access a link providing study details (see Appendix D). They provided their name and email address if they expressed interest in participating in the study. Clicking the submit button allowed the researcher access to their contact information. The researcher contacted eligible individuals by phone within five days to set up an interview. One participant could not access the link and contacted the researcher via email. Two interviews took place face-to-face, and four others via video conferencing. Once the interview date, time, and manner were determined, the participant received a confirmation email with the date, time, and manner in which the interview would be conducted and another copy of the study details (see Appendix E). The participant received an address or video conferencing link. Before the interview, the participant had time to ask questions based on information provided in the study details and had to provide verbal consent to participate. At the interviews conclusion, participants were informed that if they knew of anyone interested in participating, they could either forward the flyer or the researchers email address. Informed Consent The study information sheet described the study, the participant's role, the expected interview length, participants' rights, and how their information would be used. Again, particular emphasis was placed on the confidentiality of their information, the significance of the study, and appreciation for sharing their experiences with the study's goal of using the conversations to advance the conversation around trauma and well-being and develop actionable items to address trauma in a person-centered way. On the day of the interview, participants had the opportunity to BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 25 ask questions regarding the study and had to consent to participate before the interview began. The consent and interview were recorded. The researcher obtained audio rather than written consent to decrease the personal identifying information in the researcher's possession and increase continuity, as the interview was also recorded. Data Collection Data collection was comprised of an individual semi-structured interview completed by the researcher. The semi-structured interviews took between 40 minutes to one hour and 50 minutes. The researcher used an interview guide (see Appendix F) to navigate the interview process. The interview guide structure allowed the investigator to stay on topic but provided enough room for the participant to reflect and speak freely to tell their story (Smith et al., 2022). The researcher developed interview questions based on the literature findings, paying attention to different versions of the Adverse Childhood Experience Survey (ACEs). A top-down approach was employed, starting with broader questions and progressively becoming more specific. The interview began by prompting respondents to share information about themselves, such as their age and place of origin, for example. The introduction was followed by asking them to describe their life experiences and those that had a lasting impact. More explicitly, participants were asked in what ways the adverse experiences influenced their life, precisely their sense of wellbeing - life satisfaction, emotions, meaning and purpose, spirituality, and physical health. Stigmatization associated with trauma existed (Schomerus et al., 2021; Turmaud, 2019) and could be a sensitive subject; therefore, the term trauma was used sparingly during the interview process. Interviews concluded with a statement asking if the participant had anything more to add to the discussion. The participants were also provided with resources, such as the number for a crisis hotline, in the event the discussion created distress. Lastly, the primary investigator BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 26 thanked the participant for agreeing to the interview and ensured the participant had the investigator's contact information for follow-up comments, questions, and interview check-in. Data Management and Analysis Data collection occurred during two periods the screening process for eligible people and the interview. Once the interviews were audio recorded, they were transcribed verbatim using Temi, a transcription service, and uploaded and stored in Dedoose (version 9.0), a data analysis software. Files stored in Dedoose were only accessible to the study's researcher. A backup copy of recordings and transcripts was kept in password-protected cloud storage. The researcher removed all information identifying participants from the data set after transcription. Each participant was assigned an identification number in place of their name. The researcher kept a hard copy of the participant's names and ID numbers in a locked cabinet to reference and verify that the correct participant data was being analyzed. Data will be stored for three years following the completion of the study and deleted at that time. The confidentiality and security of the data will be maintained (Creswell & Poth, 2018) by deleting the recordings after all the data analysis is complete. Consistent with interpretative phenomenological analysis, the researcher immersed herself in the data (Smith et al., 2022). The researcher listened to the transcript recordings, read the transcripts multiple times, and wrote noteworthy observations (Smith et al., 2022). A line-byline analysis to examine the participant's statements, use of language, and context, called exploratory noting, helped the researcher gain insight into how the participant talked about and understood trauma and well-being (Smith et al., 2022). Once the researcher explored the data using the exploratory process, they constructed experiential statements, a concise and descriptive BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 27 summary of the exploration's essential components (Smith et al., 2022). The summary reflected the participant's words and the researcher's interpretation of those words (Smith et al., 2022). The researcher compared the experiential statements, looking for connections and returning to the exploratory notes and transcript as needed to ensure the participants' experiences and world views were reflected (Smith et al., 2022). Analytical memoing was utilized during the initial data reading and when constructing experiential statements. Memoing was "an avenue to examine data at a greater level of abstraction and to explore hypotheses, relationships and explanations contained within the data" (Birks et al., 2008, p. 73). Connected experiential statements were clustered together and titled. Each cluster constituted a Personal Experiential Theme ([PET] (Smith et al., 2022). The PETs were organized using a concept map and provided with subthemes as warranted. The process thus far described was used for each transcript. A secondary researcher with expertise in qualitative methods audited one of the transcripts. The researchers met via video conferencing to discuss the findings of the transcript, the themes that emerged, and the accuracy of the concept map in visualizing the themes and subthemes. The audit aids the process of typifying PETs. The primary investigator selected the interview that was audited. Participants were contacted via email with the opportunity to review the Personal Experiential Themes identified by the researcher. The member check-in process ensures that the themes reflect the participant's experiences and that the conclusions drawn by the primary investigator are reasonable (Henderson & Rheault, 2004). Clarification of meaning will occur at that time with a notation made by the researcher. Notations were reviewed to determine the impact on the Personal Experiential Themes, and adjustments were made as needed. All participants' data were compared, looking for patterns of similarities and differences among the PETs. The researcher then generated Group Experiential Themes (GETs), BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 28 highlighting the shared and distinctive features across the participants (Smith et al., 2022). A GET table was created that includes examples of responses within each theme category and where the segment can be found in the transcript. Finally, a visual representation was created to display the themes and the intersection of themes related to the research questions. Rigor/Trustworthiness Establishing trustworthiness in research depends on credibility, transferability, dependability, and confirmability (Henderson & Rheault, 2004). Credibility ensures that the research content is plausible and reasonable (Korstjens & Moser, 2018). Credibility was established through member checking, persistent observation, memoing, and auditing. Member checking occurred following the identification of the PETs. Each participant was emailed a copy of the identified themes to review and ensure the researcher accurately interpreted and captured their experience. The document allowed them to make clarifications, additions, and changes. Persistent observation was satisfied by focusing on the areas relevant to the research topic in the interview guide, an in-depth literature review, and the researcher's awareness of their experience when thinking about mental health. Memos provided a decision-making trail that facilitated and extracted meaning from the data, conveying conceptual insights. They recorded the researcher's perspective for critical analysis as needed and served as a communication tool among researchers (Birks et al., 2008). As Smith et al. (2022) described, auditing enhanced the validity of the research because it checked the creditability of the data collected and was a logical step-by-step avenue through the chain of evidence. To achieve transferability, the researcher must know that it is a complex phenomenon and requires rich data descriptions. Transferability was supported by the in-depth probing questions asked during the interview. Identifying themes that can be transferrable to similar contexts was BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 29 the goal. The specific demographic information and contextual factors supported transferability, particularly if noted participant characteristics, for example, socioeconomic status, were associated with particular patterns. Attending to detail throughout the study achieved dependability and confirmability. The detail provided in the documentation and memoing served as an audit trail supporting dependability. Conformability was accomplished through reflexivity. Reflexivity increased the researcher's awareness of potential bias during the interviews, allowing for adjustment in approach. In this study, memoing was employed to capture and process the thoughts and emotions that emerged during the initial interviews and persisted while identifying themes. Throughout the interviews, the researcher cultivated an environment where participants felt at ease, which was evident in their body language and the depth of their discussions about their experiences. The conducive atmosphere enhanced the researcher's comfort. Following each interview, notes documenting the feelings and emotions that surfaced were recorded. Additionally, memoing was consistently practiced while listening to and reading the interviews and while identifying themes. This practice fostered self-reflection and helped the researcher recognize and address any assumptions and biases as they emerged. When these biases became apparent, the researcher revisited the interviews to ensure the participants' voices were accurately represented and to minimize the impact of personal opinions. Frequent reference to the research questions was also maintained to stay focused on data relevant to the research statements, thereby mitigating the influence of the subject matter. Notably, no participant experiences paralleled the researcher's own lived experiences, which further enabled the researcher to maintain a sharp focus on the research objectives. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 30 Ethical Considerations Potential ethical considerations are sensitivity surrounding conversations related to trauma. Those who have suffered trauma, particularly in childhood, report shame and may be less likely to disclose it (Schomerus et al., 2021). Additionally, consequences of trauma, for example, PTSD, are stigmatized in our society and further make it less likely that people are willing to disclose trauma episodes (American Psychiatric Association, 2020). The term trauma was not used during the interview unless articulated by the participant to address the delicate nature of the topic. Special attention was paid to building rapport with the participant, paying attention to body language, and being cautious with probing questions. It was reiterated that participants could take a break and speak at their comfort level about any question posed by the researcher. Additionally, a national crisis counseling text line was provided for any participant indicating psychological or emotional distress resulting from participating in the interview. Results The researcher interviewed six Black American women aged between 40 and 60, exploring their perceptions of trauma and its association with well-being. Initially, eleven individuals, comprising both men and women, expressed interest in participating in the study, but only six participants followed through to the conclusion. The interview sessions varied in duration, ranging from 29 minutes to one hour and 56 minutes. During these interviews, the participants recounted and delineated adverse experiences that profoundly influenced their lives, with short-term and long-term repercussions. These adverse experiences involved race-related incidents, abuse, parental absence, unforeseen revelations concerning their parental lineage, complex family dynamics, economic hardship, exposure to familial and community-based violence, and parental mental health issues. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 31 Specifically, two out of the six participants disclosed experiences linked to race, while four of them reported instances of abuse, three of which were sexual. Additionally, three participants noted experiences related to parental absence; two cited parental mental health conditions, three mentioned family dynamic issues, two recounted unexpected DNA revelations, and one discussed issues related to poverty and violence. Notably, all participants revealed a minimum of two traumatic experiences that significantly challenged their capacity to cope and their overall well-being. These challenges encompassed various dimensions of well-being, including happiness, quality of life, and positive psychological functioning. In response to the trauma they endured, participants reported a range of adverse psychological and physical consequences. These included anxiety, depression, complex posttraumatic stress disorder (CPTSD), thoughts of suicide, nightmares, and short-term and chronic physical health issues, such as "stress bumps," inflammation, gastrointestinal problems, headaches, and obesity. Furthermore, participants described at some point having poor selfperception, demonstrated in statements such as: "I couldn't love myself because I really didn't even know who I was" (Participant 1), "I grew up with the thinking that all I had was sex" (Participant 3), "it's like that imposter syndrome" (Participant 4), "I didn't feel like I fit in," and "...people wouldn't like me, and I hate the way my body looks" (Participant 2). None of the participants reported having any physical or mental health issues prior to experiencing these adverse events. It is also noteworthy that traumatic adversity was not confined to any specific life stage, as participants recounted experiences during both childhood and adulthood. Four main themes emerged from the interview data illustrating the experiences of adversity for six Black females, the way they managed, and the outcomes. The themes are as BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 32 follows: faith as a contextual factor, longevity, emergence, and support. The theme table includes both the themes and the supporting participants quotes (see Table 1). Faith as a Contextual Factor Spirituality was a contextual factor for all participants, providing a healing influence, playing a role in instigating trauma, and sometimes even encompassing both aspects. Participants 1 and 2 shared experiences of sexual assault and molestation as minors, respectively, perpetrated by clergy members. Participant 1's faith appeared consistent, becoming a powerful source of resilience and healing. She found the strength through faith to forgive her perpetrator, even without an apology. Her faith, coupled with strong family bonds, also served as her pillar of support, helping her navigate a traumatic revelation in adulthoodan unexpected paternity finding. In this instance, faith fostered acceptance and forgiveness towards others and herself, even in the face of resistance and turmoil from those who refused to accept the truth. In the case of Participant 2, the abuser was also a family member, augmenting the experience. Her parents, who were her staunch advocates, utilized their faith as a platform to condemn the sexual abuse and reassure Participant 2 that she was not to blame for the traumatic experiences she had endured. They made specific references to the Bible to epitomize that she bore no blame in the acts perpetrated against her with her recalling, he showed me from the Bible, that you are not to uncover that nakedness of your son's daughter. Yes, that explicit. He was really saying on, every level, what happened to you was not your fault. As a result, she expressed that "...it really mitigated a lot of the potential trauma." In the narratives of Participants 3 and 5, faith was enhanced as a part of the healing. Participant 3 had no faith background as a child. As an adult, she discovered a faith community and believed divine intervention saved her during a critical medical crisis. For her, this encounter BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 33 with spirituality was transformative, "God brought me through that...it opened up a whole brand of freeing me," providing a sense of liberation and personal growth. Participant 5's faith evolved and intensified as a result of therapy, reconciliation with the abuse she suffered in her childhood and adulthood, and creating boundaries. This transformation involved distancing herself from toxic environments, including the church. In her words, "Interestingly enough, I feel like I'm closer to God" and "I think actually getting out of the environment of churchit saved me." Participant 4 and Participant 6 shared similar experiences of tightly guarded upbringings heavily framed by religion. These early experiences laid the foundation for their vulnerability to traumatic experiences as adults. For example, Participant 6's upbringing in a tightly controlled collectivistic and religious environment impacted her assertiveness, making it challenging to address the stereotyping, discrimination, and racism she faced as an adult. These experiences, in turn, negatively affected her physical and mental well-being. Conversely, in later years, she connected to her religious belief on a personal level, and her faith and faith community proved to be integral support during a traumatic birthing experience and her ongoing medical issues. She reflects, "I started to sink deeper and deeper in my faithit is impossible for me to isolate my faith for myself." The multifaceted role of spirituality underscores the complexity of its influence on individuals' coping strategies and responses to adverse life events. Longevity It was observed that every participant recounted experiences that were enduring, denoting longevity. Two primary manifestations of this longevity were evident. The first manifestation stemmed from the chronic and prolonged duration of these adverse experiences, which persisted over an extended period. The second manifestation was evident when the initial adverse experience served as a precursor for subsequent problematic experiences with adverse BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 34 consequences. Specifically, Participants 3, 5, and 6 were found to have endured adversity within the familial context, with the adverse circumstances persisting from their formative years into adulthood. Participant 3 suffered ongoing poverty, sexual abuse, maternal mental health issues, and being a witness to in-home and community violence throughout childhood. She suffered ongoing sexual abuse by her stepfather. Compounding that experience was her mother "examining meall in my vagina area looking" Her mother believed "somebody's been messed with you," and that was before the sexual abuse by her stepfather started. Others would also make comments about her body. As a result, Participant 3 "grew up with the thinking all I had was sex," becoming promiscuous, leading to acts such as adultery later in life. For her, the past is what caused her current status as single, "I'm single now because of things that I did, you know, committing adultery and everythingTherefore, I don't have a mate." The abusive relationship experienced by Participant 5 originated with her mother and persisted through the actions of her brother. Regarding her family dynamics, she reflects, the abuse from my brother didnt stop until he died. Now the effects of the, of course, are ongoing, while her mother continues to contribute to her suffering, as she remains a presence in her life, stating, "'cause she's still here." The enduring impact of these toxic relationships is evident in her subsequent unhealthy relationships and the rupture of connections with individuals who could have potentially helped mitigate the trauma. The weight of this childhood abuse, which extended into a significant portion of her adulthood, ultimately led to a diagnosis of Complex PostTraumatic Stress Disorder (CPTSD), as she explains, "always dealt with depression, always dealt with anxiety." As early as the age of five, she began experiencing physical issues, gastrointestinal issues, joint inflammation, and headaches. She reports, "I've been dealing with this my entire life," and "it was a lot of stuff that preceded the physical manifestation," referring BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 35 to the abuse. It is only in the last several years that she has made substantial progress in breaking free from the cycle of her trauma response. Participant 6 has shared profound insights regarding the enduring expectation of unwavering submission to individuals in positions of authority. She astutely reflects upon this by stating children could be disciplined by others, "you had to be mindful of what you didsomebody always watching. Remarkably, this compulsion to submit to authority persisted into her adulthood. Consequently, when she emigrated to the United States, she encountered formidable challenges in navigating issues related to racism. Prior to her emigration, she notes, "...things like prejudice and discrimination. I did not know that." Adding to the complexity of the situation was the deeply ingrained belief that questioning authority was equivalent to talking back. These experiences included encounters with a White instructor who consistently assigned her lower grades despite her work being on par with her White counterparts. She reveals that she refrained from confronting her instructor, confessing, I was scared of retaliation." When White individuals she worked for made ignorant assumptions about her background, she recollects that, while it was "shocking," she did not challenge the assumptions because I was also taught to be respectful. I didn't talk back. I didn't speak back." For some participants, the succeeding events were more trauma-inducing than the instigating event. As a result of an unwanted sexual experience in her early teens, Participant 2 coped by emotionally eating, leading to a lifelong battle with her weight. The experience of her weight became profoundly adverse, manifesting both physically and mentally. At her biggest, she acknowledges, "I was in a lot of pain and really completely unable to participate in any type of personal aesthetic that I actually liked." Her weight was also accompanied by shame, seeing the world as a "scary and dangerous" place where people would not like her, and she harbored BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 36 disdain for her appearance. The trauma associated with her weight persisted throughout a significant portion of her life, and it was only within the last few years that she could better address her weight and have a healthier self-perception. For Participant 4, it was both the chronic and precipitating nature of the events. The devout religious upbringing with parents that "kept things under a tight rein," the expectation of submission, sometimes "forced submission, and the expectations about career, early marriage, and maintaining family secrets opened the door for evolving into an adult who doubted herselfher "intelligence, independence, and capabilities," and she was delayed in expressing herself authentically. It set the stage for two failed marriages and choosing a career that pleased her parents over pursuing her dreams, which she says to this day, "I feel like a talent wasted." Regarding the career, "Never, ever, ever wanted to be a teacher in my life." In this unwanted career in an urban school system of a large city, "I didn't relate to my professional peers...I had to dumb myself down in order to fit in." Her attempt to leave and work in other school systems felt blocked: "they feel like they want you to stay here because she thinks she's better than us. So, you know, after a while, you just kind of get institutionalized." The situation over the years produced significant levels of anxiety that she struggled with for as long as she could remember. She determined this was a product of her impulse to please her parents, which carried over into her work. Additional exacerbating factors was the accumulation of debt from her decision to pursue a doctoral degree, which she did not complete, in an attempt to "interact with people on an academic level, intellectual level that was, other than what I had to deal with in (urban) city schools." She is still dealing with this debt 10-plus years later. Thus, she stays "because with these promises of forgiveness, you have to stay in public service." BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 37 Emergence Across all participants, positive well-being emerged to varying degrees. Despite experiencing sexual assault during adolescence and enduring experiences of racism, Participant 1 managed to have a healthy sense of well-being. She was happy, self-assured, and flourishing, embodied in statements like, "I was living this little chocolate fairytale." However, her journey was put to the test in middle adulthood when she discovered that the man who had raised her was not her biological father, unbeknownst to the family, including her father. This revelation led her to question her identity, compounded by her mother's steadfast denial of the truth and the subsequent vilification and estrangement by maternal family members. This turmoil took a toll on her physical health, happiness, and overall psychological well-being, as evidenced by recurring episodes of increased blood pressure, headaches, cyst formation, and a profound struggle with self-acceptance, "I really didn't even know who I was." She noted the cyst would come and go and mostly appear under stressful situations, and first appeared after her mothers ongoing behavior following the paternal revelation. The journey towards reclaiming well-being involved accepting this newfound truth, the acceptance and embrace she received from her biological paternal family, maintaining a strong connection with the man who raised her, and ultimately forgiving her mother. Similarly, Participant 2 was sexually abused, but as a young child. A healthy sense of well-being was maintained because of her parents, reflecting, "They had the intelligence enough to address it on the multiple layers that exist. She went on to explain, "They mitigated a lot of the potential trauma for me," and the adversity was just mitigated so completely." However, she had another experience of an unwanted sexual encounter when entering her teen years with someone of a similar age. This experience, coupled with adverse reactions from her parents and BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 38 religious community, significantly impacted her emotional well-being, compromising her psychological and social functioning and leading to emotional eating. Enhanced well-being was a recent phenomenon and involved therapy, time, and introspection. A pivotal shift in her perception is evident in statements like, "I have nothing but the utmost respect for her (obese self). She's the one who brought about basically every good thing in my life that I'm enjoying now." Her fat self was somewhat of a net positiveparticularly with the filtering of the undesirables, and "I think being fat saved me." For Participant 3, enduring a challenging childhood marked by sexual abuse, poverty, violence, and the burden of her mother's mental health struggles hindered her from having a positive sense of well-being. She even reached "a very suicidal point" in adulthood. Her experiences delayed her transition to healthy psychological functioning, positive affect, and quality of life until middle age, which was set in motion by a medical condition. For her, the fact that God brought her through that event brought feelings of liberation, authenticity, peace, and happiness. She asserts, Now I'm truly authenticI sleep well. When I smile and I laugh, it's for real. Through therapy, medication, establishing boundaries, and relocation, Participant 4 found improved psychological functioning and quality of life. She admits that the journey to a healthier self remains ongoing. As noted by other participants, the change in well-being took time, and as Participant 3 reported, it was propelled by a health issue. Much like Participant 4, Participant 5's pursuit of well-being remains a work in progress. The loss of a beloved family member catalyzed her journey towards well-being. However, she has now entered a phase where she wholeheartedly embraces her creativity, establishes firm boundaries, and unequivocally expresses her true self. The positive effects of this transformation, BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 39 including happiness and flourishing, are palpable in her determination to pursue "all the things I wanted to do in my twenties that I thought I couldn't do because it would disappoint my family; the church was gonna kick me out; this was gonna cause grief with so and so; I was not going to be relatable. This is not what a good mother doesI'm doing all of that. This remarkable transformation took place in her forties, following a lifetime marked by the experience of "forcing a personality" shaped by familial abuse. Finally, Participant 6 faced ongoing trauma due to racism, and a secure sense of her wellbeing evolved through the development of a personal relationship with God, support from her spouse, and friends that encouraged her to speak out and stand up for herself. She transitioned from a shy child to an assertive middle-aged adult with thicker skin, declaring, "I have no reason to hide my voice anymore" and "once you hit 40there are things I don't care about anymore," including conforming and accepting prejudicial and discriminatory behavior from others. Support In alignment with the theme of emergence, each participant enlisted the assistance of a third party to alleviate the psychological distress they were facing. Some chose to pursue formal support, with four out of the six participants opting for this approach. The remaining two individuals sought aid from friends or acquaintances. While the nature and scope of the support services were not always explicitly detailed, all participants acknowledged their utilization. About formal intervention for addressing her trauma, Participant 4 was candid about her approach, noting that she received therapy and mentioned the use of medications such as "Lexapro," "Effexor," and "all kinds of other stuff." For Participant 5, the death of a beloved family member, coupled with enduring toxic relationships, left her feeling immobilized. She said, "I literally froze and couldn't move anymore; I couldn't get out of bed. I couldn't function." BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 40 These events prompted her to engage in an intense therapeutic process to confront the trauma that had overshadowed her life. At this juncture, no topic was off-limits for discussion. She consciously decided to "unpack it" and confront her pains. This process played a pivotal role in a healthy sense of well-being, characterized by positive affect, improved psychological functioning, happiness, and an enhanced quality of life. Participant 3 did not explicitly articulate a direct correlation between her utilization of therapy and medications, of which she did both, and her burgeoning sense of well-being. However, it is noteworthy that she also exhibited a greater willingness to learn about behaviorreading and participating in various educational programs. This transformative learning experience ultimately led to self-realization and the ability to take ownership of her past failures. It also motivated her to repair her relationship with her son, with Participant 4 reflecting on how her newfound openness to learning "changed that relationship for the better." Also, important to highlight is the place of spirituality and support of a higher power. Over time, she got spiritually stronger and viewed her adversity differently. She recognized her resiliency. She reflected, "...yes, that did happen, but oh my gosh, look what happened," referring to finding purpose. An illustrative example of informal support services can be gleaned from Participant 6's experience. She confided in a friend who was already receiving professional help for her depression, characterizing their relationship as akin to a great friendship and, at times, resembling a therapist-client dynamic. In her own words, "She ended up becoming like my therapist." Additionally, Participant 6 credited her husband and friends as having a critical role in cultivating her assertiveness. During her college years, some of her friends educated her on her rights and encouraged her to speak up in the face of discrimination. She explicitly attributed her growing assertiveness to her husband, stating, "Part of me being more assertive is because of my BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 41 husband. My husband is a very strong person, and he said to me, 'Honey, I did not marry a weak wife... you're smart. You know what you're doing," particularly during moments of self-doubt. Although participants experienced varying types of traumas, had different reactions, and ultimately addressed their trauma differently, they all very much addressed it. There was also a connection between the passage of time and healing. However, it required awareness of trauma, reflection on one's circumstances, and active participation in alleviating the dysfunction caused by trauma. Discussion and Conclusion The principal aim of this study was to explore individuals' subjective perceptions of traumatic adverse experiences and to uncover the intricate connections established between these experiences and the broader construct of overall well-being. Through an in-depth examination and analysis of the detailed narratives provided by the study participants, both anticipated and unforeseen manifestations of trauma emerged. Furthermore, personal and environmental contextual factors were observed to play a pivotal role in shaping the experience of trauma. In addition, the study uncovered several overarching themes that provide valuable insights into the interplay between trauma and its impact on well-being. Expected Trauma Experiences This study's participants are situated in the larger narrative, being a part of more than half of the U.S. population who have experienced a traumatic event (Carter, 2019). Additionally, over 80% of the participants fall into the two-thirds of individuals who experienced at least one of their traumatic events by age 16 (SAMHSA, 2023). Among the traumatic events recounted, childhood sexual assault or sexual abuse emerged as the most prevalent, with two-thirds of the participants reporting such experiences. As such, they are among the around 50% of Black BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 42 women who are victims of assault (American Psychological Association, 2020; Harrel, 2011). One additional participant reported experiencing abuse, although the nature of this abuse remained unspecified. This study supports the more extensive conversation needed about addressing the sexual assault and coercion of Black women and girls. Conversations must include the gap between sexual victimization and reporting by women, particularly Black women (Kelley, 2023), and why. The historical and ongoing experiences of Black women around sexual assault include being hypersexualized by society, not being believed or being blamed, and being afforded overall less protection (Kelley, 2023; Slatton & Richard, 2019) from within and without their community. There is no surprise that underreporting is more common than not. Education about sex, sexuality, and what is appropriate and inappropriate behaviors must be normalized and commonplace in the home and community. Community encompasses schools, religious organizations, pediatricians offices, child-focused organizations like the Boys and Girls Club, and social media. Society can no longer afford sex education to continue in some respects to be taboo, particularly with sex and sexuality so readily on display in our society. Women may be more apt to report, and fewer feelings of fear, shame, and embarrassment may occur if conversations about sex and sexuality, including abuse, become normalized. The literature also appears to offer limited information regarding children reporting sexual abuse or coercion despite the estimated 61,000 American children who have experienced sexual abuse, a number recognized as an underestimate (Hansen & Wallis, 2018; Hornor, 2023). There is a critical need to reevaluate programs designed for children addressing sexual abuse and other forms of trauma and to assess the extent to which these programs are implemented. Programs, such as sexual abuse prevention programs in schools (U.S. Department of Health and BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 43 Human Services, n.d.), should be made mandatory and should incorporate intercultural factors that may hinder student reporting, as well as intracultural factors that create conditions conducive to abuse. There is evidence indicating that educators often perceive and treat Black students as unequal to their counterparts (Fallon et al., 2020; U.S. Department of Education, 2018), despite research demonstrating that higher rates of undesirable behaviors among Black students are not evident (Gion et al., 2020). Consequently, students may be less inclined to view teachers as trustworthy allies who can support them through traumatic experiences. Culturally responsive educators with specific training in trauma and the application of trauma-informed approaches could potentially increase the reporting of sexual trauma. However, culturally responsive education and its implementation are currently lacking (Williams III et al., 2023) and are not standardized. Only 35 states have some form of cultural responsiveness or competence in their education plans (Schettino et al., 2019). Furthermore, a systematic review of the use of trauma-informed approaches in schools revealed a lack of rigorous evaluation of the programs and their effectiveness in addressing various aspects of trauma (Maynard et al., 2019). This study also highlights missed opportunities for influential community members, including teachers and healthcare practitioners, to become more aware of trauma and how it may manifest differently in marginalized groups. This awareness could have led to different outcomes in childhood for individuals like Participant 5. Two of the 6 participants conveyed racism as an adverse experience, with one noting its connection to trauma, whereas the other reported no substantial adverse effects. The negative impact of racism-related incidents experienced by Participant 6 aligns with the literature that provides evidence for the link between racial discrimination and trauma. Participant 6 experienced the enduring legacy of oppression, specifically, everyday acts of dismissal and BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 44 invalidation, as described by Kirkinis et al. (2021), that led to a delayed diagnosis and morbidity. She did not associate the onset of her illness as a result of racism or other adverse experiences. However, she believed that the discriminatory behavior of healthcare professionals contributed to the worsening of her disease process, increasing the risk of premature death, as noted in statements such as, "I don't think I was listening to or believed I could have been diagnosed sooner" and "My disease progressed so fast because I got care so late. I could have died." Additionally, her depression and anxiety began after experiencing workplace microaggressions. She expressed, "I suffered from depression because of those experiences," and mentioned that work "broke me down at times. I used to have anxiety. I didn't wanna go to work." Mitigating and Aggravating Factors As anticipated, the participants engaged in discussions about their adverse experiences, with the characteristics of these experiences exhibiting both commonalities and variations. While some events, like childhood sexual abuse, is undoubtedly a traumatic experience, they do not always produce trauma. This is essential to bear in mind because unequivocal adverse experiences, such as child sexual abuse (DSM-5, 2013; ICD-11, 2018; Hampton-Anderson et al., 2021; Volgenau et al., 2022), do not necessarily manifest as a trauma response due to a layering of mitigating factors. This study provides some evidence and a place for further inquiry about the mitigation process regarding sexual abuse. Participant 2 was a prime example. She suffered ongoing sexual abuse from an adult male family member. Upon discovery, her parents took immediate action. As she reported, "my parents' choice to believe me and stand up for me and act on the abuse was pivotal...They could have written a book about how to handle this type of thing well...They had the intelligence enough to address it on the multiple layers that exist (including sex education)...it really mitigated a lot of the potential trauma for me...that was just BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 45 mitigated so completely." Attention to the specific process described by this participant could potentially neutralize an evident traumatic adverse experience, especially sexual abuse, as observed in this case. The process and context as a neutralizing agent are emphasized when the incident is compared to another unwanted encounter with a male of similar age years later. The second experience did not garner the same reaction from her parents and others in her social circle. It led to a trauma response that reverberated for years. As a response, emotional eating led to a self-inflicted trauma, obesity, and that had emotional, physical, and psychological implications. Nonetheless, it was evident that certain adverse experiences laid the foundation for subsequent traumatic adverse events. This phenomenon was particularly conspicuous in the case of Participant 4. Participant 4 depicted her childhood as one in which she was kept under a tight rein and sheltered from the negatives, only exposed to the positives. Additionally, her upbringing was deeply rooted in religious devotion, with expectations of early marriage and a replication of her mothers educational path. She further described being silenced from inquiring about her paternal parentage and never witnessing her mother advocate for her. Salient moments, like her father's willingness to sever ties with her based on unfounded assumptions, left her with feelings of self-doubt, diminished self-worth, and a lack of confidence in her abilities, intelligence, and independence. This negative self-perception significantly influenced her career choice and environment, which, in turn, had detrimental psychological and physiological consequences. Participant 3s sexual abuse in childhood was not mitigated, as was Participant 2, and led to negative self-perception, promiscuity, and, as per the participant, Im single now because of things that I did. Her promiscuity did not manifest immediately but as a young adult. The results from this study reinforce the literature findings that adverse childhood experiences BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 46 have long-term repercussions that extend into adulthood. More so, these findings indicate that there may be a delay between the adverse events and palpable evidence of emotional, psychological, and physical toll, which in these cases did not make a prominent appearance until adulthood, as seen with Participants 3 and 4. What is clear amongst almost all the participants is an eventual shift to a more positive self-image, resulting in behaviors that mitigated the effects of the trauma experienced. The shift was a recent phenomenon occurring in middle adulthood for 4 of the 6 participants and in her 30s for a fifth. What appeared evident as the catalyst for this shift was the passage of time, psychological support, whether formally or informally, an intentional reflection on one's life, or an intense and potentially trauma-inducing event. It took Participant 2 until her 40s to see that the world was not all "scary and dangerous (where) people wouldn't like me," She now genuinely appreciates the woman she disdained because of her weight. Participant 6, as stated earlier, found freedom on reaching a point (in her 40s) where she has "...no reason to hide my voice anymore." Those examples account for time and reflection. The mediating effects of a jarring event helped two participants reevaluate their lives and make changes that supported a journey to well-being. In both cases, the jarring event is a medical crisis. Further study to explore the place of adverse events in breaking the cycle of preexisting trauma behavior may provide insight into the characteristics or circumstances that allow individuals to move through trauma. It is important to recognize that all six women in this study had matriculated, were gainfully employed, and had access to support services. Evidence of the impact of psychological support in this study and others should fuel conversations about funding, education of healthcare providers, and the availability of Black therapists. Over 50% of the participants, 4 of the 6, used formal therapy services and played a BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 47 role in alleviating negative results of trauma suffered. Just as Black women are underreporting and seeking services when sexual abuse occurs, so too are Black Americans as a whole less likely to seek services when psychological distress occurs (Phillips, 2020). This results from perceptions about mental distress and illness and the lack of trust in the healthcare community. Mislabeling Black peoples' presenting concerns, misdiagnosing and overdiagnosing, and cultural insensitivity facilitate the apprehension to seek care (Phillips, 2020). At a macro level, there must be ownership of the place of systemic structures that fuel the negative perception of mental health provision in the U.S. and the willingness to address it at all levels. The Black community must also understand the limitations of the broader community in addressing Black trauma regardless of their intentionality and focus on Black-on-Black inquiry and solutions to addressing trauma within the varied context of the Black experience. Unexpected Trauma Experiences The literature describes many types of trauma experiences. Still, it does not readily include loss as it pertains to abrupt changes to family structure when individuals discover their biological parentage is inaccurate. Two participants discovered their paternal parent was not as believed in adulthood. Psychological distress and persisting physiological changes resulted and, in one participant's case, contributed to suicidal ideation. In healthcare, it is expected to identify best practices in addressing various issues, and this should be no exception, especially with genealogical testing readily available to the masses. In her daughter's curiosity about ancestry, Participant 1 and her family found out about her true biological paternal parentage. There is currently limited support for families as they grapple with the results, even though there have been calls for more mental health and genetic counselors (Kirkpatrick & Rashkin, 2017; Mahon, 2018). BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 48 The Broader Narrative The Black community must engage in substantial dialogue, recognizing the limitations within broader society, including the healthcare community, stemming from both intentional and unintentional behaviors, to address trauma. These conversations should involve Black researchers, community leaders, advocates, and healthcare providers, with a focus on all forms of adverse experiences that can lead to trauma and the potential associated outcomes. Furthermore, this dialogue and research must encompass the diverse range of Black experiences in America. The examination of Black-on-Black issues should also prioritize the normalization of conversations within the community regarding trauma and its consequences. This emphasis should extend to factors highlighted in screening tools such as the ACE Survey, as well as the subtle and seemingly innocuous events that can lead to trauma. Enhancing mental health literacy within communities, similar to the awareness of physical conditions, normalizes these discussions and reduces stigma. It creates an environment where individuals feel more comfortable seeking help (Jorm, 2012). Naturally, the assistance provided must be community and client-centered. Themes The emerging themes in this study have revealed a strong connection between trauma and the shaping of well-being, particularly in terms of mental and physical health as well as spiritual well-being. Faith as a Contextual Factor The role of faith in providing meaning to traumatic events, offering strength and healing, and mediating the harmful effects of trauma is evident in this study. Faith is exemplified in the experiences of Participants 1, 2, 3, and 6 and is consistent with previous research (Lamis et al., BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 49 2014; Stevens-Watkins et al., 2018). Remarkably, faith can play a positive role even when faith community members are involved in causing trauma. As Park (2013) suggests, finding meaning can be adaptive, especially when individuals have little control over traumatic events. Spirituality can be a central element in this meaning-making process, contributing to a more favorable understanding of one's circumstances. For example, Participant 2, upon reflecting on her life, found a sense of order in her past events and believed, "The things that have happened to me were not accidents." This shift in perspective through faith can contribute to developing a positive sense of well-being, as demonstrated by Participant 3, who saw her past traumatic experiences as integral to her present career calling with the help of her faith. While there is less direct evidence linking spirituality to reduced symptoms of traumarelated disorders like PTSD, Participant 5, who has CPTSD and a history of anxiety and depression, noted an improvement in her well-being, being more spiritually connected, and having increased life satisfaction. Throughout the interviews, spirituality played various roles that ultimately positively impacted the participants. Given the potential healing aspect of spirituality, further research into the role of spirituality in addressing trauma from both religious and non-religious perspectives is warranted. Longevity of Trauma This study underscores the enduring and profound impact of traumatic adverse experiences on mental and physical health. Therefore, healthcare organizations must prioritize the integration of trauma-informed care (TIC) into their organizational structure and ensure that all healthcare providers receive trauma education. Despite the prevalence of trauma, TIC remains relatively under-researched and inadequately implemented in standard clinical care practice (Reeves, 2015). Extending beyond healthcare organizations, education, faith-based, and BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 50 governmental organizations must be knowledgeable about and integrate trauma-informed approaches into their structure. Addressing the barriers to providing TIC should also be a priority. It is easy to make a moral argument about addressing trauma. An additional argument is the financial cost to individuals and society. The outcomes for children experiencing trauma who lack access to treatment cost the U.S. an estimated $458 billion annually, which does not account for additional societal costs (Berger, 2019). Emergence of Well-Being and Support This study affirms that well-being can emerge following trauma. Still, it often required a significant amount of time and occurred in middle age, even when the traumatic events took place in childhood. This underscores the persistence of adverse experiences and that well-being does not spontaneously develop solely with time. Some form of intervention is often necessary to facilitate positive outcomes. The existing literature supports the effectiveness of intervention for individuals experiencing traumatic adversity (Han et al., 2021), and this study reinforces the importance of intervention. Various interventions, including therapy, social support from friends, and other life-changing events, can facilitate positive changes. Future studies should explore the role of different intervention types, formal and informal, in supporting trauma victims. Study Limitations The study had two fundamental limitations. Firstly, while there was a degree of diversity in the context and experiences of the participants, it is essential to note that all six participants were gainfully employed, had access to health resources, and, by middle age, had found an improved sense of well-being. It is difficult to determine the extent to which additional participants could have provided further insights. A larger sample size might have yielded a more diverse range of experiences within the population. However, it is worth noting that the BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 51 small sample size of only six participants resulted in overlapping experiences and outcomes. This suggests that the likelihood of introducing entirely new concepts was limited even with additional participants, especially when employment, access to health resources, and well-being outcomes were comparable. The study's findings can reasonably inform about how trauma is perceived, how it is managed, and the impact on populations under similar circumstances. Secondly, the study's original intent was to collect perceptions from both Black American women and men. However, it is noteworthy that despite the initial interest of two men in participating, ultimately, no men completed the interview process. This outcome may be attributed to the sensitivity of the research topic, as previous studies have indicated that addressing trauma is less likely among Black males (DeAngelis, 2023; Motley & Banks, 2018). These limitations underscore the need for caution when interpreting and generalizing the findings of this study beyond similar groups and populations of women. Implications for Future Research The study's findings shed light on several critical areas that warrant further investigation to address the challenges faced by Black women and girls. Previous literature highlights the absence of culturally responsive educational environments in the U.S. (Williams III et al., 2023). Maynard et al. (2019) articulate, "...it is unclear as to whether the promise of this framework is actually delivering the types of systemic and programmatic changes intended, and if those changes are resulting in the outcomes the proponents of a traumainformed approach in schools hoped for" (p. 5). These deficiencies may hinder children from reporting trauma within the school environment. Future research should focus on creating culturally responsive school systems and refining trauma-informed approaches to facilitate trauma reporting, opening up more avenues for children to report or receive support when experiencing trauma. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 52 It is essential to explore specific strategies for educating communities on supporting children who disclose trauma, for example, in cases of sexual abuse. Further inquiry into individuals like Participant 2, whose contextual experiences mitigate trauma, is crucial. Educating the community on sound processes is particularly important due to the rise in access to information, both evidence-based and not. Participant 6 was a nurse who experienced racism as an employee and a patient in the healthcare system, which impacted her psychological and physical well-being. This study supports Byers et al.'s (2021) idea that there needs to be continued research on the racism-related stress of nurses. Although information on the prevalence and consequences of discrimination in the workplace is abundant (Whitaker, 2019), a greater al focus must be placed on healthcare organizations' understanding of the internal systems that reinforce prejudicial, discriminatory, or racist behavior. Current literature often focuses on major adverse experiences, such as abuse or accidents. However, this study highlights the impact of seemingly minor events that accumulate and contribute to trauma responses. Future studies should examine the nature of these "smaller" adverse events and their long-term consequences, which current trauma and stressor exposure measures may not capture. While the study participants primarily sought formal support from mental health professionals, some relied on informal support from friends and acquaintances. The current literature predominantly emphasizes formal support. Future research should explore the role and effectiveness of both formal and informal support systems in addressing trauma. This research underscores the need for further exploration in various areas, such as sexual assault reporting and prevention, the effects of racism-related experiences on health, and the BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 53 impact of minor adverse experiences on coping mechanisms. These implications should guide future studies and policy initiatives aimed at better understanding and addressing the unique challenges faced by Black women and girls. Conclusion This study conducted an in-depth exploration of individuals' subjective perceptions of traumatic adverse experiences and their intricate connections to overall well-being, focusing on the experiences of Black American women. These women often confront distressing events that inflict emotional, psychological, and physical harm, yet they demonstrate the capacity to move forward. Recognizing and addressing trauma becomes a catalyst for a transformative shift in their self-perception and coping mechanisms. The research underscores the pressing need for extensive dialogue concerning sexual assault and coercion and the importance of implementing culturally responsive care and trauma-informed approaches when assisting trauma victims. It also highlights the indispensable role of psychological support and therapy in alleviating the adverse effects of trauma, emphasizing the urgency of destigmatizing help-seeking behavior. Unexpected trauma experiences related to genealogical revelations further underscore the demand for suitable support systems for individuals dealing with such circumstances. Overall, this study underscores the enduring impact of traumatic adverse experiences on well-being and the significance and opportunities to create timely and targeted disruption of the trauma cycle. It also recognizes the potential of faith and spirituality as sources of strength and healing. These findings underscore the need to integrate trauma-informed care into various organizations and systems while acknowledging the financial and societal costs of not doing so. Ultimately, the Black community needs to engage in open dialogues about trauma, confront adverse experiences, BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 54 and strive for well-being while acknowledging the diverse range of experiences within the Black American communities. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 55 References Alkozei, A., Smith, R., Killgore, W. D. (2018). Gratitude and subjective wellbeing: A proposal of two causal frameworks. Journal of Happiness Studies, 19, 15191542. https://doi.org/10.1007/s10902-017-9870-1 American College of Cardiology. (2018). 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CDC Field Epidemiology Manual. https://www.cdc.gov/eis/field-epimanual/chapters/Qualitative-Data.html Woods-Jaeger, B. A., Hampton-Anderson, J., Christensen, K., Miller, T., O'Connor, P., & Berkley-Patton, J. (2021). School-based racial microaggressions: A Barrier to resilience among African American adolescents exposed to trauma. Psychological Trauma-Theory Research Practice and Policy. https://doi-org.proxy.kc.edu/10.1037/tra0001091 World Health Organization. (2018). Mental health: strengthening our response. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-ourresponse World Health Organization. (2018). WHO international classification of diseases (11th ed.). World Health Organization. BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING World YMCA. (2019). https://www.ymca.int/member/ymca-usa/ 77 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 78 Table 1 Theme Table Theme Faith as a Contextual Factor Participant Quotes "The things that have happened to me were not accidents." (Participant 2) God brought me through that...it opened up a whole brand of freeing me." (Participant 3) "Interestingly enough, I feel like I'm closer to God" and "I think actually getting out of the environment of churchit saved me." (Participant 5) "I started to sink deeper and deeper in my faithit is impossible for me to isolate my faith for myself."(Participant 6) Longevity of Trauma "grew up with the thinking all I had was sex," (Participant 3) "I'm single now because of things that I did, you know, committing adultery and everythingTherefore, I don't have a mate." (Participant 3) the abuse from my brother didnt stop until he died. Now the effects of the, of course, are ongoing, (Participant 5) "always dealt with depression, always dealt with anxiety." I was also taught to be respectful. I didn't talk back. I didn't speak back." (Participant 6) "I was in a lot of pain and really completely unable to participate in any type of personal aesthetic that I actually liked." (Participant 2) "I feel like a talent wasted." "because with these promises of forgiveness, you have to stay in public service." (Participant 4) Emerging Well-Being "I was living this little chocolate fairytale." (Participant 1) "I have nothing but the utmost respect for her (obese self). She's the one who brought about basically every good thing in my life that I'm enjoying now." (Participant 2) now I'm truly authenticI sleep well. When I smile and I BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 79 laugh, it's for real. (Participant 3) "all the things I wanted to do in my twenties that I thought I couldn't do because it would disappoint my family; the church was gonna kick me out; this was gonna cause grief with so and so; I was not going to be relatable. This is not what a good mother doesI'm doing all of that. (Participant 5) "I have no reason to hide my voice anymore" (Participant 6) Need for Support "Lexapro," "Effexor," and all kinds of other stuff. (Participant 4) from like that time until probably fall of 21. Yeah. I was in, I was in agony, but I was in therapy. I was like, we're gonna unpack it. (Participant 5) "She ended up becoming like my therapist." (Participant 6) "Part of me being more assertive is because of my husband. My husband is a very strong person, and he said to me, 'Honey, I did not marry a weak wife... you're smart. You know what you're doing.'' (Participant 6) BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING Appendix A Supporting Organization Recruitment 80 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING Appendix B Recruitment Flyer 81 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING Appendix C Study Eligibility Form 82 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 83 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 84 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 85 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 86 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING Appendix D Study Information 87 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 88 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 89 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING Appendix Interview Confirmation 90 BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 91 Appendix F Interview Guide African American Perception of Trauma and Sense of Well-Being Introductory Paragraph How are you? Thank you for agreeing to meet with me to be interviewed. Have you had the opportunity to read the consent document? Do you have any questions regarding the study and your participation? As a reminder, the interview will take between 45 and 60 minutes and will be recorded to capture our conversation. I will begin recording now. Please confirm that you agree to participate in this interview. Interview Tell me a little about yourself [age, family, community in which one lives]. Can you share more about your life experiences? o Please describe experiences having the most impact on your life in as little or as much detail as is comfortable. Related to the negative experiences: Do you feel those experiences overwhelmed your ability to cope in the short or long term? In what ways? What parts of your life did those experiences affect the most? How did those experiences make you feel then and now? In what way did those experiences influence or alter your relationships with others, for example, family, friends, co-workers, a higher power, and strangers? BLACK AMERICAN PERCEPTIONS OF TRAUMA AND SENSE OF WELL-BEING 92 Describe if and how the experience(s) facilitated finding meaning and purpose or detracted you from finding meaning and purpose. Can you describe if and how the experience(s) facilitated or detracted your ability to connect with a higher power(s)? Do you think those experiences affected your health? If so, in what way? Is there anything you would like to add related to our conversation? [Resource for those experiencing any psychological or emotional distress resulting from participating in the interview: Crisis Text Line, Text HOME to 741741 to connect with a volunteer Crisis Counselor.] Thank you kindly for your time today. After this, please do not hesitate to contact me if you have questions, concerns, or anything you want to add to todays conversation. ...
- Creator:
- Lindo, Chioma
- Type:
- Dissertation
17. Exploration of the Perceived Value of Self-Leadership Capacity in Physical Therapist Clinicians
- Keyword matches:
- ... Exploration of the Perceived Value of Self-Leadership Capacity in Physical Therapist Clinicians Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Diana A. Harrison, PT, DPT, PCS Copyright October 25, 2023 By: Diana A. Harrison, PT, DPT, PCS All rights reserved Approved by: Laura Santurri, PhD, MPH, CPH, aPHR Committee Chair ______________________________ Lisa Borrero, PhD, FAGHE Committee Member ______________________________ Jennifer Green-Wilson, PT, MBA, EdD Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS Exploration of the Perceived Value of Self-Leadership Capacity in Physical Therapist Clinicians Diana A. Harrison Department of Interprofessional Health & Aging Studies, University of Indianapolis 1 SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 2 Abstract Background and Purpose: Self-leadership, or leading oneself, is a critical component of leadership linked to improved individual performance, team effectiveness, and patient/organizational outcomes. This qualitative study explored physical therapist clinicians perceived value of self-leadership in their clinical practice and their interactions with peers and interprofessional team members. Method: Purposeful sampling was used to recruit participants via the maximum variation strategy. Eleven licensed physical therapist clinicians with 2-39 years of clinical experience in five different clinical settings participated. Participants engaged in individual, semi-structured interviews that were audio-recorded and transcribed using Temi. Dedoose, a data analysis software program, provided secure and collaborative analysis. Study rigor was addressed through the use of multiple coders, memoing, and the member checking process. Results: Four main themes emerged: Developing Expertise, Pursuing Professional Growth, Discovering and Amplifying Voice, and Advocacy. The why behind the actions of those interviewed was to influence patient outcomes and quality of care and to address role identity as a physical therapist in multiple contexts. Conclusion: This is the first known exploration of the perceived value of self-leadership capacity in physical therapist clinicians. Self-leadership in physical therapist clinicians is perceived as valuable in developing expertise, pursuing professional growth, discovering and amplifying voice, and demonstrating advocacy. Leadership must be reframed as self-leadership, the precursor to leading others so that physical therapist clinicians can lead at all levels in everyday practice. Leadership must also be implemented as a domain of competency in entry-level physical therapy education such that professional formation is emphasized alongside clinical competence. Keywords: self-leadership, physical therapist, leadership SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 3 Acknowledgments My dissertation journey included early mornings, medium roast coffee, instrumental music, and a faded blue couch. It is an honor to recognize the following people: To my committee members, Dr. Laura Santurri, Dr. Lisa Borrero, and Dr. Jennifer Green-Wilson, whose expertise and commitment to this process made it possible. Your enthusiasm and encouragement are refreshing and I am grateful to know you. Thank you. To my mom who walks with me every step of the way, loving, listening, and inspiring. Your curiosity and presence are incredible gifts. Thank you. To my family who supports me on all my adventures and in pursuit of all my dreams, whose love knows no limits on rental trucks and moving boxes. Thank you. To my friends who know that it takes a long time to grow an old friend. Your wisdom and perspective are grounding and your laughter is contagious. Thank you. To my friends who know that friendship looks like burrito bowls, cocktails, board games, and impromptu interpretive dance parties. Thank you. To my UIndy Team Purple crew who for reasons unknown put up with my frequent use of Bitmojis. Thank you. To my current and former colleagues whose energy is unmatched and whose devotion to others is remarkable. You are surely the light of this world. Thank you. To my students (and future colleagues), whose dedication and resilience are admirable. It is a privilege to walk alongside you. Thank you. And to the pediatric patients and their families who allowed me to be part of their rehabilitation journey. You taught me what strength, perseverance, and compassion look like. You have changed me. Thank you. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 4 Table of Contents Title Page ..1 Abstract ..2 Acknowledgements ..3 Chapter 1: Introduction .7 Problem Statement ..9 Purpose Statement ..9 Research Question ..9 Significance of Study 10 Definition of Terms 10 Chapter 2: Literature Review 10 Leadership in Healthcare Self-Leadership Strategies 12 13 14 Individual Performance 16 Team Self-Leadership 17 Leadership in Physical Therapy 18 Stakeholders ....19 Leadership Models and Competency Frameworks 26 Self-Leadership in Physical Therapy 29 Chapter 3: Method 30 Study Design ....30 Participants ....31 SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS Procedures 5 ....31 Sampling and Recruitment ....31 Informed Consent ....33 Data Collection ....34 Data Management and Analysis Rigor/Trustworthiness Chapter 4: Results 35 37 ....37 Theme A: Developing Expertise 38 Sub-Theme A1: Educational Opportunities ....39 Sub-Theme A2: Commitment 40 Sub-Theme A3: Mentorship Experiences Theme B: Pursuing Professional Growth Sub-Theme B1: Initiative ....42 ....44 ....44 Sub-Theme B2: Setting Goals ....46 Theme C: Discovering and Amplifying Voice ....48 Sub-Theme C1: Confidence ....49 Sub-Theme C2: Interprofessional Interactions 50 Theme D: Advocacy 52 Chapter 5: Discussion 55 Study Limitations 64 Implications and Future Research Conclusion References 65 ....69 ....70 SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 6 Table 1: Participant Characteristics 83 Figure 1: Visual Representation of Themes ....84 Appendices ....85 Appendix A: Study RecruitmentEmail 85 Appendix B: Study RecruitmentSocial Media 86 Appendix C: Study RecruitmentFollow-Up Screener Appendix D: Consent to Participate in Research Appendix E: Interview Guide 87 88 91 SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 7 Exploration of the Perceived Value of Self-Leadership Capacity in Physical Therapist Clinicians The ever-evolving healthcare industry has challenged organizations and healthcare professionals to navigate environments that demand higher quality care at lesser costs for patients with more complex needs (Lee, 2018). The need for interprofessional collaboration and high-functioning teamwork as a means to deliver patient-centered care, decrease patient safety events, and achieve greater employee engagement requires leadership by healthcare professionals at all levels (Bradd et al., 2017; Browning et al., 2016; Wei et al., 2020; World Health Organization, 2010). However, following several decades of prioritizing leadership development for individuals in positional leadership roles, a distinct leadership gap has emerged, as front-line providers with little to no formal leadership experience or training must lead in everyday clinical practice (Arroliga et al., 2014; Berghout et al., 2017). Although several healthcare professions including medicine, nursing, and pharmacy have pursued and implemented formal competencies and leadership development training to address the leadership gap, stakeholders within the physical therapy profession continue to struggle with pursuing comprehensive and coordinated efforts for leadership development in the academic and clinical settings (American Organization of Nurse Executives [AONE], 2015; Green-Wilson et al., 2022; Janke et al., 2016; Janke et al., 2013; Keijser et al., 2019; Tschoepe et al., 2021). Physical therapists must develop and demonstrate leadership at an individual, team, and organizational level to engage effectively with patients and fulfill their responsibilities as movement specialists on healthcare teams (American Physical Therapy Association [APTA], 2021a; Green-Wilson et al., 2022; Tschoepe et al., 2021). Self-leadership, a comprehensive self-influence perspective suggests that you must lead yourself before effectively leading others SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 8 (Manz, 1986, p. 589). It has been recognized as a critical component of leadership by other healthcare professions and national physical therapy organizations outside of the United States, and groups of researchers within the United States are urging the profession to do the same (AONE, 2015; Canadian Physiotherapy Association Leadership Division, 2012; Green-Wilson et al., 2022; Keijser et al., 2019; National Center for Healthcare Leadership, 2018; National Physiotherapy Advisory Group, 2017; World Physio, 2022). The development of self-leadership skills in physical therapists can lead to improved self-direction and self-motivation, a greater sense of empowerment and achievement, a stronger voice amongst interprofessional healthcare colleagues, and achievement of role clarification in the dynamic healthcare environment (Bradd et al., 2018; Green-Wilson et al., 2022; Sebelski et al., 2020; Tschoepe et al., 2021). However, despite substantial literature that supports the relationship between self-leadership capacity and improved individual performance, team effectiveness, and organizational outcomes, the physical therapy profession in the United States has yet to systematically and intentionally respond (Green-Wilson et al., 2022; Houghton et al., 2002; Knotts et al., 2022; Manz, 2015; Neck et al., 2020; Sebelski et al., 2021). Two discipline-specific leadership frameworks were recently developed to strengthen action on leadership within the physical therapy profession (American Council of Academic Physical Therapy [ACAPT], 2021b; Tschoepe et al., 2021). Specifically, the Leadership Competency Framework for Physical Therapists (LCF-PT) and the Excellence Framework for PT Education propose self-leadership (leading self) as a critical component of leadership and an essential competency for physical therapists (ACAPT, 2021b; Green-Wilson et al., 2022; Sebelski et al., 2020; Tschoepe et al., 2021). To truly transform society as the APTA vision statement suggests, self-leadership must be explicitly and intentionally addressed by all physical SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 9 therapy stakeholders (APTA, 2021c; Green-Wilson et al., 2021; Green-Wilson et al., 2022; Tschoepe et al., 2021). Problem Statement To fully embrace their responsibilities as a profession at a clinical doctoral level in healthcare, physical therapists must cultivate leadership at all levels by developing and demonstrating the ability to first lead themselves (Green-Wilson et al., 2022; Green-Wilson & Zeigler, 2020; McGowan & Stokes, 2015). Currently, there are significant challenges with developing, integrating, and translating leadership skills into clinical practice (McGowan et al., 2019; McGowan & Stokes, 2015; McGowan et al., 2017a; Rasmussen-Barr et al., 2019; Sebelski et al., 2021). Self-leadership must be explored further as little is known about physical therapist clinicians perceptions of self-leadership and the value of self-leadership capacity in their interactions with peers and interprofessional team members in clinical practice. Purpose Statement The purpose of this qualitative study was to explore self-leadership from the perspective of physical therapist clinicians. In addition, the perceived value of self-leadership capacity for physical therapist clinicians in their interactions with interprofessional team members was considered. Research Question The study sought to answer the following question and sub-question: 1. How do physical therapist clinicians perceive the value of self-leadership (ability to lead oneself) in their clinical practice? SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 10 a. How do physical therapist clinicians use their self-leadership capacity (ability to lead oneself) in their interactions with peers and interprofessional team members in clinical practice? Significance of the Study Exploration of the perceived value of self-leadership (ability to lead oneself) in physical therapist clinicians may provide valuable insight into individual performance (behavioral, natural reward or cognitive, and constructive-thought strategies), team effectiveness, and systems-level change (Green-Wilson et al., 2022; Knotts et al., 2022; Sebelski et al., 2021). It may also inform leadership development efforts so physical therapists can demonstrate leadership (i.e., to lead) effectively in all settings at all levels. Advocating for leadership at all levels through a better understanding of self-leadership will allow the physical therapy profession to facilitate growth, embrace change, and represent the profession as transformative leaders in a complex healthcare landscape (Clark et al., 2022; Green-Wilson et al., 2022; Tschoepe et al., 2021). The what if implications of the pursuit of effective self-leadership skills and clinical excellence by all physical therapists can create profound change within the physical therapy profession and beyond (Green-Wilson et al., 2022). Definition of Terms Self-leadership: a comprehensive process of self-influence that incorporates behavioral, natural reward or cognitive, and constructive-thought strategies that address what is to be done, why, and how it should be done; leading self at all levels of care regardless of position or title; relational leadership rather than positional or role-related (Green-Wilson et al., 2022; Houghton et al., 2002; Manz, 1986, 2015; Neck et al., 2020) Literature Review SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 11 Leadership continues to be a challenging phenomenon in the healthcare sector as healthcare organizations, academic institutions, and clinicians are tasked with navigating an ever-changing environment that demands higher quality care at lesser costs for patients with more complex needs (Arroliga et al., 2014; Bradd et al., 2018; Lee, 2018; Sullivan et al., 2022). As an industry with critical implications for both clinicians and patients, non-positional leadership must be addressed explicitly and intentionally at all levels of healthcare (Blumenthal et al., 2012; Bohmer, 2010; Bradd et al., 2018; Keijser et al., 2019; Lee, 2018; Turner et al., 2018). Emerging practice models such as those emphasizing interprofessional collaboration and teamwork (i.e., accountable care organizations) as a means to achieve improved patient outcomes have led to the need for integrating leadership at all levels in clinical practice. However, well-educated and skilled clinicians often have little to no formal leadership experience or training and perceive leadership as a position or role, creating a profound leadership gap (Blumenthal et al., 2012; Wei et al., 2020; World Health Organization, 2010). Physical therapists play an essential role in healthcare on different teams and offer a unique skill set as movement system experts with the potential to profoundly influence and impact the lives of individuals, communities, and society (APTA, 2021a; Schleifer Taylor, 2015). However, stakeholders including professional organizations (i.e. APTA), academicians, and clinicians have struggled to recognize the significance of leadership and the need for intentional leadership development in the physical therapy profession (Clark et al., 2022; GreenWilson et al., 2022; Sebelski et al., 2021; Tschoepe et al., 2021). Leadership is predominantly viewed as a position or a role rather than an act or process accessible to all providers through leading in everyday clinical practice (Clark et al., 2022; Sebelski et al., 2020; Sebelski et al., 2021). SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 12 Self-leadership, or the ability to lead oneself, suggests that healthcare professionals can and must lead themselves in clinical practice before leading others successfully (Manz, 1986; Neck et al., 2020). Self-leadership incorporates behavior-focused strategies, natural reward or cognitive strategies, and constructive thought strategies to influence individual performance outcomes (Neck et al., 2020). In healthcare, self-leadership capacity also influences team interactions and outcomes (Houghton et al., 2002; Neck et al., 2020; Pearce & Manz, 2020). To address the leadership gap in healthcare, physical therapist clinicians at all levels must practice leadership to improve their leadership capacity (Green-Wilson et al., 2022). Physical therapist clinicians must contribute as effective team members by addressing their leadership capacity through (a) leading self; (b) leading others within teams and organizations; and (c) leading within communities and society (Green-Wilson et al., 2022, p. 4; Sebelski et al., 2020; Tschoepe et al., 2021). Advocating for leadership at all levels through developing self-leadership capacity within the clinical setting will allow the physical therapy profession to heed the urgent call to improve the quality of care and patient outcomes, facilitate growth, and represent the profession as transformative leaders in a complex healthcare environment (Clark et al., 2022; Green-Wilson et al., 2022; Tschoepe et al., 2021). Leadership in Healthcare The healthcare landscape and its complex, unique considerations, including the need to consider multiple stakeholders, such as patients and clinicians, provides a fascinating backdrop for leadership (Lee, 2018). By embracing change and pursuing optimal care, effective healthcare leadership is associated with improved patient outcomes, decreased safety events, and greater patient satisfaction (Bradd et al., 2017; Sebelski et al., 2020). However, historically an overemphasis on positional leadership, or role, has led to barriers in communication and SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 13 collaboration among providers, ultimately impacting patient care and outcomes (Green-Wilson et al., 2022; Hartley & Benington, 2010). Despite extensive education and training, healthcare professionals, particularly physicians, were often evaluated and exalted through traditional systems that reject teamwork and the concept of becoming followers, often creating power struggles and a difficult dynamic for interprofessional collaboration (Stoller, 2014). Although this approach is changing, a profound leadership gap has resulted from focusing on building leadership capacity in only those with positional leadership roles (Blumenthal et al., 2012; Green-Wilson et al., 2022; Wei et al., 2020; World Health Organization, 2010). Healthcare professionals must transform the system that was originally built on prioritizing professional autonomy to one that facilitates interprofessional collaboration to make sustainable changes that can positively impact the quality of patient care and decrease costs (Arroliga et al., 2014; Lee, 2018). Highly trained healthcare professionals with unique backgrounds and areas of expertise must be celebrated for their unique skill sets but also be empowered to work together towards a shared mission (Al-Sawai, 2013; Pursio et al., 2021). A systematic and interprofessional approach must occur to address key components of leadership development early on so that health professionals can move beyond accidental leadership and be optimally prepared for the clinical setting (Blumenthal et al., 2012; Turner et al., 2018). Self-Leadership Self-leadership, defined as a comprehensive self-influence perspective, incorporates strategies to impact individual behavior and thought processes (Houghton et al., 2002; Manz, 1986, p. 589; Neck et al., 2020). The construct of self-leadership has its foundations over many years in psychology and is supported through extensive research and theory (Neck et al., 2020; Stewart et al., 2019). Conceptually, self-leadership incorporates social cognitive theory (self- SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 14 efficacy), self-determination theory, self-regulation theory, self-management, and positive psychology to describe the context in which individual self-influence processes take place (Neck et al., 2020). Self-leadership challenges the traditional leadership view that incorporates a leader and follower, as an individual serves as both the initiator and target of influence (Knotts et al., 2022; Stewart et al., 2019). Much of the existing leadership literature revolves around the leaderfollower relationship and the influence exercised by those in formal positions. However, leadership is not just an outward process, but rather, also transpires through an inside-out process, as individuals lead themselves (Manz, 2015; Neck et al., 2020). Self-leadership suggests that everyone can develop leadership and that individuals must lead themselves effectively before leading others (Houghton et al., 2002). Strategies Self-leadership moves beyond any single theory to address what we need to do, why, and how we should do it (Houghton et al., 2002; Neck et al., 2020, p. 8). This broad approach to self-influence includes the following three unique, yet related strategies: behavior-focused, natural reward or cognitive, and constructive thought pattern processes (Neck et al., 2020; Prussia et al., 1998). Self-leadership strategies provide individuals the opportunity to engage intentionally in reshaping their behaviors and cognitive processes to influence outcomes (Neck et al., 2020). Behavior-focused. Behavior-focused strategies address the management of our own behaviors and emphasize leading ourselves to do unattractive but necessary tasks (Neck et al., 2020, p.32). These strategies include self-observation, self-goal setting, self-reward, and selfdiscipline (Neck et al., 2020; Prussia et al., 1998). While individuals cannot control external SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 15 circumstances, simple changes to the immediate environment can impact how one behaves, develops, and demonstrates self-leadership (Neck et al., 2020). Natural Reward or Cognitive. Natural reward or cognitive strategies address the intrinsic value of an activity, including the positive perceptions and experiences related to accomplishing a particular task (Neck et al., 2020; Prussia et al., 1998). The pursuit of effective self-leadership can occur through the use of naturally motivating activitiesthose tasks that include a built-in incentive and do not require external or self-administered rewards (Neck et al., 2020). Naturally rewarding activities tend to promote feelings of increased competence and selfcontrol as well as provide a sense of purpose (Neck et al., 2020; Prussia et al., 1998). Constructive Thought. Constructive thought strategies emphasize the influence of an individuals psychological world on performance outcomes (Neck et al., 2020; Neck et al., 1999). The ability to develop and demonstrate effective self-leadership is directly related to the ability to analyze and manage ones thoughts (Neck et al., 2020). Thought patterns can be influenced through the use of self-analysis, mental practice, positive self-talk, and understanding the power of failure (Neck & Manz, 1996; Neck et al., 2020; Prussia et al., 1998). Multiple author groups have pursued the development of a scale to measure the construct of self-leadership to attempt to move from conceptualization to the quantification of the impact of self-leadership interventions and self-leadership capacity (Anderson & Prussia, 1997; Houghton et al., 2012; Houghton & Neck, 2002). The revised self-leadership scale (RSLQ), a measure that includes the three self-leadership dimensions of behavior-focused, natural reward or cognitive, and constructive thought strategies has demonstrated fairly strong psychometric properties as a valid and reliable measure of self-leadership skills and behaviors (Houghton & Neck, 2002). The RSLQ eliminated 17 items from the initially proposed self-leadership SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 16 questionnaire (SLQ) developed by Anderson and Prussia but is still quite lengthy with 35 total items (Anderson & Prussia, 1997; Houghton & Neck, 2002). However, in 2012, Houghton et al. (2012) developed the Abbreviated Self-Leadership Questionnaire (ASLQ), a shortened nine-item version of the RSLQ (Houghton et al., 2012). The ASLQ has been validated and allows researchers greater feasibility in incorporating self-leadership within studies (Goldsby et al., 2021). Authors have challenged whether the construct of self-leadership is distinct from other motivation theory-based constructs such as self-regulation, self-efficacy, and need for achievement (Neck et al., 2020; Stewart et al., 2011). Self-leadership includes some selfmanagement behaviors, however, focuses on internally generated processes rather than responding to externally set standards (Harari et al., 2021). Studies have concluded that not only is self-leadership a distinct construct, but it also has incremental predictive validity related to job performance, teamwork, and leadership (Furtner et al., 2015). While the majority of literature on self-leadership exists outside of healthcare, studies in medicine and nursing have demonstrated that self-leadership capacity has implications on individual performance and team effectiveness (Kim & Kim, 2019; Knotts et al., 2022; van Dorssen-Boog et al., 2020; van Dorssen-Boog et al., 2022; van Dorssen-Boog et al., 2021). Individual Performance Self-leadership is often linked to positive outcomes at the individual level. This includes associations with higher levels of performance, job satisfaction, and self-efficacy (Stewart et al., 2019). Authors suggest a strong relationship between self-leadership capacity and health and well-being (Neck et al., 2020; van Dorssen-Boog et al., 2021). Improvements in individual fitness and personal effectiveness (physiological well-being, psychological well-being, and job SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 17 performance) ultimately lead to improved organizational success (Neck et al., 2020). The Quintuple Aim includes addressing the work-life balance of providers in response to increasing reports of burnout within the healthcare workforce as one of five goals for quality improvement in healthcare (Bodenheimer & Sinsky, 2014; Nundy & Cooper, 2022). In primary care healthcare workers, the development of self-leadership capacity through participation in a training program contributed to improved work engagement, with training effects on the health and performance of individuals sustained two months later (van Dorssen-Boog et al., 2021). Recently, van Dorssen-Boog et al (2022) sought to differentiate self-leadership behaviors and self-leadership strategies, the former descriptive and the latter prescriptive, from one another in examining the influence on perceived job autonomy. The relationship remains unclear, although the authors suggest that self-leading healthcare workers have the capability of self-influencing their job autonomy (van Dorssen-Boog et al., 2022). Research also links self-leadership positively with emotional intelligence, stress management, optimism, and happiness (Neck et al., 2020). Team Self-Leadership Interestingly, while the words self-leadership and team seem contradictory, the two concepts are closely related (Houghton et al., 2002; Neck et al., 2020; Stewart et al., 2019). Neck et al. (2020) suggest that self-leadership is essential whether working alone or on a team. Importantly, individuals must demonstrate effective self-leadership skills as team members in order for a team to reach its full potential (Neck et al., 2020). A shift towards microsystem healthcare delivery, or team-based care, highlights the need for self-leadership capacity of interprofessional team members as a means to impact patient outcomes (Bohmer, 2010; GreenWilson et al., 2022). SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 18 Team self-leadership includes the incorporation of mental and behavioral self-leadership strategies by team members to influence individual contributions to a team (Neck et al., 2020). Similar to individual self-leadership, the incorporation of mental and behavioral strategies provides self-direction and self-motivation to influence a team (Neck et al., 2020). Behavioral aspects of team self-leadership include team self-observation, team self-goal-setting, team cue modification, team self-reward and self-punishment, and team rehearsal whereas mental aspects include team beliefs and assumptions, team self-talk, team mental imagery, and team thought patterns (Neck et al., 2020). Self-leadership is touted as one component of the twisted teams antidote to the socalled leadership disease of top-down centralized leadership (Pearce & Manz, 2020). Pearce and Manz (2020) define twisted teams as those with members who are empowering, socially responsible and driven by process-based leadership, which requires a profound shift to define leadership as a process rather than a role (p. 2). Although the impact of self-leadership on team outcomes is not as clear as the influence on individual performance, the paradox of selfleadership through collaboration suggests that individuals feel empowered through team engagement and benefit from interactions with others who demonstrate expertise or provide support that surpasses individual limitations (Manz, 2015; Stewart et al., 2019). This is particularly relevant in the interprofessional healthcare setting in which building trust, promoting effective communication and collaboration, and pursuing shared team goals are essential to patient-centered care, patient safety, and patient outcomes (Neck et al., 2020; Stewart et al., 2011). Leadership in Physical Therapy SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 19 As clinicians practicing at a clinical doctoral level, physical therapists are well-positioned as essential members of the healthcare team to strengthen leadership within clinical practice at all levels and participate in the transformation of healthcare (APTA, 2020; Green-Wilson et al., 2022). Due to the complexity of the construct of leadership and the numerous proposed theories and approaches, stakeholders in the United States have struggled to adopt a single definition or come to a consensus on essential leadership characteristics for physical therapists (LoVasco et al., 2016). Without a foundational understanding, comprehensive efforts to address leadership competencies and leadership development in academic and clinical settings have lagged behind. Although the quantity of literature on leadership in physical therapy has grown significantly, the collection is still quite small compared to other healthcare disciplines such as medicine, nursing, and pharmacy. Limited research on leadership in physical therapy has been conducted until recently, which has led to piecemeal efforts on the part of professional organizations, academic programs, research groups, and clinical institutions to incorporate relevant findings in a systematic and pervasive manner. Stakeholders Historically, efforts to address leadership in physical therapy, whether through guidance by professional organizations, modifications to academic curricula, or programmatic development in the clinical setting, have been inconsistent and inadequate. While professionalism is emphasized, leadership is often relegated to limited discussions regarding position or role (Clark et al., 2022; Lopopolo et al., 2004). Currently, there is a gap in the understanding and development of leadership skills and competencies in the academic setting, limited knowledge about the perceptions of the significance of leadership development in the academic and clinical settings, and significant challenge with the translation of leadership skills SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 20 to clinical practice (LoVasco et al., 2019; Sebelski et al., 2020; Tschoepe et al., 2021; Tschoepe & Goulet, 2017). Demonstrated leadership by stakeholders within each context is essential in improving patient outcomes and moving the field of physical therapy forward through growth, innovation, and collaboration (McGowan & Stokes, 2019; Sebelski et al., 2021; Wiedman, 2023). Professional Organizations. Physical therapy professional organizations play a significant role in the growth and sustainability of the profession, particularly in the dynamic healthcare industry. The American Physical Therapy Association (APTA) and World Physiotherapy are responsible for leading the profession forward both in the United States and internationally. In addition, there are many national organizations around the world including the Canadian Physiotherapy Association (CPA), the Australian Physiotherapy Association (APA), and the Irish Society of Chartered Physiotherapists that promote leadership development initiatives (Canadian Physiotherapy Association, 2022; McGowan & Stokes, 2015). Leadership within professional organizations must advocate on behalf of the profession, develop and support programming that advances the field, and serve as a trustworthy voice that promotes the expertise that physical therapists offer (McGowan & Stokes, 2019). Professional organizations have a responsibility of establishing and maintaining a professional brand that highlights the value and unique identity of physical therapy, differentiating it from other healthcare professions (Nancarrow, 2015). This is essential in the changing healthcare environment that promotes interprofessional teamwork, potentially blurring role boundaries and professional identity (Nancarrow, 2015). In the United States, professional core documents including the APTA Code of Ethics, the APTA Standards of Practice, and the APTAs Core Values of Professionalism emphasize SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 21 language about professionalism and management, with minimal mention of leadership (APTA, 2020; APTA, 2021b). While professional duty is one of the nine Core Values, and professionalism is one of six elements of physical therapist practice listed in APTAs previous Vision 2020, at best this suggests that leadership may be important (APTA, 2012). In 2013, the American Physical Therapy Association (APTA) proposed a new vision, Transforming society by optimizing movement to improve the human experience (APTA, 2021c, para. 3). The vision includes the principles of identity, quality, collaboration, value, innovation, consumercentricity, access/equity, inclusion, and advocacy in discussing what the profession and society would look like with the achievement of the vision (APTA, 2021c). Recent work on the development and implementation of competency-based education within the physical therapy profession proposes practice management and professionalism as two domains of competence with no mention of leadership (Knox et al., 2022). Physical therapists must be supported in the quest to develop self-leadership skills, and this begins with policies, procedures, and professional documents that align with valuing leadership as a competency (Green-Wilson et al., 2022; Tschoepe et al., 2021). The Academic Setting. Entry-level doctor of physical therapy (DPT) programs have an enormous responsibility to educate students to become competent, autonomous practitioners. Physical therapists possess the clinical knowledge to transform the healthcare system by advocating for the profession at the patient, program, and systems level, however, historically, academic programs have not outrightly addressed leadership skill development to encourage this (Desveaux & Verrier, 2014). While DPT programs are required to teach professional behaviors discussed in the Code of Ethics and Core Values of Professionalism, there is great variability amongst academic institutions regarding the incorporation of leadership content within curricula SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 22 (APTA, 2020, 2021b). In 2017, Emma Stokes, a former president of World Physiotherapy and a leadership scholar, likened the state of DPT education in the United States to including leadership development as a footnote rather than a critical component of developing the next generation of leadersequipped to advocate and lead the transformative change (Tschoepe & Goulet, 2017, p. 91). Currently, leadership is not explicitly addressed by the Commission on Accreditation in Physical Therapy Education (CAPTE) accreditation standards which impacts the potential for addressing professional identity in the academic setting (CAPTE, 2020). DPT programs focus significantly on the development of clinical skills, however, curriculums must be modified to include greater emphasis on leadership and advocacy to better engage in the evolving healthcare environment (Clark et al., 2022; Tschoepe et al., 2021). Clark et al. (2022) recently proposed the inclusion of leadership and professionalism as two related, yet distinct essential components of professional formation for physical therapists that must be addressed as domains of competence in the educational setting. The intentional inclusion of professional formation capabilities, which includes the domain of leadership, must occur in entry-level curricula alongside clinical skill competency to graduate students capable of immediate leadership at all levels of clinical care (Clark et al., 2022). The Clinical Setting. Similar to the academic setting, leadership is not systematically or consistently addressed in the clinical setting across care settings or organizations. Physical therapists in the clinical setting interact with patients and other health professional colleagues regularly, and thus, must demonstrate leadership behaviors to engage effectively at an individual, organizational, and healthcare systems level (Schleifer Taylor, 2015). Interestingly, Chan et al. (2015) found significant overlap in characteristics demonstrated by physical therapists with and SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 23 without positional leadership roles, suggesting that many physical therapists report that they possess leadership capacity. The percentage of physical therapist clinicians who self-declared as leaders was consistently high in studies conducted in three different countries, although the percentage varied from 74% to 94% (Desveaux et al., 2012; Green-Wilson et al., 2021; McGowan et al., 2016; McGowan & Stokes, 2017). However, to truly transform society as the APTA vision statement suggests, leadership must be intentionally addressed (APTA, 2021c; Tschoepe & Davis, 2015). Three studies in Canada, Ireland, and the United States examined physical therapists perceptions of leadership, the description and comparison of leadership characteristics and their importance across settings, and leadership development training (Desveaux et al., 2012; GreenWilson et al., 2021; McGowan & Stokes, 2017). Importantly, the construct of leadership as defined for these studies, included management and positional leadership. Each study utilized similar methods in exploring perceptions of leadership characteristics across the contexts of the workplace, health care system, and society by rating the importance of 15 leadership qualities using a five-point Likert scale. The leadership characteristics examined included credibility, motivating, communication, professionalism, business acumen, delegation, vision, adaptability, extroversion, active management, social dominance, empathy, social skills, self-awareness, and self-regulation (Desveaux et al., 2012; Green-Wilson et al., 2021; McGowan & Stokes, 2017). Communication and professionalism were identified as the two most important characteristics across all three contexts in all three studies, consistent with prior research in physical therapy, suggesting the need for both communication and professionalism to be core components in leadership development in physical therapy (Desveaux et al., 2012; Green-Wilson et al., 2021; Lopopolo et al., 2004; McGowan & Stokes, 2017). In the United States, the top five SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 24 characteristics regardless of setting included communication, professionalism, adaptability, motivating, and credibility (Green-Wilson et al., 2021). Studies have also explored the characteristics of positional and non-positional leaders in physical therapy including examination of the perspectives of physical therapy clinical specialists/advanced physiotherapy practitioners (APPs) and those in formal management roles (McGowan et al., 2019; McGowan et al., 2017a; McGowan et al., 2017b). Using the Bolman and Deal leadership theory, which consists of structural, human resource, political, and symbolic frames, McGowan et al. (2019) explored the perceived leadership capabilities of clinical specialists or APPs. Clinical specialists/APPs and physical therapy managers both utilized human resource and structural frame capabilities, with an underrepresentation of political and symbolic frames (McGowan et al., 2019; McGowan et al., 2017b). Themes within the human resource (professional development, communication) and structural (operations, strategic planning, and alignment) frames were further discussed through secondary and tertiary subthemes such as accountability, time management, goals, encouragement/motivation, support, teaching role, leadership training, empowering, and feedback (McGowan et al., 2019). The authors suggest this aligns with the prevailing culture of healthcare, as a human resources frame can help establish a culture of respect and promote team building and advocacy for patients (McGowan et al., 2017b). Interestingly, only nine percent of physical therapy managers reported the use of the political frame, which includes conflict resolution, networking with stakeholders, and power dynamics, highlighting potential difficulties with interprofessional collaboration and communication within the clinical context (McGowan et al., 2019; McGowan et al., 2017b). An additional study by the same author group found discrepancies between the leadership characteristics physical therapists perceive to be most important and the leadership SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 25 characteristics that physical therapists in formal management roles possess (McGowan et al., 2017a). While the physical therapist clinicians rated their management staff as most effective at leadership capabilities in the structural frame and least effective in the symbolic frame, the management staff rated leadership behaviors in the symbolic frame, such as demonstrate awareness of the atmosphere of the work environment, communicate their vision for the future of their team, and provide mentorship, as most important (McGowan et al., 2017a). Despite extensive literature from the business sector that distinguishes leadership from management, the healthcare industry continues to emphasize the development of management skills rather than leadership at all levels and across all settings (Knotts et al., 2022; Stoller, 2014; Stoller, 2020). Within the physical therapy profession, leadership is often an afterthought while management and professionalism are prioritized (Clark et al., 2022; Knox et al., 2022; Schafer et al., 2007). Persistent confusion regarding the differences between leadership, management, and professionalism continues to hinder meaningful progress toward the development of professional formation in physical therapists (Clark et al., 2022). A recent qualitative study by Wiedman (2023) explored professional role identity in physical therapists transitioning from clinician to leadership positions and found that participants described communication, emotional intelligence, and the ability to establish strong interpersonal relationships as essential qualities, in addition to clinical skills. Interestingly, the study participants described the alignment of their personal, professional, and organizational identities before transitioning to a leadership role (Wiedman, 2023). Although this study differentiated between the role of clinician and positional leadership, participants demonstrated a strong leadership component prior to transitioning to their leadership role, a finding supported in prior physical therapy literature (Desveaux et al., 2012; Green-Wilson et al., 2021; McGowan & SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 26 Stokes, 2017; Wiedman, 2023). This study suggests that leadership is an important component of professional role identity in physical therapist clinicians and that their role identity is malleable and encompasses much more than clinical competence (Wiedman, 2023). Study results expose a gap in the translation of meaningful leadership behaviors to the clinical setting and an opportunity to engage in leadership development within the profession that addresses individual and team-based capabilities (McGowan & Stokes, 2017; McGowan & Stokes, 2019). While several studies have examined leadership characteristics in the physical therapy profession, there are no known studies that explore self-leadership in physical therapist clinicians (Green-Wilson et al., 2021; Green-Wilson et al., 2022; McGowan et al., 2019; McGowan & Stokes, 2019). Demonstrated leadership by stakeholders within each context is essential in moving the field of physical therapy forward (Hartley & Benington, 2010; Sebelski et al., 2021). Leadership Models and Competency Frameworks Leadership is not simply achieving a list of competencies, but rather, it is a process that takes place within a particular context (Hartley & Benington, 2011). Adoption of a leadership competency framework can help establish role identity through the development of a shared identity for members of a given profession (Keijser et al., 2019; Tschoepe et al., 2021; Wiedman, 2023). It can also clarify a profession for others (Keijser et al., 2019; Sebelski et al., 2021). The utilization of a leadership competency framework can provide consistency in clinical practice expectations across settings and guide leadership curriculum development to address proficiency (Keijser et al., 2019). Leadership frameworks must consider the significance of personal development, collaboration with others, and the growing complexities of healthcare in society (Hartley & Benington, 2011; Keijser et al., 2019; Reeves et al., 2009; Turner et al., 2018). SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 27 Research suggests that a discipline-specific competency framework can provide further development and clarification of the relationships between leadership capabilities and their application to various practice settings and roles (Tschoepe et al., 2021). Initial work within physical therapy included the development of the Leadership, Administration, Management, and Professionalism (LAMP) leadership development continuing education program in 2008 by APTAs Health Policy and Administration Section (HPA), now known as APTAs Academy of Leadership and Innovation (Green-Wilson et al., 2020). The original curricular model included four components: lead wherever you are: becoming a personal leader; independent leadership project; leading others: adaptive and transformational leadership; and advanced leadership project and provides leadership-specific training to physical therapists and physical therapist assistants (Green-Wilson et al., 2020). A qualitative exploration of the perceptions of individuals who completed the program from 2009-2015 found that participants reframed their understanding of leadership development including recognizing the benefits of leading self before others and also reported growth in their leadership capacity (Green-Wilson et al., 2020). In addition, the participants acknowledged that leadership development is a journey and were inspired to act (Green-Wilson et al., 2020). Following this discipline-specific model, ACAPT established a framework that explicitly addresses leadership and leadership development and created a Center of Excellence to pursue data-driven programmatic change in 2021 (ACAPT, 2021a, 2021b). To systematically address leadership within the physical therapy profession, several author groups recently developed discipline-specific competency frameworks (ACAPT, 2021b; Sebelski et al., 2020; Tschoepe et al., 2021). After the identification of leadership competencies through the use of a Delphi panel, the Leadership Competency Framework for Physical SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 28 Therapists (LCF-PT) was developed to address leadership within the physical therapy profession (Sebelski et al., 2020; Tschoepe et al., 2021). The LCF-PT is an evidence-based framework for entry-level curricula and includes three tiersself, others, and organizations/communities, and 11 thematic clusters (Tschoepe et al., 2021). The three-tier approach of the LCF-PT proposes that leading oneself is foundational to the ability to engage with others and progress toward leading organizations/communities (Tschoepe et al., 2021). The American Council of Academic Physical Therapy (ACAPT) put forth the Excellence Framework for PT Education intended for physical therapy educators to pursue continuous improvement in the academic setting (ACAPT, 2021b). For each of the 12 leadership categories in the Excellence Framework for PT Education, three corresponding spheres of influence include skills for leading yourself, skills for working with others, and skills for mentoring others (ACAPT, 2021b). This is consistent with proposed frameworks from the National Center for Healthcare Leadership and other healthcare professions that utilize three unique dimensions including Me, Others, and Society to acknowledge a shift in role identity or the re-professionalization of disciplines (Keijser et al., 2019; National Center for Healthcare Leadership, 2018). The LAMP leadership curriculum, the LCF-PT, and the Excellence Framework for PT Education emphasize self or leading yourself as a critical component of leadership, consistent with other healthcare professions (ACAPT, 2021b; American Organization of Nurse Executives, 2015; Green-Wilson et al., 2020; Keijser et al., 2019; Tschoepe et al., 2021). Researchers agree that the profession of physical therapy must move urgently towards emphasizing leadership as a measurable competency and not simply a behavior (Clark et al., 2022; Sebelski et al., 2020; Tschoepe et al., 2021). While existing literature has explored leadership characteristics, no SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 29 known studies examine the role of self-leadership capacity as a critical component of leadership in physical therapist clinicians. Self-Leadership in Physical Therapy To fully embrace their capabilities as leaders in healthcare, physical therapists must develop skills that enhance their ability to first lead themselves (Green-Wilson et al., 2022; McGowan & Stokes, 2015). In alignment with the proposed leadership framework competencies, building self-leadership capacity is necessary for all physical therapists regardless of position, particularly for those in the clinical setting that must engage with others at an individual, team, and organizational level (Green-Wilson et al., 2022; Sebelski et al., 2020; Stewart et al., 2011; Tschoepe et al., 2021). However, despite the recommendation that self-leadership is an essential component of leadership competency, there are currently no known studies that explicitly examine self-leadership in physical therapist clinicians (ACAPT, 2021b; Green-Wilson et al., 2022; Sebelski et al., 2020; Tschoepe et al., 2021). Exploration of the perceived value of self-leadership (ability to lead oneself) in physical therapist clinicians can provide valuable insight into individual performance including the use of behavioral, natural reward or cognitive, and constructive-thought strategies (Knotts et al., 2022). In addition, the examination of self-leadership in physical therapist clinicians may help inform leadership and team development efforts so that physical therapists can lead effectively in all settings (Green-Wilson et al., 2022; Sebelski et al., 2021). Conclusion The profession of physical therapy must respond to the current healthcare landscape and pursue meaningful action toward the incorporation of leadership into the profession both on the academic and clinical sides, with effective and urgent guidance from professional organizations SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 30 (Desveaux, 2015; Sebelski et al., 2020). Leadership competencies housed within a leadership competency framework must be emphasized alongside clinical competencies to address the call to improve the quality of care and patient outcomes and become transformative leaders in a complex healthcare landscape (Clark et al., 2022; Green-Wilson et al., 2022; Tschoepe et al., 2021). For physical therapists to fully embrace their capabilities in healthcare, they must develop leadership skills that enhance their ability to first lead themselves (Green-Wilson et al., 2022; Green-Wilson & Zeigler, 2020; Neck et al., 2020). Exploration of the perceived value of selfleadership in physical therapist clinicians is necessary to address role identity clarity and improve patient outcomes through optimizing teamwork within the dynamic healthcare environment. Ultimately, a greater emphasis on self-leadership capacity as an essential component of leadership in the clinical context will promote success and recognition of the value that physical therapists have in healthcare (Clark et al., 2022; Green-Wilson et al., 2022; Tschoepe et al., 2021). Method Study Design For this qualitative study, a basic interpretive approach was used, as the aim was to gain insight into the experiences of participants and their associated meanings (Merriam, 2002). The basic interpretive methodology incorporates concepts from constructionism, phenomenology, and symbolic interaction, yet with a primary purpose of uncovering and interpreting meaning (Merriam, 2002). Specifically, the study examined self-leadership from the physical therapist clinician perspective. In addition, the study explored the influence of self-leadership on physical therapist clinicians interactions with interprofessional team members. Leadership is a complex SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 31 construct that can be examined through the implementation of qualitative methodology. Further exploration provided insight into the meaning of self-leadership in physical therapy clinicians and explored the significance of self-leadership ability in interprofessional team interactions. Participants The participants included a diverse group of physical therapy clinicians as defined by age, gender identity, workplace, and clinical practice area. The participants met the following eligibility criteria: Inclusion criteria: Licensed physical therapist in the United States Currently practicing as a clinician for a minimum of 35 hours/week in a clinical practice setting Currently practicing as a clinician in a clinical practice setting for at least two years Exclusion Criteria: Holds a formal management/leadership role/position in which time practicing in patient care is less than 50% of workload Serves as an owner of the clinical practice in which they provide patient care Unable to comprehend and speak English fluently Procedures Sampling and Recruitment Institutional Review Board approval was obtained from the University of Indianapolis prior to the initiation of sampling and recruitment. Purposive sampling was used to recruit participants who could offer in-depth information on the research topic at hand. Specifically, maximum variation sampling, a strategy proposed by Patton (1990), ensured that the participants SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 32 selected offered diverse perspectives on self-leadership from a variety of physical therapy clinical settings including acute care, inpatient rehabilitation, outpatient, and pediatrics, at a minimum. The small sample of great diversity (several different clinical settings) allowed for greater quality and depth within each unique case. In addition, the identification of commonalities or shared patterns across heterogeneous cases illuminated key components or considerations of self-leadership within the physical therapy profession (Patton, 1990). The number of participants was determined by the concept of information power, which considered the study aim, sample specificity, theoretical background, quality of dialogue, and strategy for analysis when determining the sample size (Malterud et al., 2016). Given a narrow study aim, a highly specific sample, limited theoretical support, and an in-depth analysis of interviews, a sample size of eleven participants was utilized (Malterud et al., 2016). Through a stepwise approach that included initial and recurrent assessment, adequate information power was achieved (Malterud et al., 2016). Participants were recruited from known professional contacts of the researchers and from a list of physical therapist clinicians that were clinical partners of the primary researchers institution. Each professional contact and clinical partner received an email from the primary researcher that included study eligibility criteria and a study information sheet that provided the study purpose, anticipated time commitment, and privacy measures (See Appendix A). Participant contact information was stored on the password-protected personal laptop of the primary researcher. Simultaneously, a social media script that included study information and eligibility criteria was posted on the LinkedIn page of the primary researcher (See Appendix B). Interested individuals were instructed to email the primary researcher with any questions or concerns. The primary researcher provided an email response to further clarify eligibility criteria, SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 33 discuss study information, and answer any outstanding questions. At that point, if the individual agreed to participate in the study, the primary researcher scheduled a time for the follow-up eligibility screen (See Appendix C) and informed consent process (See Appendix D). The primary researcher confirmed the individuals clinical practice setting to adhere to the maximum variation sampling technique by recruiting physical therapy clinicians from diverse clinical settings. If eligibility criteria were met, the interview immediately followed. These methods resulted in the recruitment of one former colleague of the primary researcher; however, the voluntary nature of participation was emphasized and the primary researcher ensured full transparency about the purpose of the study. Since adequate participant recruitment occurred through the above-noted processes, purchasing a member mailing list from the American Physical Therapy Association was not necessary. A list of eligible participants was maintained in case unforeseen circumstances disqualified a previously confirmed individual from participating; however, this list was not utilized. Informed Consent Verbal informed consent was obtained by the primary researcher at the beginning of the interview session using the University of Indianapolis minimal risk study information sheet (See Appendix D). The study information sheet provided information about the study purpose, eligibility criteria, participation requirements, anticipated length of time, methods to protect confidentiality, and potential risks or discomforts. Since the primary researcher was a physical therapist, careful attention was paid to provide an unbiased presentation of the information. The primary researcher explained that participants would not directly benefit from the study; however, the results of the research may better inform the physical therapy profession regarding self-leadership and leadership development needs. The study was at a minimal risk level given SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 34 that it did not involve a vulnerable population nor a treatment intervention. Participants were informed that all data would be de-identified and stored on password-protected personal devices, with anticipated dissemination following the primary researchers dissertation work in the Doctor of Health Science program at the University of Indianapolis. Data Collection Data was collected through individual, semi-structured, digital audio- and video-recorded interviews conducted by the primary researcher. In keeping with prior qualitative studies conducted with physical therapists, the semi-structured interview format allowed for the exploration of individual experiences and perceptions of leadership (McGowan et al., 2019; McGowan & Stokes, 2019). Each interview took place virtually in a private location to protect participant privacy. Virtual interviews were approximately 60-90 minutes in length and utilized Zoom and a digital recording device. A semi-structured scripted interview guide (See Appendix E) that provided questions and prompts to promote dialogue and flexibility within the interview structure was utilized. The initial portion of the interview consisted of questions to acquire demographic information, physical therapy work experience, interprofessional team experience, and leadership development or training experiences. This information was used to further consider connections with the development of patterns and themes. The interview guide was developed to address identified gaps in the literature including the need to better understand the construct of selfleadership in physical therapist clinicians. Interview guide questions focused on understanding physical therapists perspectives of self-leadership in clinical practice and the influence of selfleadership on physical therapist clinicians interactions with interprofessional team members. General questions addressing the participants role in physical therapy provided the opportunity SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 35 to build rapport before asking questions more specific to self-leadership in the clinical setting. The incorporation of prompts and follow-up questions encouraged adequate thoroughness and detail during each interview session. Upon completion of the interview, each participant was provided with a $15 Target gift card via email. Participants were also reminded to anticipate communication from the primary researcher within six to eight weeks regarding the member checking process. Throughout the data collection process, the primary researcher participated in memoing to address reflexivity by achieving greater self-awareness of how past clinical experiences influenced current thoughts, biases, and interpretations of self-leadership (Creswell & Poth, 2018; Miles et al., 2020). Data Management and Analysis Recorded interviews were saved as mp3 files on the primary researchers passwordprotected computer and external hard drive. The interviews were imported to Temi, transcribed verbatim, and stored on the primary researchers password-protected laptop and external hard drive. Transcripts were de-identified, reviewed, and edited as needed for accuracy by the primary researcher within one week of the interview by comparing them to the original audio recording. Data analysis included the concurrent completion of data analysis and data collection as described by Miles et al. (2020). The data analysis process included the following: The primary researcher and a second researcher with expertise in qualitative research independently read through one de-identified transcript, writing notes and initial interpretations through the process of memoing (Creswell & Poth, 2018). Memoing ensured transparency and greater substance throughout the coding process and allowed for better reflection of the process from start to finish with an auditable trail (Henderson & Rheault, 2004; Marshall & SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 36 Rossman, 2011; Stuckey, 2015). The two researchers independently coded one interview transcript, engaging in data condensation, including recognition of recurring patterns, before collaborating for the comparison of codes and the development of a codebook (Miles et al., 2020). Coding methods included the elemental approaches of in vivo coding and descriptive coding methods and the affective approach of emotion coding (Miles et al., 2020). Emotion coding was particularly relevant for portions of the interviews that explored perceptions of interprofessional teamwork, as this method examines participant perspectives and worldviews as they relate to interpersonal experiences and actions (Miles et al., 2020). Subcoding was utilized to provide greater clarity and depth, particularly as relationships emerged between the primary codes (Miles et al., 2020). Following code-recode procedures, theme development occurred through a collaborative discussion approach that incorporated one interview transcript. A thematic matrix was developed and utilized to collect and document identified themes (Miles et al., 2020). Engaging in the process of memoing throughout data analysis also assisted with code development and revision (Miles et al., 2020). The entire data analysis process was iterative and modified based on data content (Mack et al., 2005; Miles et al., 2020). Dedoose (Version 9.0.107), a computer-assisted qualitative data analysis software program, provided a platform that promoted secure, collaborative analysis and effective visualization and analytic options (www.dedoose.com). Member checking was carried out with study participants through email communication by the primary researcher to verify the accuracy of data interpretation in reflecting their actual experiences (Letts et al., 2007). Specifically, aggregated themes across all participant interviews were provided and participants were asked to provide thoughts, additions, SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 37 clarifications, and corrections regarding the researchers interpretation of their personal experiences (Henderson & Rheault, 2004; Marshall & Rossman, 2011). Rigor/Trustworthiness Several strategies to address credibility, transferability, dependability, and confirmability, the four components of study rigor or trustworthiness, were incorporated (Henderson & Rheault, 2004). Credibility, or the truth value of the results, was addressed by engaging in memoing throughout the study process, utilizing two researchers during the coding process, and incorporating member checking with all study participants (Henderson & Rheault, 2004; Letts et al., 2007; Miles et al., 2020). Confirmability, which seeks to reduce bias, was also addressed through the strategies of reflexivity and triangulation and the use of memoing (Henderson & Rheault, 2004). Transferability, or the ability to apply the results to similar individuals in comparable contexts, was achieved by acquiring thorough background information on participants to allow for comparison to others and provide information regarding the context (Henderson & Rheault, 2004). Discussion of the context of the study and the attributes and background of the study participants ensured that the sample was representative of the larger group of physical therapist clinicians. Dependability was addressed by providing a detailed description of the study methods including an audit trail to allow others to replicate the study. In addition, memoing and the completion of code-recode procedures with multiple researchers incorporated triangulation and addressed the consistency of the results (Henderson & Rheault, 2004). Results Eleven participants completed the study and included physical therapist clinicians from across the United States. Ten women and one man ranging in age from 27 to 62 years old were SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 38 interviewed. Participants had 2 to 39 years of experience as licensed physical therapists and worked in a variety of clinical practice settings, including the acute hospital (n = 2), pediatrics (n = 2), outpatient orthopedics (n = 3), outpatient hospital-based (n = 2) and inpatient rehabilitation settings (n = 2). Identification codes were used to protect participant confidentiality. Participant characteristics are described in Table 1. Following data analysis of participant interviews, four main themes emerged that explore physical therapist clinicians perceived value of self-leadership (ability to lead oneself) in their clinical practice. Three primary themes, Developing Expertise (A), Pursuing Professional Growth (B), and Discovering and Amplifying Voice (C), each have several corresponding subthemes. The fourth theme, Advocacy (D), for self, others (including patients and colleagues), and the physical therapy profession, was threaded throughout and played an important role in the participants discussion of their perceived value of self-leadership. The interconnectedness between the four major themes and sub-themes is shown in Figure 1. Importantly, the why behind the actions of those interviewed was to influence patient outcomes and quality of care and to address role identity as a physical therapist in multiple contexts. Theme A: Developing Expertise Developing expertise as a physical therapist clinician was noted as a predominant theme across all participant interviews. Study participants spoke of their efforts to improve their clinical performance by advancing their knowledge and skillsets from novice to expert in the clinical setting. As clinicians, participants emphasized the desire to engage in best practices and acknowledged the commitment to their patients as a driving force for wanting to develop SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 39 expertise. The perceived value of demonstrating self-leadership while engaging in mentorship experiences was also discussed. This theme was comprised of three sub-themes: Educational Opportunities (A1), Commitment (A2), and Mentorship Experiences (A3). Additionally, Developing Expertise informs the study theme of Advocacy (Theme D), in which participants expertise was demonstrated through advocacy for others, including patients and colleagues. Sub-Theme A1: Educational Opportunities Educational Opportunities, such as attending continuing education courses and pursuing specialty certifications, were described by participants as ways to develop expertise as a clinician. Participant 0021 questioned, If youdon't want to keep up with what's happening, like first of all, why are you doing this? Individuals described their purpose in participating in educational opportunities beyond the need to maintain their licensureto improve their patient outcomes and provide better quality of care. Yourecognize that you don't have all the answers and so you have to always be open to learning new ways and new techniques thatmight be better than what you've done stated Participant 0027. Participant 0023 described feelings of obligation to his patients, So just the population itself, my patient population required me to have better understanding of woundsdiabetes, cardiovascular disease, things like that. Sowe had totake on the roleof educating ourselves in that. Sowe did that. Additionally, participants identified the relationship between the pursuit of lifelong learning and the quality of clinical care provided. Participant 0025 stated, I think I've always kind of felt like that [it] was important to learn what is new and the best research so that you're practicing in the bestmost effective way for patient care, while Participant 0026 reported, I SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 40 come back [from a course]excited and rejuvenated, andexcited to practice those things. And so, yeah, it kind ofgives you more oomph todo your job better. Acquiring certifications, including board-specialist certifications, was perceived as an additional way to develop expertise. Five participants self-reported obtaining board-certified specialties that were either maintained currently or in the past. In addition, other participants discussed receiving certifications in content areas such as vestibular therapy, pelvic health, and obstetrics. These achievements were perceived as valuable and an indication of an effective clinician. Participant 0024 stated: Everyone that I had met before that had their OCS [Orthopedic Clinical Specialist], I feel like I always looked up to 'em and I felt like they had good skills and they were good clinicians and so I just was likeif that's something that they went for, it seems like it's something that would be valuablefor me as well. Study participants also discussed the benefit of sharing their newly acquired knowledge with their colleagues. Participant 0022 explained: I'm really proud of the knowledge that I have gained from that certification. And so, sharing it with others is, that's like the greatest joy you can get from having a certification is being able to share that with others and help otherswho wanna help other people get better. Sub-Theme A2: Commitment Developing expertise as a physical therapist clinician was described by many study participants as a manifestation of commitment to patient care. Practicing self-leadership including demonstrating altruistic behaviors and adaptability in patient care scenarios was perceived to improve individual performance and influence patient outcomes. Participant 0026 SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 41 explained her efforts in treatingpatients like you would treat family or treat yourselfmaking sure that you put your best foot forward in terms of treating them. Participant 0023 recalled: as therapists, we got into this for patientsyou don't get into physical therapy for glory you know to make the time, make the effortto get it doneyou really have to just make the sacrifices and have the discipline to do what needs to be doneand to do itfully. Commitment to patient care was also described by the incorporation of effective communication skills and extensive patient education in their interactions with patients. Participant 0021 suggested, people will tell me that I'm the first one that's explained certain concepts to them, or that I'm the first one that's given them the time of day to answer questionsto be able to have people be heard. She continues on: that education component has always been huge for me. I want people to understand why I'm asking them to do what I want them to do and help them learn more about their bodies so that they can prevent things from happening later or whatever that looks like. So, I try to use education for empowering people. I want them to be their own advocate (Participant 0021). Study participants expressed feeling a greater sense of purpose and competence from demonstrating an incredible commitment to patient care, an indication of the incorporation of the natural reward or cognitive self-leadership strategy. Participant 0027 suggested, we kind of give people their lives back, you know, I meanit's just so great. I mean, how could you not love this?... people get better and get to go home and what could be better than that? Additionally, Participant 0023 explained, What I love is physical therapy. What I love is SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 42 watching patients get better. What I love is taking what I've learned, taking my passion of physical therapy and then, and seeing that passion transfer to other peoplea patient. I enjoy it. I super, super enjoy it. Sub-Theme A3: Mentorship Experiences Mentorship experiences were discussed frequently in the context of developing expertise as physical therapist clinicians. Throughout their clinical careers, study participants identified with the roles of mentee, mentor, or both. Study participants with the most years of clinical experience (greater than or equal to 17 years) were responsible for the majority of excerpts coded mentor, while those participants with less clinical experience more frequently discussed the mentee role. Participant 0027 suggested the metaphor of a two-way street and stated, I should be learning from you as much as youre learning from me. The opportunity to practice selfleadership was demonstrated particularly through those in the mentor role, while the mentees demonstrated initiative to engage in a mentorship relationship also was indicative of selfleadership. Participant 0019 recalled, someone worked with me and mentored me, well, I need to be able to do, to turn around and do that for the next person and so on and so forth. Participants recalled how mentorship encouraged the development of their clinical skills. Participant 0019 stated: I remember very clearly my first clinical setting was acute care, and there was an older therapist who I just adored. I thought she was great with patients and with our colleagues andI kind of picked her brain every chance I could with what do you think about this situation? And how about this patient and this discharge? Andafter enough times of her SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 43 supporting my decision, like it, it gave me that confidence to kind of move forward in my own job andbe able to be a little bit more independent Study participants reported that mentorship experiences often centered on clinical skills and clinical reasoning regardless of whether they were in the mentee or mentor role. As a mentee, Participant 0021 elaborated: he [participants boss] really has been great in not only clinical skills, which are obviously super important, but in developing my clinical reasoning even further and working with me on my ability to be more independent in clinic, becausewith the setting that I was in originally, I did not have a chance to be comfortable being a professional. I just would show up and hope I did okay. Participant 0018 described her experience as a mentor: So, because I've been a therapist for as long as I have beenI can help guide new staff memberskind of talking through maybe some difficult caseloadsso that I can help guide them in treatment ideas or patients that maybe they haven't seen that type of population before. More specifically, mentors promoted clinical reasoning discussions that encouraged mentees to address their confidence and decision-making capabilities. Participant 0023 acknowledged: I try and instillthe why, the clinical reasoning, becausethe clinical reasoning allows for the confidence in your ability to stand firm with your decisions that you madeso that you are not bulldozed or pushed over and you can standstrong in the decisions that you make for your patients. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 44 Notably, while all study participants acknowledge the importance of developing expertise through educational opportunities, demonstrated commitment, and mentorship experiences, several individuals identified barriers to doing so, including financial requirements and time restrictions. Participant 0025 stated, It can be hard to kind of do some of those things when you're in the trenches of patient careA lot of it ends up being on your own time versus beingbuilt into your treatment time or your day. Theme B: Pursuing Professional Growth The second theme discussed by interviewees was the pursuit of professional growth. Study participants incorporated behavior-focused, natural reward or cognitive, and constructive thought pattern self-leadership strategies such as self-goal setting, self-reflection, and mindset to intentionally address their individual professional growth. Even in the seemingly ordinary, the desire to grow was discussed. Participant 0021 reflected, So I think even just going from Monday to Tuesday, you have to look atwhere can I improve. Participants also acknowledged the importance of time management skills, focused attention, and the role of self-motivation in their day-to-day pursuit of growth. Rather than be motivated by external accolades, participants discussed trying to be the best at what you're doing because that's what you feel like is right and that's what you wanna do versussomebody dangling a promotion over your head (Participant 0025). The participants interviewed had no current positional leadership roles and spoke broadly about professional growth through two sub-themes, Initiative (B1) and Setting Goals (B2). Pursuing professional growth also served to inform the theme of Advocacy (Theme D), as study participants were compelled to advocate for themselves. Sub-Theme B1: Initiative SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 45 Initiative was perceived as an influential component of pursuing professional growth. Participants proposed that initiative is essential to being an effective physical therapist clinician. You have to inherently be a doer stated Participant 0021, you cant really be like a super passive PT and do it super well. Taking initiative was noted as crucial to developing autonomy as Participant 0018 stated, if you don't have that self-directed initiative, thenyou're constantly looking for guidance from someone elseand that's not always available. Additionally, Participant 0021 linked initiative and advocacy for self, having stated: I knew that if I wanted to pursue growththatI had to do something about it myself. And so, I took that initiative of seeking out a new clinic advocating for myself and speaking up for myself, doing the work behind the scenes to make that career move happen. I think all of that made me realize that I'm capable of more than I thought I was. And I can do hard things. And that was a really big growing moment for me in realizing that while it's, I've always been a follower, I've not ever been one to really like take charge of things, but recognizing that sometimes even like pushing for yourself to take charge makes a huge difference. Participants also recalled experiences in which demonstrating initiative led to unique opportunities for professional growth. Participant 0024 reported, I was like let's just look for the opportunity and they happen[ed] to be needing someone at the pelvic clinic they had. So, I jumped into that and then with this job here I kind of mentioned that that was something I wanted to continue doing. Similarly, Participant 0023 recalled his journey to acquiring a teaching position within a physical therapy program: SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 46 Irealized that eventually I was going to have to move into that situation if I really wanted to do itlet's make that next step. So, Ijust kind of sent outan email and some applications to some open positions of teacherscontacted my old PT schooltalked to the director of the programdiscussed with him what steps should be takenand just happened to where I contacted one of those people and they responded back. Sub-Theme B2: Setting Goals Goal setting was a strategy discussed by all study participants for pursuing professional growth. Although several individuals reported setting goals reluctantly or solely as a required component of their annual employment review, most participants discussed it as a requisite behavior to pursuing growth. Self-leadership practices such as intentional goal setting are included within the category of behavior-focused strategies that align with performance improvement outcomes. Participant 0022 reported, having those attainable goals I think is really important when it comes to building yourself as a professional. Additionally, the practice of goal setting was described as knowing what you want to grow into and a means to move toward checking all the boxes thatmy brain and my heart had been wanting (Participant 0017, Participant 0021). The acknowledgement of the need to manage self and apply self-motivation behaviors through goal setting to their clinician role was an additional indication of incorporating self-leadership strategies. Several study participants delved into their approach to setting goals. Participant 0020 likened it to her approach as a clinician and stated, I did it kind of how I do with my patients. So, I kind of broke downhow would I get there andwhat avenues could I take and what people could I bug or askto help me achieve those things. Participant 0022 also discussed her SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 47 method stating, I set a schedule for myselfI plan out each week or each monthsetting small attainable goals for myself in order to reach that big final goal. Participants reported setting goals that addressed many different areas including pursuing additional knowledge, becoming a published author, and acquiring a positional leadership role. Only a few of those interviewed discussed intentions to pursue a positional leadership role in the future. Although some participants did acknowledge the potential to make a difference without a title, many seemed to perceive leadership as distinct from their role as a physical therapist clinician, rather than something that could and should occur simultaneously (Participant 0024). Two of the eleven participants interviewed previously held positional leadership roles but had since returned to a staff physical therapist role. They had pursued formal leadership positions with the intent to make a greater impact but returned to full-time clinical care to re-engage with the why behind their chosen professionimproving patient outcomes. While there appeared to be confusion in differentiating leadership from management, study participants that graduated from DPT programs more recently pointed to generational differences and discredited the perceived need to climb the ladder to earn respect and opportunities to lead (Participant 0017). In addition to the previously identified barriers to developing expertise, study participants also noted difficulty pursuing professional growth as practicing clinicians. Participant 0025 stated: it's hard to have the time to do the things I feel like that help you be a leader, help youeducate and improve the practice of people around you if you're treating six hours a day and don't have timethat's, I think has been thebiggest barrier is like being able to have some blocked time. I'm a senior PThow do you expect me tocontinue to lead if SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 48 you don't give me the time because I'm real busy outside of work too, like I don't have the time to do all this at home either. So that's I think the biggest frustration for me. Theme C: Discovering and Amplifying Voice The theme of discovering and amplifying voice was considered through the perspective that self-leadership capacity can and should be developed and demonstrated at all levels. The opportunity to discover and amplify voice has direct implications for the development and understanding of role identity as an individual clinician and collectively as a profession. Participants acknowledged the significance of their voice in leading patient-provider interactions, however, suggested that not all physical therapist clinicians do. Participant 0021 stated: I don't think all PTs understand the leadership role that they hold every PT is a leader of their patients. I don't know that everybody gets that but they totally need to. Study participants detailed their own personal processes of discovering their voice within the context of patient care. Participant 0027 stated: SometimesI think our job is kind of like being an actor in a play ora flight attendantwe have to bring that energyI might be in the office typing, but now my patient's here and it's like, I'm on, you know? And soI might be, you know, a little more upbeat and engaging than I was when I was in the office typing. Participants also suggested that through the process of career advancement, role identity as an individual physical therapist clinician changes. Participant 0021 suggested: the ability to even change roles requires a huge amount of self-leadership going from student roleto new grad role and maturing in your career tofor some, for those who are interested in management, all the way upto the management level. If you stay a new grad forever, that's a problem. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 49 Discovering and amplifying voice as an expression of individual self-leadership capacity was also considered in the context of interprofessional team interactions. The implications of clarification of role identity at an individual level are such that engagement with interprofessional providers must also be impacted. Study participants elaborated on experiences that required role clarification on behalf of the physical therapy profession leading to changes in team interactions, team effectiveness, and ultimately, patient outcomes. Discovering and amplifying voice was explored further through the two sub-themes of Confidence (C1) and Interprofessional Opportunities (C2). Furthermore, this theme was linked to the study theme Advocacy (Theme D) through demonstrated advocacy for the physical therapy profession. Sub-Theme C1: Confidence Study participants described confidence, or the lack thereof, as impactful on their ability to develop and use their voice, ultimately influencing the outcomes of interactions with patients, colleagues, and other healthcare professionals. Participant 0023 stated: I think that humility and confidence will varydespite how long we've been outI think a lot of new grads who may have the newest informationmay not be confident enough in their ability to do that. But the old guys like me who have been doing it for almost 20 years sometimes are overconfident in our abilityor maybe not humble enough to say, Hey, I'm not quite sure. Participants described experiencing fluctuation in their confidence regardless of their level of clinical experience. You always go through those periods of like having an imposter syndromeyou really first start out, you know nothing, and then a year in you're like, I got this. I finally got it. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 50 And then like three years hits and you're like I'm the stupidest person to ever liveand it's justbig waves ofsometimes you feel like you're rising high and then sometimes you're like, I am the dumbest human ever (Participant 0020). The influence of confidence on their pursuit of new aspects of their role identity was also discussed by study participants. While reporting that developing confidence to pursue a positional leadership role is difficult, Participant 0017 came to the realization that she can still lead from where [she is]. Similarly, as she pursues expanding her role identity to include clinical instructor, Participant 0021 described: I wanted to be confident in who I was as a clinician so that one of these days I can take a student and I can help that student, butI can't be a CI [clinical instructor] if I don't know what I'm doing. So ultimately everything is justbuilding me closer and closer to that clinical instructor role and just feeling better about signing my name at the end of my notes and owning, yes, I ran that treatment, I did that eval, and here's where I feel confident in what I did today. Sub-Theme C2: Interprofessional Interactions Discovering and amplifying voice was also discussed within the context of interprofessional interactions. Study participants discussed engaging with a wide variety of healthcare professionals including physicians, nurse practitioners, nurses, occupational therapists, speech therapists, social workers, and case managers. Interprofessional interactions were predominantly patient-care driven, most often in the context of patient status updates or discharge planning. Study participants described the opportunity to discover and amplify their voices during interprofessional patient care scenarios as overwhelmingly beneficial and SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 51 impactful. Participant 0017 stated, we do have a unique skillset that shouldn'tbe minimized by other professions. We have an important voice and we can make a big impact. Interprofessional interactions were often discussed within the team context. Participant 0021 reported, We have very open lines of communication amongst everybody and everybody's on even ground. And the majority of the physicians see us as teammates in the patients care, which helps incredibly to know that we're all on the same team. Participant 0018 suggested, working with a team really makes me feel better as a professional because I know thatwe're working together, we're accomplishing goals, we're collaborating with each other and also like bouncing ideas off of each other that we think will benefit the patient. When working effectively on an interprofessional team, physical therapist clinicians possess the ability to serve as the movement system expert and the perspective to see the big picture and put it all together (Participant 0017). Respecting one anothers roles was frequently addressed. Participants discussed interprofessional interactions requiring collaboration and communication that were perceived as either challenging or effective if pursuing a common goal. While Participant 0017 suggested, I definitely think you wanna go in feeling like you are valued and you're gonna be heard, Participant 0021 acknowledged, I can't be on your team if you won't even let me on the field. With increasing levels of clinical experience, study participants noted that their ability to amplify their voice during interprofessional interactions grew. Participant 0020 noted this change in her communication: I've gotten much better at not overexplaining things cause physicians wanna knowwhat I do, not necessarily how I do itwhich took me a long time to learn becauseI want everyone to know all the thingsthat took me a long time to learn that SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 52 they don't want to know all the thingsI think that has gotten more positive as I have grown as a clinician and been able to explain myself a little bit better. Approaching interactions with humility was also suggested as a way to address interprofessional communication and improve team effectiveness. This included acknowledging ones own limits, as suggested by Participant 0027 who stated, being open to learning and to be able to admit that I don't have all the answers. I think that would go a long way in building rapport with another discipline. Participant 0023 elaborated: You can be standoffish and you can say, Nope, you're wrong. This is what's going on. This is what's in the best interest for the patient. And then every interaction you have with that certain person after that situation, they're going to probably be defensive, defiant, and they're automatically going to come into that situation with a maybe a negative or bad attitude. Oryou can change your attitude, not necessarily your goal, but your attitude, the way you handle those people. And then after a couple interactions, you're one of the nicest people that they've ever met. They're more willing to help you out. Study participants discussed interprofessional interactions as influential on the development of their role identity within the dynamic healthcare environment. Participants spoke unapologetically in stating that the profession of physical therapy has work to do in addressing establishing role identity as a profession at a systems level. Stated simply, I dont thinkwere there yet (Participant 0026). In addition to developing role identity, increasing confidence and engaging in interprofessional interactions were described as mechanisms to improve teamwork and thus, impact patient outcomes and quality of care. Theme D: Advocacy SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 53 Advocacy (D) for self, others, the practice of physical therapy, and the physical therapy profession was considered within the context of the previously discussed themes: Developing Expertise (A), Pursuing Professional Growth (B), and Discovering and Amplifying Voice (C). Importantly, demonstrated advocacy ultimately influences patient outcomes and quality of care and leads to changes in individual and professional role identity. Developing Expertise (Theme A) was ultimately expressed as advocacy for others. Advocacy for colleagues was demonstrated through Mentorship Experiences (A3), whereas advocacy for patients was addressed through all three sub-themes, Educational Opportunities (A1), Commitment (A2), and Mentorship Experiences (A3). As mentors, participants discussed their role in advocating for their less-experienced physical therapist clinician colleagues. Participant 0019 stated, right now there's a couple of really new therapists and I absolutely offered to be a mentor because I feel like everyone needs that sounding board. Study participants described a clear relationship between developing expertise and advocacy for patients resulting in improved patient outcomes and quality of care. Participant 0025 stated, In bettering myself in my practice, it has definitely improved my outcomes with patients. Pursuing Professional Growth (Theme B) manifested as advocacy for self as a physical therapist and was explored through the sub-themes of Initiative (B1) and Setting Goals (B2). Interestingly, participants described the pursuit of professional growth as essential to developing their role identity as physical therapists. Participant 0023 explained, you have to be willing to make the sacrifices or take that extra stephave the initiative, have the discipline maybe to do what's necessarynot necessarilywhat's easy maybebut definitelywhat's necessary, what needs to be done. In addition, demonstrating initiative and setting goals was perceived as SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 54 promoting lifelong learning and a posture of growth which ultimately influence patient outcomes and quality of care. Discovering and Amplifying Voice (Theme C) was expressed as advocacy for the practice of physical therapy within team and institution-based systems and the physical therapy profession through the sub-themes of Confidence (C1) and Interprofessional Interactions (C2). As physical therapist clinicians without positional leadership roles, participants clearly expressed a greater affinity for advocacy for patients rather than advocating for the physical therapy profession. However, study participants frequently discussed the need to engage effectively with interprofessional colleagues on a team and at an organizational level to advocate effectively for the physical therapy profession. Although all study participants suggested that the physical therapy profession must continue to progress, only a few participants reported involvement with formal advocacy efforts on behalf of the profession either within or outside of the APTA. Participant 0017 suggested: we still need to continue to push for things to change if we want to be recognized and respected, which sometimes it's you having to convince people that you're worth it and if we don't, no one else is gonna do it for us. So, I think that's wherethe profession needs to continue to grow is showing people it's okay to be a leader and be wrong orbe a leader and put yourself out there. Four major themes emerged from the study including Developing Expertise (A), Pursuing Professional Growth (B), Discovering and Amplifying Voice (C). The fourth theme, Advocacy (D) was evident across all themes through advocacy for self, for others (patients and colleagues), and for the physical therapy profession. The behaviors and actions identified by physical therapist clinicians through the exploration of the perceived value of self-leadership capacity in SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 55 the clinical setting were noted to ultimately influence patient outcomes and quality of care and to address role identity as a physical therapist across multiple contexts. Discussion Physical therapists must develop and demonstrate leadership to engage effectively with patients and interprofessional team members and fulfill their responsibilities at all levels within healthcare organizations and systems (Clark et al., 2022; Green-Wilson et al., 2022; GreenWilson & Zeigler, 2020). Existing literature links self-leadership capacity to improved individual performance, team effectiveness, and organizational outcomes; however, little is known about the perceived value of self-leadership in physical therapist clinicians. Gaining a greater understanding of the physical therapist clinician perspective is essential to the continued development, integration, and translation of leadership skills into clinical practice (McGowan et al., 2019; McGowan et al., 2017a; Rasmussen-Barr et al., 2019; Sebelski et al., 2021). Therefore, the purpose of this qualitative study was to explore the perceived value of selfleadership capacity in physical therapist clinicians clinical practice. In addition, the perceived value of self-leadership capacity in physical therapist clinicians interactions with peers and interprofessional team members was addressed. This study provides a greater understanding of the perceived value of self-leadership capacity in physical therapist clinicians in the United States. The qualitative methodology afforded study participants the opportunity to share their lived experiences and engage in discussions of great depth to make meaning of the role that self-leadership plays as clinicians in their professional roles. Research within the physical therapy profession on leadership is growing and suggests that self-leadership is an important component of professional formation at the individual, organizational, and societal levels (Clark et al., 2022; Green- SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 56 Wilson et al., 2021; Green-Wilson et al., 2022; Sebelski et al., 2020; Tschoepe et al., 2021). Despite limited initial familiarity with the construct of self-leadership, study participants provided rich conversation and thoughts on self-leadership in the clinical setting expressed through the following four themes: Developing Expertise, Pursuing Professional Growth, Discovering and Amplifying Voice, and Advocacy. Developing Expertise Study participants perceived developing expertise as a conduit to improve their performance. This desire to improve aligns with the Core Values for the Physical Therapist and Physical Therapist Assistant put forth by the APTA, particularly excellence, altruism, and duty (APTA, 2021b). Participants detailed their actions as altruistic clinicians, describing incredible dedication, sacrifice, and devotion to their patients (APTA, 2021b). Duty, or commitment to ones obligations, requires a patient-centered approach, one that study participants engaged in and perceived as necessary to provide effective care to their patients (APTA, 2021b). As previously suggested, study participants found that engagement in selfleadership led to a greater commitment to tasks and goals, including patient outcomes (Bligh et al., 2006; Neck & Houghton, 2006). As physical therapists seek to truly embody the core values of the profession, the development of self-leadership capacity provides a necessary foundation from which to engage with intention. Study participants described the self-influence process of purposefully identifying behaviors, actions, and thinking patterns that led to achieving a particular desired outcome (Neck et al., 2020). Self-leadership is thought to influence performance through several mechanisms including self-motivation, self-efficacy, and work engagement (Knotts et al., 2022; Manz, 1986; Neck & Houghton, 2006; Neck et al., 2020; Prussia et al., 1998; van SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 57 Dorssen-Boog et al., 2021). Self-motivation, a practice within natural reward or cognitive strategies can lead to the development of self-determination and autonomy (Green-Wilson et al., 2022). The successful acquisition of board specialist certifications was one example shared by study participants when describing the process of self-leadership and selfmotivation leading to greater self-determination and autonomy in clinical practice. Developing clinical expertise in this way provided study participants with the opportunity to shift from self-influence to influencing others, empowering their patients to engage fully in their care and develop their own autonomy. Changes in self-efficacy, or an individuals perceived ability to perform a specific task, may lead to improved performance outcomes (Manz, 1986; Neck & Houghton, 2006; Prussia et al., 1998). Although there has been limited exploration of self-efficacy within the physical therapy profession, study participants suggested that the acquisition of additional knowledge and skillsets influenced their levels of self-efficacy (Sebelski, 2017). Several participants discussed the ongoing pursuit of opportunities as a means to achieve or maintain higher levels of self-efficacy, such that they understood the direct impact on their performance. Work engagement was not specifically addressed, although several participants did allude to feeling passionate about their current clinical roles. Subthemes within the major theme of developing expertise included educational opportunities, commitment, and mentorship experiences, aligning with findings from McGowan et al (2019) in which clinical specialist and advanced physiotherapy practitioners described their leadership capabilities as predominantly within the human resource frame (professional development and communication) of the Bolman and Deal leadership framework. Study participants also perceived self-leadership capacity as a necessary building block to influencing SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 58 others, in agreement with McGowan et al (2019) who suggest that supporting, motivating, and empowering others is essential alongside clinical expertise. Clinical practice is centered around the patient, and thus, the desire to develop expertise as a physical therapist clinician was predominantly an expression of commitment to patient care. From a foundation of self-influence, study participants progressed to leading, influencing, and motivating others (Clark et al., 2022). A greater sense of purpose and competence, both results of natural reward or cognitive strategy implementation, were commonly addressed by study participants and may be additional mechanisms through which self-leadership influences performance, patient outcomes, and quality of care (Knotts et al., 2022). Study participants also described mentorship experiences as a component of developing clinical expertise. Mentorship experiences provided opportunities for self-assessment, selfreflection, and feedback, practices that address behavior-focused and natural reward or cognitive self-leadership strategies (Green-Wilson et al., 2022). Through engaging in mentorship conversations, study participants also incorporated constructive thought pattern strategies including a positive mindset and the ability to acknowledge their own limitations. Study participants suggested that developing expertise and self-leadership are absolutely intertwined. To be an effective clinician, physical therapists demonstrate intentional engagement and self-motivation in their pursuit of expertise. As clinicians gain expertise, their self-efficacy also presumably increases. The intentional pursuit of clinical expertise by study participants demonstrates the interconnectedness of self-leadership, selfmotivation, self-determination, self-efficacy, and performance which aligns with prior literature (van Dorssen-Boog et al., 2022; van Dorssen-Boog et al., 2021). There may be value in SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 59 considering influence as a competency within the self tier of the LCF-PT, as it is a foundational component to move toward leading others (Sebelski et al., 2020; Tschoepe et al., 2021). Pursuing Professional Growth Study participants suggested that engaging in self-influence processes to pursue growth required self-motivation, initiative, and a growth mindset. Self-motivation was noted as essential during ordinary day-to-day tasks alongside the behavior-focused strategies of time management skills and focused attention. Rather than being driven by external accolades, study participants suggested an intrinsic desire to do what they perceived was right or best. Interestingly, self-motivation seemed to be so ingrained that many participants laughed at the idea of practicing self-rewarding behaviors following the achievement of a goal. The mentality of being a doer and demonstrating initiative was proposed as inherent to being an effective physical therapist clinician, one that is supported by prior literature (Wiedman, 2023). Demonstrating initiative provided participants with decision-making opportunities within their department and team contexts, leading to greater perceived professional autonomy. Prior research in nursing described autonomy as including decisionmaking and the ability to utilize ones competence, or initiative (Pursio et al., 2021). Similar to prior literature, study participants suggested that the pursuit of professional development or growth may assist clinicians in developing competence and autonomy (Pursio et al., 2021; van Dorssen-Boog et al., 2020; van Dorssen-Boog et al., 2022). Study participants also discussed incorporating the behavior-focused practice of selfgoal-setting to address professional growth. In addition to setting goals to address clinical skills, study participants described professional goals related to acquiring non-clinical SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 60 knowledge, becoming a published author, and obtaining a positional leadership role. Physical therapists are expected to engage in lifelong learning and professional development activities, concepts put forth by the APTA as requirements for physical therapist practice (APTA, 2012). While several study participants suggested that goal setting was simply an annual employee review component, many participants engaged in goal setting independent of external requirements. Self-motivation, initiative, and self-goal setting were important strategies for study participants to consistently demonstrate in pursuit of their professional growth. Discovering and Amplifying Voice To discover and amplify their voice, physical therapist clinicians engaged in selfleadership behaviors to address their professional role identity. Study participants described leadership in a variety of ways which influenced their ability to consider the relationship between self-leadership and their professional role identity as a clinician. Several participants viewed leadership as a role distinct from being a clinician and suggested that leadership was a future goal that they could pursue. This apparent difficulty in defining and acknowledging the significance of leadership within the physical therapy profession aligns with prior literature (Clark et al., 2022; Green-Wilson et al., 2022; Sebelski et al., 2021; Tschoepe et al., 2021). Notably, all study participants identified as leaders when discussing patient interactions, consistent with prior studies in which the percentage of physical therapist clinicians that selfdeclared as leaders was consistently high (Desveaux et al., 2012; Green-Wilson et al., 2021; McGowan & Stokes, 2017). Although professional identity formation considers individuals experiences within a professional role across individual, organizational, and societal realms, study participants were challenged by considering the implications at the organizational and societal levels (Clark et al., 2022). This suggests that study participants may predominantly SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 61 experience professional formation at the individual level through a patient-focused identity (Clark et al., 2022). Interestingly, two study participants left positional leadership roles to return to full-time clinical care, suggesting role conflict in their ability to navigate the perceived duality of clinician and leadership roles, a finding discrepant with recent literature (Wiedman, 2023). Physical therapist clinicians may not view leadership as compatible with the full-time clinician role, and rather perceive that it is necessary to possess a title to demonstrate influence. This persistent misunderstanding of leadership within the profession hinders progress and must be addressed (Clark et al., 2022). Participants discussed the dynamic process of discovering and amplifying their voice, acknowledging that their professional role identity continues to change throughout their careers. This finding is in alignment with Wiedman (2023) who reported that study participants considered their professional role identity as malleable. Participants in this study also discussed fluctuating levels of confidence as they navigated interactions with patients and colleagues, however, noted that self-leadership capacity allowed them to move through periods of perceived discomfort with intention (Wiedman, 2023). The process of discovering and amplifying voice ultimately led to increased confidence with study participants acknowledging the daily opportunities to lead in patient care interactions. Confidence and self-efficacy were also described as essential components to the pursuit and successful acquisition of new responsibilities, including assuming the role of clinical instructor. This study also considered how physical therapist clinicians used their self-leadership capacity in their interactions with interprofessional team members in clinical practice. Selfleadership is central to being an effective team memberas self-leadership capacity develops, the ability to influence and empower others increases (Green-Wilson et al., 2022; Knotts et al., SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 62 2022; Pearce & Manz, 2020). Study participants detailed the role of effective communication and collaboration within the interprofessional team context while pursuing common goals related to patient care updates or discharge needs (Neck et al., 2020; Stewart et al., 2011). This emphasis on communication is consistent with prior studies in Canada, Ireland, and the United States that identified communication as one of the top two most important characteristics for physical therapists to possess across the contexts of the workplace, health care system, and society (Desveaux et al., 2012; Green-Wilson et al., 2021; McGowan & Stokes, 2017). The previously described paradox of self-leadership through collaboration suggests that effective self-leadership requires developing collaborative connections with others (Stewart et al., 2019). Choosing to collaborate with others in a team context as an intentional self-leadership strategy leads to empowering experiences and may alert individuals to areas for improvement (Stewart et al., 2019). This study aligns with prior literature that suggests connections between demonstrated self-leadership and higher levels of trust and commitment in a team environment (Bligh et al., 2006). Study participants reported feeling empowered through opportunities for team engagement and benefitted from interactions with others who demonstrated expertise or provided support (Manz, 2015; Stewart et al., 2019). Although prior literature suggests that constructive thought strategies are particularly important in demonstrating team commitment, study participants discussed minimal incorporation of mental imagery or self-talk (Bligh et al., 2006). Study participants suggested that self-leadership or influence is necessary for role clarification conversations with interprofessional colleagues. Challenging interprofessional interactions that required role clarification led to perceived positive changes in communication and collaboration, essential components of patient-centered care, patient safety, and patient SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 63 outcomes (Neck et al., 2020; Stewart et al., 2011). Self-leadership, one of four complimentary strands of leadership proposed in twisted teams, may very well be the antidote to the centralized top-down leadership disease (Pearce & Manz, 2020). This study adds to the literature by suggesting that the development of self-leadership capacity can lead individuals that are experiencing role conflict to a place of role understanding and clarity. Advocacy Effective self-leadership can lead to improved advocacy efforts through increasing feelings of empowerment, competence, and purpose (Neck & Houghton, 2006). Study results align with these findings as participants discussed a greater ability to engage in advocacy efforts and empower others. Advocacy, for self, others, physical therapy practice, and the physical therapy profession, were explored within the context of the other three major themes. The combination of self-leadership and self-advocacy bolstered the ability of participants to advocate for others and the physical therapy profession within the clinical setting. The incorporation of self-leadership strategies provided opportunities for study participants to advocate on behalf of their patients in the interprofessional team setting, particularly related to discharge planning needs. Those clinicians further along in their clinical careers discussed the ability to pay it forward, advocating for and empowering others through mentoring lessexperienced physical therapist colleagues. Although study participants frequently discussed advocacy for physical therapy practice within the interprofessional context, this tended to occur at an individual patient level. For example, study participants described providing recommendations for patient length of stay or discharge disposition that were initially discrepant with medical providers. Interestingly, as full-time clinicians without positional leadership roles, some study SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 64 participants suggested that it may not be necessary or feasible to advocate on behalf of the physical therapy profession in their current roles. This aligns with a prior study that reported physical therapist clinicians as least likely to engage in the political frame of the Bowman and Deal leadership framework which includes networking with stakeholders and power dynamics (McGowan et al., 2019). Study data was not collected on participation and membership in professional organizations, however, the majority of participants denied formal involvement in advocacy efforts at the local (i.e., community), state, and national levels. Advocacy is one of nine principles identified as necessary to achieve the APTAs vision to transform society, thus, this is important information for the APTA to consider (APTA, 2021c). The profession must identify effective ways to engage physical therapists across all settings at all levels in advocacy efforts. Developing self-leadership capacity will encourage physical therapist clinicians to engage and demonstrate influence at all levels, advocating effectively regardless of position or title. Study Limitations This study contains limitations. The primary researcher recruited and conducted all participant interviews and participated in the coding of all data, presenting the potential for researcher bias (Henderson & Rheault, 2004). In addition, all interviews were conducted virtually, which may have limited non-verbal communication and opportunities for rapport development between the primary researcher and study participants. Gubas Four Aspects of Trustworthiness including credibility, transferability, dependability, and confirmability, were addressed through the incorporation of several strategies (Henderson & Rheault, 2004). The primary researcher, a physical therapist that worked full-time in the clinical setting for twelve years, engaged in memoing throughout the study process to address reflexivity. Memoing SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 65 provided an auditable trail and encouraged regular reflection on the potential contribution of researcher bias. Two researchers, including one expert in qualitative methodology, participated in the initial coding and codebook development processes to address triangulation. Additionally, the primary researcher engaged in code-recode procedures to address dependability. Member checking was conducted through email by providing study participants with the aggregated study themes across all patient interviews. Seven out of eleven study participants engaged in the member checking process, acknowledging that the proposed study themes aligned with their lived experiences. Study participants included ten women and one man from across various geographic regions in the United States with a wide range of years of clinical experience and practice settings. The collection of thorough demographic and background information suggests that the study participants represent the larger group of physical therapist clinicians. Since information about membership in professional organizations was not collected, potential connections with self-leadership and advocacy at the organizational and societal levels may be limited. In addition, study participants were not initially familiar with the construct of self-leadership, nor the strategies utilized to engage in the self-influence process. This may have impacted the ability of study participants to fully consider the manifestations of self-leadership in their clinical roles. Implications and Future Research This study adds to the existing literature as the first known exploration of the perceived value of self-leadership capacity in physical therapist clinicians. Physical therapist clinicians demonstrate self-leadership through influence, motivation, initiative, empowerment, and commitment. Self-leadership in physical therapist clinicians is perceived as valuable in SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 66 developing expertise, pursuing professional growth, discovering and amplifying voice, and demonstrating advocacy. The demonstration of self-leadership skills in physical therapist clinicians does indeed lead to improved self-direction and self-motivation, a greater sense of empowerment and achievement, a stronger voice amongst interprofessional healthcare colleagues, and achievement of role clarification in the dynamic healthcare environment (Bradd et al., 2018; Green-Wilson et al., 2022; Sebelski et al., 2020; Tschoepe et al., 2021). Study participants perceive that self-leadership capacity ultimately influences individual performance, patient outcomes, and quality of care in the clinical setting. There are several major implications of this study. First, leadership must be reframed as self-leadership, a self-influence process and the precursor to leading others. Physical therapists must understand and demonstrate leadership at all levels as it has profound implications within the dynamic healthcare setting. Study results demonstrate an ongoing lack of familiarity with leadership, self-leadership, and leadership competency frameworks in the profession of physical therapy (Clark et al., 2022; Green-Wilson et al., 2021). The assumption that leadership is exclusively a top-down, hierarchical-based role, position, or title is flawed and incongruent with the dynamic healthcare setting that now relies on practice models that emphasize interprofessional collaboration and teamwork. To become transformative leaders, physical therapists must embrace their role as movement system experts and begin leading in everyday clinical practice (Clark et al., 2022; Sebelski et al., 2020; Sebelski et al., 2021). Leadership at all levels includes influence, initiative, and the empowerment of physical therapist clinicians and the closing of the leadership gap that has formed as a result of focusing on positional-based leadership development. Reframing leadership as an intentional self-influence process will lead to improved understanding of professional formation including greater professional role clarity SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 67 and confidence in physical therapist clinicians (Clark et al., 2022; Green-Wilson et al., 2022). Individual self-leadership capacity in the context of interprofessional teams will also increase collaboration, improve the quality of patient care, and decrease healthcare costs. This reframing of leadership will lead to an abundance of leadership development opportunities for physical therapist clinicians in both intraprofessional and interprofessional contexts. While self-leadership occurs naturally, it is often not effective, and therefore targeted self-leadership development must occur (Pearce & Manz, 2020). Second, the profession must move beyond accidental leadership and address barriers to engaging in leadership development and self-leadership processes (Blumenthal et al., 2012). Study participants discussed two major barrierstime and financial resources. Understandably, physical therapist clinicians are asked by employees to prioritize patient care, however, the lack of emphasis placed on non-patient care opportunities is detrimental to individuals and institutions. Leaders at the department and organizational level must consider regularly scheduled time for leadership development opportunities such as mentorship and continuing education courses. Physical therapist clinicians should not be expected to pursue leadership development opportunities independently or exclusively outside of working hours. Intentional leadership development training in healthcare workers can positively impact work engagement, performance, and health in employees through developing self-determination and motivation (van Dorssen-Boog et al., 2021). Financial resources are also a barrier. Study participants discussed displeasure and frustration with the costs associated with continuing education courses, specialist certifications, and the acquisition and maintenance of professional organization memberships. While institutions must set financial boundaries, there is incredible opportunity for front-line physical therapist clinicians to play a role in planning and implementing sustainable SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 68 and innovative solutions. Opportunities to acquire continuing education units (CEUs) that address non-clinical topics such as leadership and professional formation should be provided and accepted. State licensing boards should consider courses that address leadership and professional formation as a requirement for license renewal. The APTA and other professional organizations within physical therapy must consider how to prioritize professional formation, including leadership, alongside clinical competence. Finally, leadership must be implemented as a domain of competency in entry-level physical therapy education. Professional formation, which includes the two related, yet distinct competencies of professionalism and leadership, is crucial to the professional identity of physical therapists and must be prioritized alongside clinical competence in academic programs (Clark et al., 2022). Currently, leadership is not considered a domain in the competency-based education model proposed for the profession of physical therapy (Knox et al., 2022). Leadership is indeed the fuel necessary to truly transform society and move the profession forward (Clark et al., 2022). Leadership competencies housed within a leadership competency framework, such as the LCF-PT, will facilitate leadership development in a systematic way such that graduates are capable of demonstrating immediate leadership in clinical care (Green-Wilson et al., 2022; Tschoepe et al., 2021). Waiting to initiate intentional leadership development upon entry to clinical practice is a mistake and a perpetuation of the leadership gap. Rather, entry-level programs must engage students in purposeful exploration of self-leadership as an ongoing dynamic process, fostering the development of a mindset that leads to growth, influence, and empowerment. Future research opportunities addressing self-leadership in physical therapy are numerous. All stakeholders within the profession including clinicians, academicians, researchers, SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 69 and professional organizations must participate in moving the profession forward through the intentional incorporation of leadership. Entry-level physical therapy programs must include leadership as an essential competency and as such, examine student and faculty perceptions and explore relevant faculty and curriculum development changes. Researchers may also consider the development of assessment tools that determine criteria for demonstrating leadership competence and the translation of leadership skills from the classroom to the clinical setting. In both the academic and clinical settings, studies can further explore the application of a leadership competency framework, such as the LCF-PT, to guide leadership development efforts. The impact of self-leadership training programs on interprofessional team effectiveness, including the areas of communication, collaboration, and patient outcomes, is necessary to examine in the clinical setting. Studies may also consider the need for demonstrated self-leadership when engaging in advocacy efforts, particularly at the organizational and societal levels. Conclusion Physical therapist clinicians perceive self-leadership capacity as essential to developing expertise, pursuing professional growth, discovering and amplifying voice, and demonstrating advocacy. Developing self-leadership in physical therapist clinicians impacts individual performance and interprofessional team interactions, and ultimately leads to improved patient outcomes and quality of care. 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(2022). https://world.physio/ SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 83 Table 1 Participant Characteristics Identification Code Age Years as Licensed Physical Therapist Geographic Region Clinical Practice Setting 0017 0018 0019 0020 0021 0022 0023 0024 0025 0026 0027 35 43 42 33 27 28 46 30 36 33 62 9 18 19 9 2 4 17 6 12 5 39 Mid-Atlantic Northeast Northeast Mid-Atlantic Midwest Southeast Southeast Pacific Northwest Texas Pacific Northwest Pacific Northwest Pediatrics Acute Hospital Acute Hospital Pediatrics Outpatient Orthopedics Outpatient Orthopedics Outpatient Orthopedics Outpatient, Hospital-based Inpatient Rehabilitation Outpatient, Hospital-based Inpatient Rehabilitation SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS Figure 1 Visual Representation of Themes and Sub-Themes 84 SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 85 Appendix A Study RecruitmentEmail Subject Line: Self-Leadership and Physical Therapy--Study Participants Needed Dear [NAME], I am conducting a research study exploring physical therapist clinicians perceived value of selfleadership (ability to lead oneself) in their clinical practice and interactions with peers and interprofessional team members. Self-leadership is a critical component of leadership and is linked to improved individual performance, team effectiveness, and organizational outcomes in healthcare. Participants must meet the following eligibility criteria: Inclusion criteria: Licensed physical therapist in the United States Currently practicing as a clinician for a minimum of 35 hours/week in a clinical practice setting Currently practicing as a clinician in a clinical practice setting for at least two years Exclusion Criteria: Holds a formal management/leadership role/position in which time practicing in patient care is less than 50% of workload Serves as an owner of the clinical practice in which they provide patient care Unable to comprehend and speak English fluently Participation will take 1-2 hours total and includes the completion of an online virtual interview. There are no anticipated risks or discomforts for participants and participation is voluntary. Upon completion of the interview, participants will receive a $15 Target gift card. This study is being completed as part of my dissertation research as a Doctor of Health Science student at the University of Indianapolis. Please see the attached document for additional study information. If you are interested in participating or have any questions, please contact me at dharrison@uindy.edu. Thank You, Diana Diana A. Harrison, PT, DPT, PCS This research project has been approved by the University of Indianapolis Institutional Review Board (IRB). Approval date 1/20/2023; Approval number 01785. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 86 Appendix B Study RecruitmentSocial Media Attention Physical Therapists: Lend your voice and perspective on leadership! Self-leadership, or leading oneself, is a critical component of leadership and is linked to improved individual performance, team effectiveness, and organizational outcomes in the healthcare setting. A University of Indianapolis research study is exploring physical therapist clinicians perceived value of self-leadership in their clinical practice and interactions with peers and interprofessional team members. Participants must meet the following inclusion criteria: Licensed physical therapist in the United States Currently practicing as a clinician for a minimum of 35 hours/week in a clinical practice setting Currently practicing as a clinician in a clinical practice setting for at least two years Participation will take 1-2 hours total and includes the completion of an online virtual interview. There are no anticipated risks or discomforts for participants and participation is voluntary. Additional study information is available here. Upon completion of the interview, participants will receive a $15 Target gift card. If you are interested in participating or have any questions, please contact Diana Harrison at dharrison@uindy.edu. Thank you! Diana Diana A. Harrison, PT, DPT, PCS This research project has been approved by the University of Indianapolis Institutional Review Board (IRB). Approval date 1/20/2023; Approval number 01785. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 87 Appendix C Study RecruitmentFollow-Up Screener Hello, This is Diana Harrison, the primary researcher for the University of Indianapolis study on selfleadership in physical therapist clinicians. Thank you for your interest in the study. I want to be sure that you meet the eligibility criteria. Can you please confirm your current clinical practice setting? Inclusion criteria: Are you currently a licensed physical therapist in the United States? Are you currently practicing as a clinician for a minimum of 35 hours/week in a clinical practice setting? Are you currently practicing as a clinician in a clinical practice setting for at least two years? Exclusion Criteria: Do you currently hold a formal management/leadership role/position in which time practicing in patient care is less than 50% of workload? Do you currently serve as an owner of the clinical practice in which they provide patient care? Are you unable to comprehend and speak English fluently? Please provide the clinical practice setting that you work in: SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 88 Appendix D Consent to Participate in Research Department of Interprofessional Health & Aging KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS The purpose of this study is to explore self-leadership, or the ability to lead oneself, from the physical therapist clinician perspective. A secondary purpose is to gain a greater understanding of the influence of self-leadership on physical therapy clinicians interactions with peers and interprofessional team members in clinical practice. Consent is being sought for research and participation is voluntary. The participants will meet the following eligibility criteria: Inclusion criteria: Licensed physical therapist in the United States Currently practicing as a clinician for a minimum of 35 hours/week in a clinical practice setting Currently practicing as a clinician in a clinical practice setting for at least two years Exclusion Criteria: Holds a formal management/leadership role/position in which time practicing in patient care is less than 50% of workload Serves as an owner of the clinical practice in which they provide patient care Unable to comprehend and speak English fluently The total expected participation time is approximately 1-1.5 hours in duration. Participants will engage in the completion of an online virtual interview (45-60 minutes) with a researcher. There are no anticipated risks or discomforts for participants. You will not directly benefit from your participation in the research; however, the research results may inform the physical therapy profession regarding self-leadership and leadership development needs. Upon completion of the interview, participants will receive a $15 Target gift card. CONSENT TO PARTICIPATE IN RESEARCH STUDY Exploration of the Perceived Value of Self-Leadership Capacity in Physical Therapist Clinicians Study Principal Investigator (PI): Laura Santurri UIndy Email: santurril@uindy.edu UIndy Telephone: 800-232-8634 Laura Santurri, Ph.D., MPH, CPH from the Department of Interprofessional Health & Aging Studies at the University of Indianapolis (UIndy) is conducting a research study. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 89 Why is this study being done? The purpose of this study is to explore self-leadership from the perspective of physical therapist clinicians. A secondary purpose is to gain a greater understanding of the influence of selfleadership on physical therapy clinicians interactions with interprofessional team members. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Engage in a phone conversation with the primary researcher to confirm that you meet study eligibility criteria and provide an opportunity for you to ask questions about the study. Participate in a virtual recorded interview (45-60 minutes) with the primary researcher with questions that address your perspective of self-leadership in your clinical practice and the influence of self-leadership on your interactions with peers and inteprofessional team members. The interview will also include questions about your demographic information, physical therapy work experience, interprofessional team experience, and leadership development or training experiences. Correspond with the primary researcher through email within 4-6 weeks of your interview to verify the accuracy of the data interpretation. You may also provide additional thoughts, clarifications, or corrections about your personal experiences at this time. How long will I be in the research study? Participation will take a total of approximately 1-1.5 hours including the completion of an online virtual interview. Are there any potential risks or discomforts that I can expect from this study? There are no anticipated risks or discomforts. Are there any potential benefits if I participate? You will not directly benefit from your participation in the research. The results of the research may better inform the physical therapy profession regarding self-leadership and leadership development needs. Will I be paid for participating? You will receive a $15 Target gift card upon completion of the interview. Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences, or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation or teaching materials. Will the data from my study be used in the future for other studies? It is possible that de-identified data from this study could be used for future research or shared with other researchers for use in studies, without additional informed consent. De-identified means that any codes and personal information that could identify you will be removed before the data is shared. What are my rights if I take part in this study? SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 90 You can choose whether you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you, and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and remain in the study. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments or concerns about the research, you can talk to the one of the researchers. Please contact: Diana Harrison, PT, DPT, PCS Email: dharrison@uindy.edu Phone: 484-888-1771 Laura Santurri, Ph.D., MPH, CPH Email: santurril@uindy.edu Phone: 800-232-8634 The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. How do I indicate my informed consent to participate in this study? If you consent to participate in this study, then you affirm that you satisfy inclusion criteria and your consent is voluntary. You do not need to sign this, or any other document to indicate your consent. Completion of the interview indicates that you are willing to participate. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 91 Appendix E Interview Guide Introductory Paragraph Thank you for allowing me to interview you today. My name is Diana Harrison and I am conducting this interview as part of my dissertation research in the Doctor of Health Science program at the University of Indianapolis. As a healthcare professional, I am interested in selfleadership in physical therapist clinicians. I appreciate your willingness to participate and provide your perspective on this topic. The purpose of this study is to explore self-leadership from the physical therapist clinician perspective. In addition, I would like to gain a greater understanding of the influence of selfleadership on physical therapist clinicians interactions with interprofessional team members. You will provide the perspective of a physical therapist clinician. The interview will take approximately 45-90 minutes. The responses you provide are for the purposes of my dissertation research and dissemination. Everything you say will be kept confidential. Your participation is voluntary. You may stop the interview at any time, and if there is a question(s) that you prefer not to answer, let me know. Do you have any questions that I can answer now about the interview process or how the data will be used once the interview is over? As you know, I will be audio and video recording the interview to capture your responses accurately. Is it okay for me to begin the recording now? (Turn on recording) Great, the recording has started. Background Information First, I would like to get some additional background information from you. Name Age Location Years as Licensed Physical Therapist SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 92 Workplace Clinical Practice Setting Leadership Experience (formal, informal) Interprofessional Team Experience Interview Questions 1. Tell me more about your day-to-day experience as a physical therapist. Probe: Tell me about your experience as a physical therapist clinician. 2. Tell me what leadership means to you? Probe: Describe your thoughts on the need for leadership in your current healthcare environment. 3. Tell me what self-leadership means to you. Probe: Tell me in what ways self-leadership impacts your work as a physical therapist clinician. Probe: How do your own self-leadership capabilities impact your clinical work? 4. Take me through an experience in your clinical work when you used self-leadership skills. Probe: What self-leadership skills do you perceive as essential for physical therapist clinicians in their everyday clinical practice? Probe: Please discuss in what ways physical therapist clinicians need to demonstrate self-leadership skills. 5. To help yourself work towards achieving your professional goals, tell me about a time when: a. You intentionally set specific goals b. You rewarded yourself SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 93 c. You self-managed or controlled/disciplined yourself 6. Describe a situation that you participated in that resulted in feelings of increased competence or a greater sense of purpose. Probe: Tell me about an experience that made you feel a greater sense of purpose. 7. Describe a time when your own thoughts impacted your ability to engage effectively as a clinician. Probe: Tell me about an experience where you incorporated practices such as your mindset, self-talk, or self-analysis/reflection to influence your thinking/thought patterns. 8. Discuss your thoughts about the need to use self-leadership skills during interprofessional interactions. Probe: Tell me about a time that you incorporated self-leadership skills into your clinical work with other health professionals. Probe: Tell me about a time that you incorporated self-leadership skills into your clinical work with an interprofessional team. Probe: Describe opportunities that you have to work with other healthcare professionals. 9. Tell me your thoughts about the need for leadership capabilities/abilities to be demonstrated by all clinicians at all levels of clinical practice. Probe: Tell me your thoughts about the need for leadership capabilities/abilities to be demonstrated only by those in positional/formal leadership roles. 10. Describe any formal and informal leadership training that you have participated in related to your professional career. Probe: Did these experiences include interprofessional providers? If so, describe. Probe: Does your institution and/or department provide leadership development opportunities? If so, describe. 11. Describe your understanding of the incorporation of leadership development within academic Doctor of Physical Therapy programs. SELF-LEADERSHIP AND PHYSICAL THERAPIST CLINICIANS 94 Probe: Are you aware of the discipline-specific leadership competency frameworks developed within the physical therapy profession? If so, describe your understanding. Wrap-Up 12. Is there anything you anticipated sharing today, but didnt have a chance to say? 13. Is there anything else you would like to share on this topic? Thank you for taking the time to talk with me today. As a reminder, I will be in touch with you within 4-6 weeks with a summary of your interview so that you can verify the accuracy of my interpretation. If you have any questions regarding the study or data collected, please contact me at dharrison@uindy.edu. ...
- Creator:
- Harrison, Diana
- Type:
- Dissertation
18. College Students’ Perception of Personal Interoceptive Awareness Regarding Stress and Coping
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- ... College Students Perception of Personal Interoceptive Awareness Regarding Stress and Coping Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Stephanie L. Phares, MOT, OTR/L Copyright December 6, 2023 By: Stephanie L. Phares, MOT, OTR/L All rights reserved Approved by: Jennifer Fogo Burhenn, PhD, OTR Committee Chair ______________________________ Stephanie Kelly, PT, PhD Committee Member ______________________________ Kelly Mahler, OTD, OTR/L Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS College Students Perception of Personal Interoceptive Awareness Regarding Stress and Coping Stephanie Phares Department of Interprofessional Health and Aging Studies, University of Indianapolis 1 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 2 Abstract Objective: College students experience stress due to numerous life transitions and changes between ages 18 and 24, in addition to the rise of mental health diagnoses for this age group. Coping with stress requires an individual to complete internal and external appraisals and respond accordingly. Interoceptive awareness (IA) is part of the internal appraisal process. Understanding the IA of college students may help to improve coping skills within this population. Method: Eight participants from a mid-sized, private, Midwestern university participated in a semi-structured interview regarding their lived experience with stress, coping, and IA. Utilizing interpretive phenomenological analysis, two primary themes and several subthemes emerged. Results: Theme one, IA and experiences of stress, contained sub-themes relating to IA:1) the physiological effects of stress, 2) the effects of stress on eating behaviors and levels of arousal, 3) the interpretation and the impact of stress on daily life, and 4) ways participants know they are no longer experiencing stress. Theme two, coping strategies, covers helpful and not helpful means of managing stress. Conclusion: After education on IA, the participants discussed more bodily sensations in relation to stress. The researcher suggests a follow-up survey may provide data on whether or not education on IA affected the awareness of stress and coping strategies of the participants. Education on IA, in general, may improve how individuals understand their bodily signals. Learning to interpret personal IA appropriately can improve stress management, coping strategies, social participation, emotional regulation, and academic performance. Keywords: interoception, interoceptive awareness, emotional regulation, coping INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 3 Acknowledgements I am thankful for the lessons I have learned, the organizational skills I picked up along the way, and the beautiful people who helped me reach my goal. Without each of them, I know I would not have made it this far! First, I would like to thank the faculty and staff at the University of Indianapolis who helped me shape my dissertation topic. Dr. Santurri, Dr. Borrero, and Dr. Stith all assisted me in exploring and then narrowing my topic into something manageable. My dissertation committee members helped me to stay on target and be realistic about this process. I am grateful to Dr. Jennifer Fogo Burhenn, my committee chair. She talked me through the process, answering phone calls and texts and helping me organize my scattered thoughts. Dr. Stephanie Kelly guided me through navigating the data and deciding what was genuinely relevant to the research. Finally, I could not have asked for a more qualified content expert. Without the breadth of research and advocacy Dr. Kelly Mahler has dedicated her career, I may not have been aware of interoceptive awareness's importance in our lives. Dr. Mahler was kind, patient, and encouraging throughout the entire process. I was overjoyed she entertained meeting with me, let alone agreeing to be my content expert! The guidance and feedback of my committee helped shape the research study into something I really enjoyed completing. My fellow classmates helped me maintain my sanity throughout this process as well. I am grateful to all of my group mates for having such dedication and focus on our work. I looked forward to getting on virtual meetings with them. It made me feel connected and not so alone in this process. However, I would like to give a special thanks to Elizabeth Harvey and Earlene Masi. Our weekly meetings are what got me through Statistics and through the program. The love and support these women have given me is something for which I am truly grateful. I am thankful we still connect out of enjoyment rather than to complete an assignment. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 4 Most importantly, I would like to thank my family. You kept me sane and grounded. Paul, you have taken the lions share of responsibility and work these last three and a half years. I am so thankful for you. You are a loving, encouraging, and supportive partner. I seriously would not have made it this far without you. Zee and Luke, your humor helped keep things in perspective for me. We will be joking about IBM SPSS for many years to come!!! Most importantly, your understanding of my going back to school helped our household run smoothly. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 5 Table of Contents Problem Statement ...................................................................................................................... 9 Purpose Statement ....................................................................................................................... 9 Research Questions ................................................................................................................... 10 Significance of the Study .......................................................................................................... 10 Definition of Terms ................................................................................................................... 10 Literature Review.......................................................................................................................... 11 College Students and Mental Health ......................................................................................... 12 Stress and Coping ...................................................................................................................... 13 Sensory Awareness, Interoception, and Emotional Regulation ................................................ 14 Mental Health Supports for Undergraduate Student Population............................................... 16 Current Services Available on College Campuses ................................................................ 17 Occupational Therapy as a Support to College Students ...................................................... 18 Method .......................................................................................................................................... 20 Study Design ............................................................................................................................. 20 Participants ................................................................................................................................ 20 Setting........................................................................................................................................ 21 Procedures ................................................................................................................................. 21 Sampling and Recruitment .................................................................................................... 21 Informed Consent .................................................................................................................. 22 Data Collection ...................................................................................................................... 22 Data Management & Analysis ............................................................................................... 23 Rigor & Trustworthiness ........................................................................................................... 25 Results ........................................................................................................................................... 26 Overview of Findings ................................................................................................................ 27 Interoceptive Awareness and Experiences of Stress ................................................................. 29 The Physiological Sensations Related to the Experience of Stress ....................................... 31 Impact of Stress on Appetite, Eating Behaviors, and Levels of Arousal .............................. 31 Experience of Stress and the Impact of Stress on Daily Life ................................................ 36 Interoceptive Awareness When No Longer Experiencing Stress .......................................... 39 Coping Strategies ...................................................................................................................... 41 Helpful Coping Strategies ..................................................................................................... 41 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 6 Not Helpful Coping Strategies .............................................................................................. 42 Discussion ..................................................................................................................................... 44 Personal Interoceptive Awareness When Experiencing Stress ............................................. 45 Role of Personal Interoceptive Awareness in Preferred Coping Strategies .......................... 48 Connecting IA to Undergraduate College Students Lived Experience with Stress ............. 51 Limitations ................................................................................................................................ 53 Real World Implications ........................................................................................................... 53 Future Research ......................................................................................................................... 54 Conclusion .................................................................................................................................... 55 Researchers Self-Reflection Statement ....................................................................................... 55 Human Subjects Statement........................................................................................................ 57 References ..................................................................................................................................... 58 Tables ............................................................................................................................................ 67 Table 1 ....................................................................................................................................... 67 Demographic Information on Participants ............................................................................ 67 Table 2 ....................................................................................................................................... 68 Sample of Themes Emerging from the College Students Perceptions of Personal Interoceptive Awareness Regarding Stress and Coping Interviews ...................................... 68 Figures........................................................................................................................................... 73 Figure 1 ..................................................................................................................................... 73 Interoceptive Awareness in Regards to Stress and Coping ................................................... 73 Appendices .................................................................................................................................... 74 Appendix A ................................................................................................................................... 74 Informed Consent Document for Research Study Participation ................................................... 74 Appendix B ................................................................................................................................... 79 Recruitment Flyer ......................................................................................................................... 79 Appendix C ................................................................................................................................... 80 Information Sheet.......................................................................................................................... 80 Appendix D ................................................................................................................................... 81 Google Form ................................................................................................................................. 81 Appendix E ................................................................................................................................... 82 Interview Guide ......................................................................................................................... 82 Interview Guide Questions ........................................................................................................ 83 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 7 Appendix F.................................................................................................................................... 85 Interview Descriptive Summaries ................................................................................................. 85 A ................................................................................................................................................ 85 B ................................................................................................................................................ 87 C ................................................................................................................................................ 89 D ................................................................................................................................................ 91 E ................................................................................................................................................ 93 F................................................................................................................................................. 95 G ................................................................................................................................................ 97 H ................................................................................................................................................ 99 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 8 College Students Perception of Personal IA Regarding Stress and Coping By age 24, up to 75% of people will experience a mental health condition (National Alliance on Mental Illness [NAMI], 2022). Students with a mental health diagnosis make up one-third of college students with disabilities (Spencer et al., 2018) and 64% of these students are likely to leave college without graduating (Gruttadaro & Crudo, 2012). Mental health affects mood, emotions, thinking patterns (Spencer et al., 2018), sensory processing (Bailliard & Whigham, 2017), and interoception (Critchley & Garfinkel, 2017; Khalsa et al., 2018). Interoceptive awareness (IA) provides information about the physiological state of the body, such as appetite, heart rate, and energy levels, and has evidence linked to emotional processing (Critchley & Garfinkel, 2017; Khalsa et al., 2018; Price & Hooven, 2018; Schmitt & Schoen, 2022; Schuette et al., 2021; Uddin et al., 2017). People who are more aware of their interoceptive signals typically have better emotional regulation (Critchley & Garfinkel, 2017; Price & Hooven, 2018; Schmitt & Schoen, 2022; Schuette et al., 2021). Better emotional regulation improves stress management and coping skills (Price & Hooven, 2018; Schuette et al., 2021; Wethington et al., 2015). College students who struggle to manage their stress can experience disruption in their ability to function daily (Amanvermez et al., 2021; Bistricky et al., 2018). Students may not realize they are under stress until they are overwhelmed and in academic distress, presenting as poor attendance, an inability to maintain an appropriate grade point average, or struggling to complete daily tasks. Services available to college students on campus often include basic counseling, workshops, and educational sessions regarding stress management (Amanvermez et al., 2021). Even with supports in place, many college students are still at risk of experiencing unmanaged stress (Bistricky et al., 2018). While many professions focus on coping skills and INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 9 stress management, an occupational therapist promotes awareness of interoceptive signals within a framework that relates IA to daily life (Khalsa et al., 2018; Schmitt & Schoen, 2022). Exploring the role of interoception awareness in connection with emotional regulation can improve coping skills and stress management (Price & Hooven, 2018), a goal for promoting healthy campuses (American College Health Association [ACHA], 2020). Problem Statement How a student chooses to cope with stress will affect their behaviors, emotions, relationships, physical well-being, and academic endeavors (Boke et al., 2019). Prior research has shown the link between IA and emotional regulation (Price & Hooven, 2018; Schmitt & Schoen, 2022). Consideration of the student stress experience is key to understanding their stress profile and subsequent treatment strategies (Boke et al., 2019). Without addressing IA, students may not realize they are under stress until they are overwhelmed and in academic distress, presenting as poor attendance, an inability to maintain an appropriate grade point average, or struggling to complete daily tasks. Current research addressing college students lived experience with stress does not explore the relationships between IA, stress management, and coping (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Rodriguez & Provident, 2018; Sapadin & Hollander, 2021; Shi, 2019; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). An opportunity exists to understand how IA influences stress and coping abilities in college students. Purpose Statement This interpretive phenomenological study aims to understand whether undergraduate college students aged 18-24 who live on campus use IA to identify when they experience stress and engage in chosen coping strategies. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 10 Research Questions 1. What is the personal IA of undergraduate college students aged 18-24 when experiencing stress? a. How do undergraduate college students interpret their personal physiological interoceptive sensations when experiencing stress? b. What is the undergraduate college students perception of personal physiological interoceptive signals when experiencing stress? 2. What role does personal IA play when engaging in preferred coping strategies in undergraduate college students aged 18-24? a. How does personal IA inform undergraduate college students when choosing coping strategies? b. How does personal IA affect continued engagement with preferred coping strategies to manage stress? Significance of the Study By understanding students' perspectives on personal IA with stress and coping, college campuses can explore integrating IA into mental health interventions. Studying the link between IA and stress management in college students may have an impact on overall student wellness, academic performance, and coping strategies. Additionally, occupational therapy practitioners may expand services on college campuses to address students interoceptive needs. Thus improving college students stress management and overall quality of life. Definition of Terms INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 11 Emotion(al) Regulation: The ability to create an appropriate emotional response to a situation based on internal cues and external demands or circumstances (Price & Hooven, 2018). Interoception: How the brain senses, receives, understands, and categorizes the physiological signals it receives from the body, conscious and unconsciously, then interprets them into an emotional state or feeling (Khalsa et al., 2018; Quigley et al., 2021; Uddin et al., 2017). Detection of changes comes from sensory receptors on the internal organs (American Occupational Therapy Association [AOTA], 2020). Interoceptive awareness (IA): The ability to become consciously aware of the interoception signals from the body and integrate those signals with cognition and emotional responses (Price & Hooven, 2018). Literature Review Mental health issues can negatively influence college students' academic success (Amanvermez et al., 2021; Bke et al., 2019; Rodriguez & Provident, 2018; Straud & McNaughton-Cassill, 2019). Learning what factors contribute to stress externally and internally can help students manage stress and cope appropriately. External factors include deadlines, noisy study areas, and annoying roommates. Internal factors include feeling cold, tired, and hungry, also known as interoception (Critchley & Garfinkel, 2017; Khalsa et al., 2017). For example, a person who is aware of being cold or hungry will seek heat or food respectively when they understand those signals from the body (Paulas & Stewart, 2014). IA gives a person the ability to acknowledge those bodily signals, discern the signals meaning, and manage emotions accordingly (Schuette et al., 2021). A person with IA may notice a racing heartbeat with increased anxiety and explore ways to decrease their anxiety (Schuette et al. 2021). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 12 Misinterpreting or not noticing the bodys cues is common, leading to greater stress levels and poor emotional regulation (Schuette et al., 2021). The ability to regulate emotions leads to better executive functioning skills, social skills, and problem-solving skills (Pinna & Edwards, 2020). Students have access to counseling centers but do not always seek help when needed (Amanvermez et al., 2021; Gruttadaro & Crudo, 2012; Pedrelli et al., 2015; Shi, 2019). Understanding how undergraduate students experience and perceive stress, using IA, may improve services available on campus to ensure academic success. This literature review focuses on the mental health status of undergraduate college students, the connections between interoception, emotional regulation, stress management, and coping, current trends in services available on campus, and the role occupational therapy can play on college campuses. College Students and Mental Health The typical age for traditional college students is 18 to 24 (The Hamilton Project, 2017). Most people with a mental health diagnosis will experience onset before age 25 (NAMI, 2022; Pedrelli et al., 2015). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-5) (American Psychiatry Association [APA], 2013), common diagnoses within the college age population include attention-deficit hyperactivity disorder (ADHD), bipolar disorder, autism spectrum disorder (ASD), learning disabilities (LD), eating disorders (ED), depression, and anxiety disorders (Pedrelli et al., 2019; Schindler, 2019; Yzer & Gilasevitch, 2019). Anxiety and depression are the most prevalent among young adults (Bke et al., 2019; Pedrelli et al., 2015; Shi, 2019; Yzer & Gilasevitch, 2019). Stress is rising among college students, which can lead to difficulty in maintaining daily functioning when living independently (Bistricky et al., 2018). Skills required to live independently include money management, laundry, meal preparation, and school-life balance INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 13 (DAmarco et al., 2018). Schindler (2019) reported that success in college requires problemsolving skills, organizational skills, concentration skills, and judgment, in addition to having personal awareness when setting goals and advocating for self. According to numerous studies, the most common stressors within this population include living independently for the first time, navigating roommates and serious relationships, working, managing bills, choosing a career path, and maintaining satisfactory academic standing (Amanvermez et al., 2021; Bistricky et al., 2018; Pedrelli et al., 2015; Schindler, 2019; Shi, 2019). Living with extreme levels of stress or a mental health diagnosis makes it even more difficult to function in these capacities (Schindler, 2019; Yzer & Gilasevitch, 2019). Good performance in higher education requires students to be disciplined and responsible for maintaining attendance. College classes often do not meet daily, schedules can have significant breaks, and assignments require time management skills to meet deadlines (Schindler, 2019). Numerous studies credit the stress students experience in college as a source of low academic performance, relational issues, and contributes to increased college dropout rates (Amanvermez et al., 2021; Bke et al., 2019; Rodriguez & Provident, 2018; Schindler, 2019; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). Understanding the importance of stress management and effective coping strategies is key to academic success (Rodriguez & Provident, 2018). Stress and Coping According to the World Health Organization (WHO, 2021), stress is how the body responds to something physical, emotional, or psychological that requires action or attention from the person. College students who do not manage their stress effectively are more likely to develop depression, anxiety, substance use, and panic attacks (Bke et al., 2019; Shi, 2019; Yzer INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 14 & Gilasevitch, 2019). Numerous studies have referenced the seminal research of Lazarus and Folkman (1984), stating managing stress and coping relies on a person's ability to understand the external demands of a situation along with possessing the internal capacity and resources to respond (Bke et al., 2019; Folkman et al., 1986; Lewis-Kipkulei et al., 2021; Straud & McNaughton-Cassill, 2019; Wethington et al., 2015). Identifying a stressor and possessing the ability to cope is a continual undertaking necessary for survival (Folkman et al., 1986). The process of coping requires a person to appraise the situation, maintain emotional regulation, and sustain efforts to achieve the desired outcomes (Straud & McNaughton-Cassill, 2019; Wethington et al., 2015). Successful coping requires a person to have an awareness of internal and external input, and then respond accordingly (Bke et al., 2019; Lewis-Kipkulei et al., 2021). A person uses external appraisal to examine the environment and demands of the situation or task (Bke et al., 2019; Folkman et al., 1986; Lewis-Kipkulei et al., 2021; Straud & McNaughton-Cassill, 2019; Wethington et al., 2015). Internal appraisal requires a person to understand their bodily sensations, emotional state, and coping strategies available (Bke et al., 2019; Folkman et al., 1986). Seeking information, problem solving, avoidance, denial, revising goals, and utilizing support systems are common forms of coping (Wethington et al., 2015). Personal awareness of an emotional state requires a person to understand their physiological reaction to the stressor and interpret it by their response to the stressor (Critchley & Garfinkel, 2017). In addition to understanding when a situation is stressful, a person must also interpret internal bodily sensations and sensory input, which can affect stress levels regardless of the persons awareness of them. Sensory Awareness, Interoception, and Emotional Regulation INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 15 A leading pioneer in occupational therapy, A. Jean Ayers (1979), developed the sensory integration theory to describe how the brain interprets sensory input from the environment and the body. Over time, sensory processing and modulation have been included to expand the concept of sensory experiences. Sensory processing refers to how information like touch, sight, taste, smell, and sound are processed, and sensory modulation refers to how the person adapts and responds to that information (Craswell et al., 2020). People have individual sensory preferences and thresholds, which influence mood and emotional expression, activity and environmental setup preferences, and overall daily functioning (Craswell et al., 2020; Dunn, 2001; Metz et al., 2019). Some researchers noted that people who experience depression or anxiety disorders demonstrated increased sensory processing difficulties, thus affecting their ability to function in daily life (Billiard, 2015; Metz et al., 2019). Further sensory experience research revealed numerous studies referring to interoception as the awareness of bodily sensations and physiological needs, allowing for appropriate appraisal and response to that input, or IA (Adolfi et al., 2017; Arora et al., 2020; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al., 2020; Khalsa et al., 2018; Pinna & Edwards, 2020; Price & Hooven, 2018; Schutte et al., 2021; Uddin et al., 2017). These bodily sensations and physiological needs refer to the information received from areas such as the heart, gut, bowels, skin, and lungs, resulting in experiences including pain, hunger, and changes in heart rate (Critchley & Garfinkel, 2017; Khalsa et al., 2017; Uddin et al., 2017). These same findings connect interoception to emotional awareness and the outward expression of emotions, or emotional regulation (Adolfi et al., 2017; Arora et al., 2020; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al., 2020; Khalsa et al., 2018; Pinna & Edwards, 2020; Price & Hooven, 2018; Schuette et al., 2021; Uddin et al., 2017). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 16 IA requires the brain to evaluate the body's sensations (Craig, 2002) and interpret those sensations into an emotional response to stressors (Price & Hooven, 2018). The process requires the ability to accurately detect, attend to, and interpret interoceptive cues with discernment, insight, and awareness of the sensitivity or intensiveness of the signal (Khalsa et al., 2018). Successful emotional regulation requires the person to be aware of and manage interoceptive input from the body (Adolfi et al., 2017; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al., 2020; Khalsa et al., 2018; Pinna & Edwards, 2020; Price & Hooven, 2018; Schuette et al., 2021; Uddin et al., 2017). Interoception is connected to the autonomic nervous system (ANS) and the expression of emotion, as demonstrated by an emotional and physiological reaction to a situation such as anger with a red face, racing pulse, and flushed skin (Pinna & Edwards, 2020). Other physiological sensations related to IA include hunger (Stevenson et al., 2023) and levels of arousal related to the sensation of being tired (Arora et al., 2020). Poor IA, either heightened or dulled awareness, is linked to the diagnoses of schizophrenia, depression, anxiety, eating disorders, post-traumatic stress disorder, and chronic pain disorders (Bonaz et al., 2021; Khalsa et al., 2017; Nord & Garfinkel, 2022). While the authors agree more research is necessary, poor IA can also directly affect sleep, eating habits, substance use, and nonsuicidal self-harm (Arora et al., 2020; Paulas & Stewart, 2014; Stevenson et al., 2023; Young et al., 2021). A person who can use emotional regulation and coping strategies will successfully appraise the situation and respond efficiently (Pinna & Edwards, 2020; Price & Hooven, 2018). Thus, successful stress management and coping strategies hinge on being aware of and managing internal appraisals and IA. Mental Health Supports for Undergraduate Student Population INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 17 The American College Health Association (ACHA, 2020) created the Healthy Campus Framework to provide recommendations for campus environments that support all students' physical and mental health. Researchers report a shortfall in studies that examine the students perceptions and understanding of stress and coping strategies (Amanvermez et al., 2021; Shi, 2019; Yzer & & Gilasevitch, 2019). Shi (2019) reported that 28% of college students responding to a stress management survey indicated they felt unable to manage their stress. Moreover, many of those respondents reported being aware of stress management techniques but could still benefit from actively engaging in stress reduction strategies (Shi, 2019). Shi (2019) noted that students with awareness of the risks of stress engaged in more information seeking behaviors to manage their stress. Amanvermez et al. (2021) acknowledged that while college students benefitted from evidence-based stress management programs, universities needed to address barriers to seeking help among the student body. Sapadin & Hollander (2021) reported a need for early intervention services to decrease the demand for crisis services on college campuses. The authors suggested early intervention strategies promote improved emotional regulation for healthier coping strategies among college students (Sapadin & Hollander, 2021). Current Services Available on College Campuses Many colleges and universities have counseling services for students to access for support, counseling, or treatment for a mental health diagnosis (Amanvermez et al., 2021). Most services focus on cognitive interventions and health behaviors to address stress management (Amanvermez et al., 2021; Bistricky et al., 2018). College counseling services report a growing number of students seeking counseling or services provided by the university (Mazurek Melnyk et al., 2016; Sapadin & Hollander, 2021; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). Sapadin and Hollander (2021) reported an increase in the number of students INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 18 seeking crisis services since 2015, requiring university counseling services to spend more time completing crisis assessments, making referrals for other services, and directly admitting students to hospital services. The authors noted that responding to crises requires counselors to cancel scheduled appointments; further disrupting student services (Sapadin & Hollander, 2021). Counseling centers often feel overwhelmed and ill equipped to assist students with these growing demands (Mazurek Melnyk et al., 2016; Sapadin & Hollander, 2021; Straud & McNaughtonCassill, 2019; Yzer & Gilasevitch, 2019). Even though the number of college students seeking counseling services is growing, only a fraction of the students who could benefit utilize the available services (Amanverez et al., 2021; Gruttadaro & Crudo, 2012; Pedrelli et al., 2015; Shi, 2019). Gruttadaro and Crudo (2012) conducted a study focusing on college students and mental health and discovered that many college students who could have accessed their university counseling services did not. Students who left college reported being unaware of the services offered or did not think they needed the services (Amanvermez et al., 2021; Gruttadaro & Crudo, 2012). Some of the reasons students did not utilize services were a lack of information about what services were available, negative beliefs about seeking treatment, and a belief in the ability to manage the stress themselves (Amanvermez et al., 2021; Pedrelli et al., 2015; Shi, 2019). Increasing the availability of services and information leads to an increase in the number of students accessing support services provided by the university and counseling centers (Amanvermez et al., 2021; Gruttadaro & Crudo, 2012; Pedrelli et al., 2015; Shi, 2019). Occupational Therapy as a Support to College Students Occupational therapy (OT) practitioners have a long history of addressing mental health to facilitate active and full lives (AOTA, 2016). The occupational therapy scope of practice INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 19 focuses on a persons health, well-being, participation, and engagement in desired occupations (AOTA, 2020). Occupational therapy practitioners provide a variety of skills and occupationbased interventions to promote success in daily life (AOTA, 2020). Currently, occupational therapy practitioners who work on a college campus assist students with social interactions and life balance (Spencer et al., 2018). OTs assist with identifying academic skills necessary for success with the student. Assistance with skill acquisition may present as connecting a student to support services, promoting self-advocacy, providing assistance with identifying appropriate accommodations, and creating healthy habits and routines (Spencer et al., 2018). Another possible role for occupational therapy practitioners on college campuses is to bring awareness to interoceptive signals of college students while participating in occupations. College students engage in the occupations of health management, work, school, leisure, and social participation (AOTA, 2020). The Occupational Therapy Practice Framework: Domain and Process (4th Ed.) (AOTA, 2020) states managing emotions, expressing needs, and utilizing coping strategies are key factors to the occupation of health management. Other ways a person engages in the occupation of health management include self-care tasks like physical activity, nutrition management, and sexual health (AOTA, 2020). Appropriate health management allows for improved performance in the other roles college students occupy. Addressing student body mental health leads to a healthy campus (ACHA, 2020). Increasing general outreach and awareness of mental health services across the campus, not just for those who need it, can help reduce stigma and help students be more proactive in their care (Sapadin & Hollander, 2021). Stress management programs benefit students regardless of their levels of stress (Amanvermez et al., 2021). Gaining an understanding of how college students perceive IA as it relates to stress and coping can help improve stress management programs on INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 20 college campuses. Occupational therapy practitioners bring a wealth of knowledge and skills to the college population that can ease the role counseling centers play, contributing to a healthy campus community (ACHA, 2020; Spencer et al., 2018). Improving student stress management leads to improved occupational performance and participation, a benefit for the entire campus community. Method Study Design This interpretive phenomenological study seeks to understand and find shared meaning of college students perception of personal IA as it relates to experiencing stress and choosing coping strategies among undergraduate college students. Interpretive phenomenological research focuses on the lived experiences of a homogenous group with the probability of having a shared perspective of a phenomenon (Larkin et al., 2019). The collaboration between the researcher and participants allows for an exploration of the phenomenon on a deeper level (Smith & Fieldsend, 2021). The participant's descriptions of their awareness of personal interoception signals with stress and coping will provide an overall understanding of the phenomenon among college students aged 18-24 (Phillips-Pula et al., 2011). Institutional Review Board (IRB) permission granted before conducting any research study activity. Participants The inclusion criteria for this study were any residential undergraduate student aged 1824 years old. Exclusion criteria were students who did not speak or read English, as all study materials were in English. Any students living at home or off campus were also excluded due to familiar household schedules prompting them to eat or sleep. The typical age range for students INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 21 attending a four-year university or college is 18-24 (The Hamilton Project, 2017). Therefore, participants outside that age range are outliers and excluded from this research study. Setting The setting is a private, mid-sized Midwestern university that offers counseling services on campus. Procedures Sampling and Recruitment Purposeful homogenous sampling (Smith & Fieldsend, 2021) and snowball sampling (Smith et al., 2009) allowed the researcher to gather information to answer the research questions in a rich environment (Smith et al., 2009). A small sample size of eight students allowed the researcher to spend time detailing the richness of the data collected (Smith & Fieldsend, 2021). Participants were chosen based on demographic information to ensure a broad representation of the population (Smith & Fieldsend, 2021). The representation of the population was able to provide information on the convergence and divergence patterns that arise within the study of the phenomenon (Smith et al., 2009). Recruitment fliers were sent via an online weekly newsletter to the student body by the Associate Vice President for Academic and Student Affairs & Dean of Students, as well as posted in the Wellness and Recreation Center. The flyers described the general research study and contained a link and QR code to a Google Form for further information and participation. The Google Form provided inclusion and exclusion criteria to participate in the study, the estimated length of time for each interview, how the information will be collected and deidentified to protect participant privacy, demographic information, and the researchers email address and office phone number for questions. Demographic information included gender INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 22 identity, age, year in undergraduate studies, ethnicity, degree path, and distance from closest family or caregiver support. The individual completed the Google Form with contact information for the researcher to determine eligibility and schedule an interview. The researcher contacted interested participants via telephone as the form responses were received until the study had ten eligible participants to provide a breadth of data. However, only eight participants responded in the timeframe. Informed Consent The researcher provided interested parties verbal information regarding voluntary participation and withdrawal from the study, the purpose and procedures for the data collection, a confidentiality statement discussing personal privacy throughout the study, permission to record the interview, and any risks or benefits of the study to obtain consent when contacted about the study (Creswell & Poth, 2018). An information sheet containing this information was provided to the participant at the time of the interview. The researcher coded each participant at the time of consent to ensure personal privacy. This code was used to code audio recordings, printed transcripts, and field notes uniquely for each individual. Data Collection Data was collected via semi-structured interviews. Semi-structured interviews gave the researcher the ability to set an agenda for the interview but allowed the participant to expand upon their lived experience as necessary (Smith et al., 2009). Using an interview guide developed from the research on interoception, stress, and coping, the researcher explored stress and coping among residential undergraduate college students. The semi-structured interview guide contained broad, open-ended questions used to understand the perception and meaning placed on stress and coping regarding personal interoception. The sub-questions explored INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 23 whether or not interoception awareness factors into stress levels and chosen coping strategies. Prompts were used as needed to explore more detail and depth in the responses. The interview finished with questions focusing on how a person knows when they are no longer experiencing stress, current stress management, coping techniques, support systems, and if there is anything else they need in terms of helping them manage stress. Finally, the participants had opportunity to share anything else they thought was pertinent to the research. Interviews took place in person, on campus, in a familiar yet quiet location of the students choosing. Interviews lasted 25 to 35 minutes. The researcher used a digital recorder to collect audio from the in-person interviews. The researcher used a notebook to collect field notes for all interviews. Data Management & Analysis The interviews were transcribed via the dictation feature on Microsoft 365 Word. The researcher de-identified the transcripts by issuing the participants code to indicate when the participant is talking. The key that links the participants to their codes was kept in a locked filing cabinet behind a locked office door. Prior to listening to the recordings, the researcher engaged in bracketing to reduce researcher biases regarding personal experiences, beliefs, values, emotions, or thoughts regarding the phenomenon of interoception as it relates to stress and coping (Tufford & Newman, 2010). With the first review of the data, the researcher memoed and dated the bracketing at the top of each transcript to reduce bias. The researcher listened to the recordings numerous times to make manual corrections to the written transcripts to ensure the accuracy of the data. The researcher added observations of body language from the field notes to the transcript. The transcripts were uploaded to Dedoose (9), a password-protected data analysis INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 24 software (Dedoose, 2022), to begin the coding process. The researcher manually printed transcripts to facilitate ease of cross-referencing. All printed or written materials related to the study, such as transcripts, field notes, bracketed observations, and memos related to the interviews, were stored in a locked filing cabinet in the researcher's locked office. De-identified data analysis that occurred electronically was stored on the researchers password-protected computer in a locked office. Each participant had a password-protected electronic file and a hard file in a locked cabinet containing notes, memos, field notes, and report drafts (Groenewald, 2004). The data analysis process followed the steps for interpretive phenomenological analysis (IPA) described by Smith et al. (2009). Before exploring themes in the data analysis, the researcher typed memos in Dedoose (2022) and wrote on the transcripts; indicating bracketing took place before analyzing the data. The data analysis moved from focusing on each participant's individual statements and experiences to broader and more complex themes that focused on how all participants reported experiencing stress and coping (Creswell & Poth, 2018). The IPA process allows for analysis within cases and across cases to fully grasp and comprehend the participants' experience (Smith & Fieldsend, 2021). The researcher began by reading and rereading the data of one participant at a time to make that participant the focus of the analysis, which included occasionally listening to the recording while reading to highlight important or more profound sections of the data (Smith et al., 2009). The second step of IPA is initial noting. Smith et al. (2009) describe noting in the following process. While reading and re-reading the data, the researcher will begin exploratory commenting, noting anything of interest with descriptive, linguistic, and conceptual comments. Descriptive comments will focus on areas that highlight the structure of the participants INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 25 experience and deepen in meaning with each subsequent data review. Linguistic comments will pay attention to the language used, the repetition of phrases or words, and the use of metaphors. The researcher will use conceptual comments to note the participants overarching idea of the phenomenon (Smith et al., 2009). The researcher examined the units of meaning to develop clusters of common themes and significant topics representing coping and stress among each participant (Groenewald, 2004; Smith et al., 2009). These themes combined to create a descriptive summary of the phenomenon of stress and coping for each participant to ensure the essence of their experience is captured (Creswell & Poth, 2018). The researcher sent participants a descriptive summary of themes via password-protected email along with another copy of the transcript for reference. Once verified and corrected for accuracy, the researcher examined at the interviews collectively and identified commonalities and variations among participant experiences (Groenewald, 2004; Smith et al., 2009). The final report contains significant individual statements from the participants regarding their lived experience with stress and coping, the general themes that emerged, and a composite summary explaining the overarching essence of the phenomenon (Creswell & Poth, 2018; Smith et al., 2009). Rigor & Trustworthiness To establish rigor and trustworthiness, the researcher addressed credibility, transferability, dependability, and confirmability throughout the study (Henderson & Rheault, 2004). Purposive sampling, participants being encouraged to share their experiences, and member checking established credibility (Henderson & Rheault, 2004; Marshall & Rossman, 2011). The researcher used a field journal to collect notes on body language, facial expressions, and essential memos to the best of the researchers ability during the interview (Marshall & INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 26 Rossman, 2011). Member checking occurred through participants receiving the descriptive summary of the analysis of themes and interview transcripts, allowing for corrections. Bracketing occurred during data analysis to reduce researcher bias for credibility and confirmability (Henderson & Rheault, 2004). To further ensure credibility and dependability, structural coherence was employed with the interview guide, data analysis, and reporting of the results (Henderson & Rheault, 2004). Additional researchers with experience in qualitative research reviewed the interview guide to certify that the questions asked were pertinent to the research questions. Committee members also reviewed the data analysis to ensure the results accurately reflect the research questions and the participants' lived experiences (Creswell & Poth, 2018). Listening to the interviews repeatedly while making notes addressed dependability and credibility by corroborating themes and generalities in the data analysis to fully depict the phenomenon while reducing bias (Henderson & Rheault, 2004). Demographic information was collected for transferability purposes and not used in a way that identifies the participant. Transferability to other colleges and universities with similar settings and demographics occurred by ensuring the interview guide reflects the research questions and themes in the data analysis are general to coping and stress. Results Eight participants were interviewed for the research. Demographic information included gender identity, age, year in undergraduate study, ethnicity, and degree path (Table 1). Results show that 75% of participants identified as female and 25% as male. Fifty percent of participants were seniors in college, and 25% were freshmen. The remaining 25% of the participants split between sophomore and junior years in undergraduate studies. All participants identified their ethnicity as Caucasian, with one participant also identifying as Latina. Two participants were INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 27 studying communications, one was studying psychology and sociology, and all remaining participants were working towards some form of exercise science or exercise science and human performance degree. Interviews were conducted in person at the campus library, ranging from 25 to 40 minutes. Overview of Findings All interviews began with the interviewer asking the participants about their college experience thus far. The participants could differentiate their challenging and rewarding experiences while acknowledging their personal growth. Many participants formed new friendships and learned how to manage difficult situations. Extracurricular activities provided a space for connections and achieving personal goals. Academics served as a source of growth and stress, with many participants taking 16 credits or more. Participants discussed how they maneuvered through COVID-19 challenges, which they experienced at some point in their college transition. The participants describe multiple factors that contributed to their stress levels. These factors were consistent with those described in the literature and included academic load, managing friendships, and transitioning into college. The personal factors participants noted related to diagnosis, traces of perfectionism, being a high achiever, overloading their schedule, and the feeling of being in a constant state of stress. Four out of the eight participants selfreported mental health diagnoses among the participants were depression, anxiety, and attention deficit hyperactivity disorder (ADHD). Physical health was affected by injuries, tendonitis, and kidney stones. Family, friends, and trusted adults were also consistently identified as sources of support. All of the participants were aware of campus counseling support available to them, yet none of them utilized the services. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 28 To understand how participants perceived and experienced stress, it was essential to get a working definition of stress from each participant. Even though individuals experience stress differently, resoundingly, the participants definitions carried similar themes. The terms worry, anxiety, and overwhelmed surfaced frequently in the interviews. When discussing the feelings of worry, being overwhelmed, or anxiety, all the participants seemed to accept those feelings as a natural part of being a college student. Words such as draining and negative could illustrate the toll stress took in some participants lives. Some participants discussed how stress caused them to overthink or have racing thoughts, causing difficulties in their daily lives. Many of the participants needed time to consider their definition of stress. One participant summed up the definitions of stress by stating: (sighing and thinking) That's the tough one. Gosh. Um. Just like...feeling overwhelmed. I guess, not being able to handle those situations like presented to me? Um, in a more relaxed manner? Which was the time those situations are relaxed and I just overthink. I get stressed...and anxious about it (Participant F). Other participants with mental health diagnoses discussed how dealing with a mental health diagnosis, in addition to stress, led them to a feeling of burnout or a desire to avoid stress altogether. Lastly, many participants described stress's role concerning motivation to complete daily tasks. Two themes emerged from the interviews regarding participants experiences with perceptions of IA regarding stress and coping. Table 2 provides an overview of the themes, theme definitions, and sample quotes supporting the theme. Theme one, interoceptive awareness and experiences of stress, contained many sub-themes relating to IA: 1) the physiological effects of stress, 2) the effects of stress on eating behaviors and levels of arousal, INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 29 3) the interpretation and the impact of stress on daily life, and 4) ways participants know they are no longer experiencing stress. Theme two, coping strategies covers helpful and not helpful means of managing stress. Figure 1 depicts the connection between all the themes. Interoceptive Awareness and Experiences of Stress The central theme of IA and experiences of stress emerged due to the participants descriptions of their experiences with stress. The participants were asked about their perceptions and interpretations of stress in the interview to understand their IA and awareness of stress in their bodies. Perception of stress refers to the physiological IA sensations within the body, such as heart rate, temperature, hunger, tiredness, and toileting needs. IA also requires an individual to adequately interpret those physiological sensations and respond accordingly. The participants mainly described stress as acute physiological sensations and a cognitive experience. Some words used to describe being aware of feeling stressed included feeling heightened stress, feeling overwhelmed, and feeling awkward. Participants reported feeling like they were doing too much, overthinking things, and catastrophizing situations. Together, perception and interpretation of IA became the experience of stress in coding for themes. Participants were asked to describe how they experienced stress in their bodies. While participants could identify bodily sensations related to IA, such as heart rate, an increase in temperature, and a nervous stomach, most were only aware of the term IA after receiving the educational handout (Appendix C). The handout described how IA affects a person, such as social participation, emotional regulation, and bodily sensations concerning stress. Once the participants understood that IA encompassed the sensations of hunger, tiredness, boredom, toileting needs, and mood, they could use a more detailed description of how they experienced stress. Two of the participants were surprised and appeared excited to learn INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 30 about IA. Participant F exclaimed, Whoa, okay! (taking a flyer and looking interested by sitting forward in the chair)," and Participant G stated, I was looking at it, like, (loud exclamation) Oh, these are what this means! Some participants were surprised at the connection between physiological IA and their reactions during stress. Participant H simply stated, Crying. Sleeping. Eating. After reading the handout, the participants understood that IA affected social participation and emotional regulation and could speak to the ways stress impacted their moods. When discussing mood, most participants noted they became more easily annoyed, withdrawn, and irritable with others. Participants described not being able to handle social situations, handle coursework, or focus in class when experiencing stress. Participants would spend less time in social situations with friends or roommates in times of stress. Participant F reported, Oh, little problems start to be, like, way bigger. Participant H stated she asked her roommates to leave her alone. Some participants reported never experiencing a time when they were not feeling stressed, and it was difficult to notice how their bodies felt when no longer stressed. Several participants explained having a baseline of stress that felt constant and integrated into their daily lives. Participant B defined stress from personal experience, "I mean, like, the more technical definition would be, like, undo worry, but I've just been doing stress for a while. So. It's just part of life for me (very matter of fact in tone). The participants frequently described physiological sensations related to heart rate, temperature, hunger, and sleepiness. Sub-themes related to the impact of stress on hunger and arousal levels related to the experience of stress focused on how participants noticed these IA signals when stressed. The participants diverged significantly when describing how stress INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 31 affected hunger and sleep, as well as how they responded to their personal physiological IA regarding stress. The Physiological Sensations Related to the Experience of Stress The following terms were the most used to describe the experience of stress in the body: being alert, increased heart rate, hunger, loss of appetite, restlessness, tension, sore muscles, thirst, tired, tremor, increased startle reflex, physically hot, nervous stomach, lightheaded, sweating, and mood swings. A few participants focused on the physical feelings associated with stress. Participant A was able to identify how she feels nervous, Like...I'll get like butterflies in my stomach...or... like, be sweating or things like that. (moving hands to show emphasis)." Along with sweating, another participant described becoming physically hot (Participant B). A racing or pounding heart was also a descriptor Participant D used to describe her experience: I get really sweaty. Or...I. I feel, like, racing thoughts as well as, like, a...an increased heart rateIt's, for a lack of a better term, like, I can feel my heart kind of pounding, and I'm sweaty, and I'm just kind of, like, jittery. Participant H also noted a racing heart, "My hands will shake...And I have a heart condition (looking serious and bringing hands to heart)So, my heart beats really fast. But like...when I'm stressed...like, my resting heart rate gets faster." Participants A and E noticed restlessness and a need to move. Muscle tension in the neck and back was also noted, I guess I maybe I get a little bit tense, like, my muscles might get a bit tense (Participant C). Impact of Stress on Appetite, Eating Behaviors, and Levels of Arousal The experience of hunger became a source of divergence among participants. Some participants noticed the sensation of hunger more acutely and engaged in stress eating. Others did not notice their hunger sensations at all. The IA of hunger, or lack thereof, impacted the INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 32 eating behaviors of the participants. Some participants connected their IA of hunger to their stress levels and noticed that their IA of hunger returned to normal when they no longer experienced stress. A few of the participants did not correlate their IA experience with hunger to stress at all. Participant C described her experience the following way: Well, definitely...So, it's kind of, like, a hit or miss. Like, sometimes if I'm stressed, I'm hungry. Other times, it's I have no appetite at all. Um, So... I don't really know, like, what's the difference, like, what causes the difference between, but sometimes it's, like, either one of those. Participant H drew attention to her appetite regarding stress, "Um, ah...But I eat a lot (stressing a lot) when I'm stressed." Many discussed eating because they were stressed and not because they were hungry. Participant D summed up her IA of hunger when experiencing stress by making this observation: I would say more, like, not physiological, but more psychological feelings. Like, Oh I'm guilty because I ate something even though I'm not hungry. Like, I couldn't control my psychological, like, appetite instead of actual hunger or drive for hunger. Participants noticed they would feel bad after overeating, using words like guilty or gross. When overeating, participants noticed cravings for certain foods, such as sweet or salty snacks, versus eating healthy foods. Participant C noted: (Smiling and thinking) I guess, they'll just be...like...I'm gonna stress eatIm just gonna eat this box of goldfish, that's my thing sometimes. P1: And does that...so, with the stress eating, do you notice your level of fullness at all or? PC: Yeah, and I usually regret it instantly (smiling and nodding). P1: Okay. So is it just, like, eat...eat and then all of the sudden...? PC: Like, I'll pour myself like a bowl of Goldfish or something and then I'll be, INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 33 like, you really...and then finish it and then go, You really didn't need to eat that. And so, then Im just, like, it's not, like, I just give up. It's not like I'm guilty (stressing the word guilty) of eating, like, feel guilt of eating it. It's just that I'm like, I'm like, you just ate that and you weren't even really hungry. So, like... Participants who overlooked their IA of hunger often required outside cueing from others to eat. Those with family members on campus noticed mood changes and asked participants if they had eaten. Some roommates provided the cues by reminding the participant the cafeteria was closing soon. Participant D went on to discuss how her decreased IA concerning hunger required outside interventions to remind her to eat: Yes, usually, usually, like, when Ive been studying or, like, my roommate is studying, it's usually one of our suitemates that comes into our room and is like, Hey, do you guys want to go to dinner? Like, it's almost time for it to close in the cafeteria or something like that. And we'd be like, Oh, like look at the time, and then Some participants noticed they were hungry at times but not at other times when experiencing stress. Participant H demonstrated the most varied personal experiences with hunger: Yeah, like, I'm starving all the time. Like, theres days...which that's actually really interesting because there's days where I'm, like, I cannot get enough to eat, where, like, I'm (stressing the next few words) constantly starving. So, I wonder if I was stressed out in those days. That's interesting. But yeah, hunger definitely increases. I, like, inhaled six wings, fries, and, like, a whole salmon filet in, like, 30 minutes one day, and I was, like, What is my problem? (looking back at handout) Like, full. Like, what does that mean? P1: Being aware that you're feeling full, like, after you've eaten? PH: Oh, I can't talk on that. I have a lot of stomach problems. So, I will eat two bites of food, and I will INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 34 feel full, and I had to keep forcing myself to eat because I know that my body needs more food. The participants also noted how their moods were affected by overeating or not eating. Some participants became dysregulated after not eating, i.e., stating they were grumpy or hangry, or felt guilt after overeating. Chapter 5 will explore the relationship between IA and emotional regulation more in-depth regarding the literature. Once students understood the full scope of what IA encompassed, the feeling of tiredness appeared in their discussions. However, their IA of tiredness varied among them. Many of the participants noted their sleeping habits were affected by stress. Some participants felt more tired when experiencing stress, while others felt more alert. Participants who noticed they became more alert focused on how this causes feelings of anxiety, wariness, and stress. Participant A focused on the ways stress increased alertness by stating, I definitely feel, like, anxiety. It's, like, take oneumlike, racing heart rate. P1: Thank you forPA: Um, yeahI feel, like, not really tiredness (sounding thoughtful) more like, being awake Participant C stated, I feel like my alertness is actually better when I'm stressed. Ah. And I'm usually not calm. I'm usually pretty, like, I guess I'm maybe I'm a little anxious when I'm stressed and stuff, but Participant G acknowledged the connection between heart rate and feeling more alert, Um. I try to be alert. I'll say one when my heart rates up, I'm usually alert (laughing)." Participant G summed up her experience by stating, I think I'm least stressed when I'm less alert. Many of the participants connected stress to the physical sensation of feeling tired. A few participants connected the IA of feeling tired to studying and boredom. When asked about managing stress, Participant F stated, Um, I kind of sleep (big smile and soft laugh). Participant C described struggles with her sleep cycle: INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 35 Umm, a little bit. I do find myself like more...like, I like to go to bed early, but when I'm stressed, I tend to then stay up later and then, like, I just feel like I become...by the end of the week, if I'm really stressed, I just feel like exhausted and just, like, want to have no motivation to do anything. Sleep also interfered with class attendance, as one participant noted if he did not get 8 hours of sleep, he would miss a class. Participant C stated, I guess I usually just feel pretty tired then. That's the other, like, physical thing is that I just, like, feel like tired by the end of the day." Participant F noticed how being tired affected his focus and attention: I definitely get, like, tired. I will say I noticed. I don't know if this is, like, a physical or like a mental, but, like, if I'm really stressed about something, and I haven't had time to, like, think it through or, like, identify the issues, I'll have a hard time focusing. Participant D spoke on how she tries to manage the tired feelings while studying: Um, I know that I do kind of feel more tired when I am stressed, especially because, like, I associate stress with, like, a lot of studying or exams or anything like that. So, as well as boredom. Like, sometimes I'm just, like, I don't want to study anymore. I've studied for so long. I'm just, like, if I know it, I know it, if I don't, I don't. So I'm just, like, I'm trying to, like, encourage myself as well as, like, friends of mine to take breaks. And be, like, Hey, you deserve something, like, something you enjoy (stressing the word enjoy) after working so hard doing this. So it's kind of, like, a, a give and take almost relationship. Participant G simply expressed how being tired affects focus, (looking at the paper) Tiredness? 100 percent. All the time. I'm always tired. Um. Focus. Especially if I'm tired. One participant observed that sleep is not out of tiredness but out of avoidance, Cause it's just, like, it's not I'm tired, and I wanna go to sleep. It'sI just don't wanna be awake (slight INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 36 shake of the head)" (Participant B). He went on to discuss his desire to sleep when under stress as a means of avoiding the stress: When I get stressed, I shut down (cocking head to the right and slumping in the chair to indicate a tired or defeated posture). P1:Like, going into that like overwhelm (moving hands to indicate a wide space)? PB: Yeah, that's just it. Like, sometimes the solution is, I feel so bad I'm just gonna go to sleep (using a tone that indicates being aware of how bad things are). The participants could identify increased heart rate, nervous stomach, and sweat as the main bodily sensations when experiencing stress. Most participants were not aware of the ways hunger, levels of arousal, and mood related to IA. Not being able to interpret the personal physiological sensations of IA adequately led some participants to have trouble completing their daily activities. Experience of Stress and the Impact of Stress on Daily Life Even though IA relates to physiological sensations, IA requires individuals to notice the physiological sensations and act accordingly. Many participants used terms to describe the outward expression of the perception rather than identifying the physical sensation attached. Common terms to describe their stress were getting inside their head too much, isolating, overthinking, hyper-focus, shutting down, no motivation, and feeling self-conscious. Awareness of mood, such as grumpy or annoyed, also came into the descriptions. Participant A started by saying, "Yeah, and if its likemy mind keeps coming back to it. Like, I can't get it off my mind (slower, lower voice and stressing this point)." Participant C also noticed hyper-focus: INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 37 So when I feel start feeling stressed, I kind of just shut down, and I become very zoned in on, like, the things that I have to accomplish (stressing I have to accomplish) and I don't necessarily take a step back, back to, like, refocus. The effects of stress on mood were noticed, with Participant C getting crabby and Participant E noticing a change in behaviors related to her mood: I kinda just feel a little bit different. Like, I'm usually a very bubbly, talkative kind of, like, person like that (talking with hands and moving upper body in a relaxed way). And so, like, I know when I'm stressed, like, I don't talk as much. I kind of just. I almost, like, sometimes get a little annoyed when people try to, like, converse with me. P1: OKAY. PE: And so it's a lot of just like that social aspect kind of, like, disappears. Motivation. Motivation was an area that participants differentiated. Some participants noticed a lack of motivation while others became more motivated. Participant D made this observation: Um. I think stress, it depends on the situation, at least for me. Like, I know there are people who get stressed, and they sort of, like, shut down and they don't want to do anything or they become demotivated in any way. I can say for a number of situations I've had that as well. But I would say stress is also, like, a motivator for me as well. Participant C also noticed how stress can become a motivator, stating, But I guess, like, on the good side of stress is that...it drives me to...want to achieve something?" Participant E was able to identify how the lack of motivation is a cue to her being stressed: And then um, like, I'll, like, realize right away like that I just have, like, no motivation to do anything. Because again, I'm a very motivated person as well, like, I am very self- INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 38 motivated. And so, for me to, like, have the want to do nothing, that's when it kind of, like, you know it hits. Overall, the participants were able to identify how stress affected them, but they could expand upon their perceptions and interpretations of stress once they received the handout and explanation on IA. While the general experiences of stress did not change, participants were able to go deeper into their understanding and awareness of how stress affected them. Participant E noted, And just, like, everything's like at, like, the highest level it can be (nodding in awareness)." Participant F noted how the awareness contributes to his stress levels, "So, like, if I know that I'm stressed, does it change? Um... I feel like sometimes I get more stressed because I'm stressed, honestly. Participant G described what her IA experience was in relation to her diagnoses: So, so I would, so I think they happen (stressing the word happen), but I don't think I recognize them. I think I underestimate them, like, what you're saying, because I think for me. Especially since I've had, like, a history of anxiety and depression, I feel like these have been just all of these symptoms, I feel like, are just a constant for me. But it's, like, Oh! You know? Like, they happen. It's like, you know, we just gotta live with it. Habits and Routines. Participants discussed the ways stress affected their daily habits and routines. Some participants noticed how their activities of daily living (ADLs) and instrumental activities of daily living (IADLs) would suffer due to stress. Participant G stated, Just trying to take care of myself, like, for me with depression, anxiety, just brushing my teeth was a struggle enough, so just doing that goes back to self-care for me. Brushing my hair. Participants E and H noticed how their laundry became harder to manage when stressed. Participant B described how the stress of not being late to class affects his ADLs: INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 39 Um... Somewhat? I know in, like, in order to not be late...like, I will always leave early so I'm not late. Um, if I have to get up early for, like, a class, I will prioritize getting to class on time rather than, like...ah, like, taking a shower or brushing my teeth. Participant F observed he would miss class due to stress, Oh, I definitely missed class, just due to stress. I did not even go to practice one time just due to stress. The effects of stress on habits and routines can be detrimental to academic performance. Missing classes or not turning in assignments affects grades and overall GPA. The participants were able to identify how college life affected their stress levels and explore how their coping strategies helped or hindered them. Interoceptive Awareness When No Longer Experiencing Stress Participants were asked how they knew they were no longer stressed. Many responses focused on words like relaxed and calm, but specific IA sensations were not always immediately identified. Only a few participants were able to make the connection, such as Participant A, who stated: Like, I don't have that sweating or need to, like, move, and you know, I don't have that racing heart rate. I just feel like, calm (moving hands in a calming gesture). Like, I'm able to focus on things. P1: Yes. Don't need to move.talk about that a little bit more. PA: UmI guess that kind of goes with, like, focus. Like, just able towork on whatever I'm doing or, you knowstill in class or (looking thoughtful). Participant A went on to state, "Yeah, umI thinkjustlike, normallike, I don't notice any of those things. Like, I'm able to sleep at night. Like, yeah, um. Im just more comfortable, I guess, in my body." Participants mainly attributed this feeling of normal to a normal heart rate. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 40 A few participants demonstrated difficulty identifying how they know they no longer feel stressed. The participants could identify feeling calm, without worry, and at ease but not precisely describe how that felt in their bodies. Participant C attempted to describe it the following way: I just feel like, like, a weights been lifted off my shoulders, like, I just feel very, like, calm. P1: What does calm feel like in your body? PC: Ah... (long and thoughtful pause, looking around the room in thought) P1: Or maybe this...oh well, Ill let you think on it. PC: Oh, it kind of...I honestly can't really put into words, like, what it would, what it feels like. Like. Umm... (continuing to look thoughtful). With the assistance of the handout to understand the connection between IA and physiological sensations, some participants could identify when they were no longer stressed. Participants with this awareness reported their IA was easier to understand. Participant C focused specifically on how feeling tired and hungry are experienced differently: Oh, I'd just, I definitely am not really then, tired. Um...like, I, I wanna go do something fun then, usually. And then I guess, like, I'm usually. I know that I'm not, like, stress eating, like. P1: Okay. PC: That's...it's, like, a normal hunger? P1: Yeah. PC: It's, like, Im not that... I'm just gonna sit here and eat this because I'm, like, trying to crank out like a paper. Once participants became more aware of the sensations involved with IA, they could speak deeper into their lived experiences. This transferred into the participants being able to speak on the second theme, which is coping strategies. Coping strategies covers helpful and not helpful means of managing stress. For the purpose of this research study, helpful coping strategies focus on things the participant did that allowed them to relieve stress in a healthy INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 41 way, such as paying attention to their bodily needs, reaching out to others, and engaging in selfcare. Not helpful coping strategies refers to something the participant did to escape or avoid stress that became detrimental to them, such as overeating or oversleeping, substance use, and nonsuicidal self-harm. Coping Strategies The coping strategies participants identified ranged from exploring stress from a topdown perspective to utilizing IA through sensory tools, sleep, and food. Participants noted that using food or sleep can be a healthy form of self-care or a destructive form of escape. All participants identified a support system consisting mainly of family and friends. For many of the participants, their mother was the number one source of support, and they would call her as a means of coping with stress. Helpful Coping Strategies The helpful coping strategies mentioned by the participants focused on support systems, self-care, sensory input, movement, and healthy distraction. Seeking out the support systems emerged as participants calling family members or spending time with friends. Many participants appeared visibly happy when discussing their helpful coping strategies, as demonstrated by smiles and stating the strategy made them feel relaxed. Participant G noted, I will say self-care is something I do. Participant G and Participant H commented in the interviews that self-care can be difficult when depressed. Participants noted that using healthy coping strategies helped them feel more in control or out of their heads when stressed. Participant E demonstrated this while discussing her use of fidgets and spa days to help with stress, stating: (Deep breath while thinking and looking around) Um...with both of them, I think it's kind of feeling just... like, I'm able to control everything (voice going up). Like, especially INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 42 with the fidgets, like, being able to just, like, kind of sit there, like, gets everything out, and then I'm just like, Okay. I can move it at my own pace. Focusing on movement and healthy distraction, many participants sought movement as a way to keep their minds off of the stressors. Television, reading, and music were the most common ways to distract the mind. Yoga, walking, and sports were other common ways to engage in movement. Participant D discussed engaging in many of these activities as a coping strategy, I go to the gym quite often. Um, I like exercising. Mainly. I like lifting more so than cardio, but I do both. Um, I talked to my family. Watch TV sometimes I read. Many of the participants identified therapy as helpful in their stress management. Participant G identified medication and therapy (nodding and sounding grateful) as key to her coping strategies. The discussion on coping strategies demonstrated how the participants were able to identify how some coping strategies can be good in small amounts but damaging if done excessively, as well as how some coping strategies do not work for every person. Not Helpful Coping Strategies While some participants identified many helpful strategies, some participants experienced the opposite. Sleep became a common thread among the interviews as a means of avoidance. Many participants noted they ate as a coping mechanism, not out of the physiological sensation of hunger. Some coping mechanisms that were named as helpful coping strategies by participants, like professional help or relaxation techniques, created the opposite effect for other participants. Some participants reacted negatively to medications and therapy. Participant B remarked, Yes! If I hear (counting down on fingers) yoga, a planner, meditation, or journaling one more time? I swear to God. (sounding exasperated, smiling and shaking head and looking down). Participant F did not find meditation useful for him during high stress. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 43 Other participants remarked that they felt less stress when feeling less alert, seeking coping strategies to reduce their arousal levels. Participant G posited this could be the reason some college students engage in substance use: Drug usage is a thing...that a lot of college students use to escape...a lot of these symptoms that I feel, like, we have constantly. So... P1: What would you, like,...is that part of your routine, or is it? PG: It is, uh, something I engage inEvery now and then... uh...weed (saying weed in a matter-of-fact tone) P1: Okay, I was assuming, but I didn't wanna...like...PG: (smiling and laughing slightly while scrunching up shoulder and face) It feels weird to talk about, you know what I'm saying? (nodding) But yeah, it is something I think a lot of us do just to, like, take away from all of these symptoms that I feel like we do. And also, I think it's a part of escaping the alertness aspect as well. Just recognizing that you're not just thinking out there. Participant H also discussed using substances for coping, Being a 22-year-old, I dabble in drinking. She went on to explain it more: That helps. I mean, like, it's, like... (pausing to think about it) I don't know...I dont know if it helps, but it's just like. You know? Sometimes, you just need a drink (shrugging shoulders). I'm, like, I just need a drink, and then I'm, like, Okay, let's go (snapping fingers then pointing ahead with both arms up and smiling). I just need a break. Like, sometimes I just need a hard mental reset...(pausing to think). A few participants discussed self-harm, explicitly cutting on self or chewing on the skin around the nails. Participant G described it as Umm, okay, so, like, a few years ago. Depression, anxiety, self-harmThat was something I had done. P1: What did you do when you're self-harming? PG: I think it was. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 44 So, I, Ive cut myselfBut I don't remember if it was or not, but chewing on my skin, apparently around my fingernails, is self-harm? And I didn't realize that. I think that was more for me, a habit. The coping strategies participants named mainly focused on taking their minds off the stressor or finding a way to get out of their heads. Many of the participants were unable to specifically identify how they felt or their IA after they engaged in coping strategies, similar to their inability to determine when they were no longer experiencing stress. The primary themes regarding the interoceptive awareness and experiences of stress and coping strategies demonstrated many similarities and differences that highlight the personal experiences of the participants. The participants all reported a similar understanding of what stress was and what events in their college experience contributed to their stress. The participants had some knowledge of what IA was but not the full scope of what IA encompassed. Information on IA provided in the interviews allowed participants to explore their stress experiences more deeply. Coping strategies unanimously included talking to family and friends. Many of the coping strategies directly related to personal IA experiences, but the participants were not always aware of this connection. How college students perceive personal IA regarding stress and coping in conjunction with the literature will be further discussed in the following section. Discussion This interpretive phenomenological study endeavored to understand whether undergraduate college students aged 18-24 who live on campus use IA to identify when they experience stress and engage in chosen coping strategies. The first research question focused on the personal IA of undergraduate college students, looking at how they perceive and interpret INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 45 their personal physiological sensations when experiencing stress. The second research question shifted to exploring personal IA's role when using preferred coping strategies. The summaries of the interviews (Appendix F) revealed how vast the IA experience was for the participants. The researcher provided participants with information on the concept of IA, as no one knew of the term. The content on the handout was based on extensive research on IA conducted by a national expert (Mahler, 2023). Participants could recognize personal physiological sensations of IA after receiving a handout explaining the basis of interoception and IA. The results demonstrated that the information on the handout helped the participants explore physiological IA sensations when experiencing stress and engaging in chosen coping strategies beyond just heart rate and feeling anxious. The participants appeared more thoughtful when discussing their lived experience of stress and their physiological IA. Most participants could differentiate when they experienced stress in their bodies versus no longer feeling stressed. Personal Interoceptive Awareness When Experiencing Stress Craig (2002) explained how the bodys ability to check in with its physiological state is the basis for how humans experience emotions. Craig (2002) also stated that IA allowed the brain to determine emotional states based on what the physical body was experiencing. IA cues come from the cardiovascular, pulmonary, gastrointestinal, genitourinary, nociceptive, chemosensory, osmotic, thermoregulatory, visceral, immune, and autonomic systems (Khalsa et al., 2018, p. 501). Optimal physiological interoceptive awareness allows a person to become aware and process hunger, pain, toileting needs, arousal levels, heart rate, and emotional status (Arora et al., 2021). Emotional regulation relies on the bodys ability to interpret IA and respond appropriately (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). Nord and Garfinkel (2022) INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 46 noted that an individuals ability to perceive and interpret their IA signals accurately affects the emotional response. The brain appraises the signals received from the body and then elicits an emotional response or reaction. The researchers stated that the same IA signal could be experienced very differently among individuals (2022). Schuette et al. (2020) discussed the connection between poor emotional regulation and poor IA. The researchers also noted a correlation between IA and adaptive coping behaviors (2020). Schmitt and Schoen (2022) supported the integration of IA into quality-of-life research by stating interoception was an essential dimension of health. The authors state that adequate IA supports individuals' ability to trust their feelings and promotes a sense of security. Thus, promoting IA enhances an individuals sense of safety and security (2022). An elevated heartbeat, changes in breathing patterns, flushed skin, sweating, and piloerection are all observable interoceptive signs (Khalsa et al., 2018, p. 502). The fact these sensations are observable with a starting and ending point could be why they were the initial physiological sensations reported by the participants associated with stress. Additionally, a normal heartbeat and feeling more at ease were some ways participants could identify no longer feeling stressed. However, the concept of IA expands beyond heart rate to everyday experiences such as hunger, tiredness, pain, toileting needs, focus, and boredom (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020; Schuette et al., 2020; Stevenson et al., 2023). By opening the experience of IA and stress to more than the immediate and observable sensations, participants began to explore their experience of stress and IA on a broader spectrum. The participants began to explore how IA also affected their cognition, focus, emotional regulation, self-care, and social participation when presented with the handout (Mahler, 2023). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 47 The results of this research study indicated that stress affected the participants IA, particularly in hunger and arousal. Stevenson et al. (2023) researched hunger in relation to IA and discovered wide variations in how individuals experience hunger. The researchers noted that the experience of hunger could be from the influence of an outside food that is desirable to eat, a desire or awareness of the need to eat, or the temporal aspect of when to eat (2023). One group of participants in this research study reported not feeling or not noticing hunger when feeling stressed. Many noticed someone else frequently reminded them to eat while studying because they were not taking regular breaks to eat. Not experiencing hunger during times of stress means participants were either not using IA to notice the physical sensations of hunger, internal cues, or they were not aware of the passage of time since last eating, external cues. On the other hand, several participants reported stress eating, or eating when not physically experiencing hunger. Stevenson et al. (2023) determined that the variations in hunger with IA warrant further research to determine what IA cues each individual is attributing to hunger, especially in areas related to uncontrolled eating. Quigley et al. (2021) determined that adequate IA and multisensory integration were necessary for eating. Another sub-theme that emerged from the interviews related to participant arousal levels when experiencing stress. While Arora et al. (2021) acknowledged a need for more research around sleep and IA, the researchers noted connections between poor sleep, overeating, and emotional dysregulation. According to Boke et al. (2019), higher stress rates were directly related to poor sleep. For some individuals, one of the IA signals associated with stress includes increased heart rate, which is also linked to poor sleep (Arora et al., 2021). Many of the participants noticed they felt more alert when experiencing stress, which contributed to poor sleep and feeling anxious. In addition to poor sleep, the participants felt more exhausted and less INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 48 engaged in daily activities. Participants noted that they would miss class or activities due to not sleeping well or feeling tired. This is consistent with students struggling to stay caught up in class. Equally important to understanding how IA connects to the awareness of stress is how IA helps identify when an individual is no longer feeling stressed. The word normal was frequently used when discussing no longer feeling stressed. The participants who understood their perceptions of their personal IA could describe the experience of being no longer stressed. They noted their heart rates decreased, sleep improved, and they would eat because they were hungry, not because they were experiencing stress. Some participants could recognize feeling less restless and could focus in class when not under stress, consistent with research identifying a connection between stress and ability to perform in school (Bistricky et al., 2020; Boke et al., 2019). All participants noted an improvement in emotional regulation when not experiencing stress, consistent with the literature (Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). Being able to describe stress in terms broader than heart rate, flushed skin, and feeling anxious demonstrated how the participants understood how IA affected their lives after the immediate observable sensations. Recognizing their personal stress reactions through IA led participants to discuss how they knew when they were experiencing stress and when they were no longer stressed. Most of the participants identified coping strategies they used to help decrease stress. Although the participants discussed similar coping strategies, not everyone experienced the same outcomes. Individuals seek out coping mechanisms that provide a sense of relief. However, many are not aware of the connection between coping and IA. Role of Personal Interoceptive Awareness in Preferred Coping Strategies INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 49 The coping process requires constant appraisal between internal and external environments to determine if enough resources are available to manage the demands of the situation (Folkman et al., 1986; Straud & McNaughton-Cassill, 2019). Similar to the process of coping, several researchers noted IA requires the constant internal appraisal of bodily sensations to determine the most appropriate emotional state (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al, 2015; Khalsa et al., 2017; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). The body is in a constant process to achieve homeostasis (Arora et al., 2021; Folkman et al., 1986; Khalsa et al., 2018; Spira, 2019). Recognizing IA signals can help determine the necessary interventions to achieve homeostasis (Spira, 2019). Being able to interpret personal IA accurately helps individuals understand what is happening in their bodies and respond accordingly (Schuette et al., 2020). However, the researchers noted IA might not consistently lead to healthy coping strategies (2020). Rodriguez & Provident (2018) conducted a study that provided evidence supporting that college students may not have adequately acquired skills to cope with the stressors they face. The researchers discovered that when college students' awareness of coping strategies increased, their ability to engage in them increased (2018). The more social support and connections an individual can access, the resilience and ability to manage stress increase (Sapadin & Hollander, 2021). Adolfi et al. (2017) reported the link between IA, emotion, and social cognition. In this research, the participants noticed they could engage in more social activities and felt more like themselves after reducing stress. Activities that promote calm inherently reduce heart rate and respirations, two components of IA that are most noticeable (Khalsa et al., 2018). According to Spira (2019), the body and brain will create a map with IA cues to achieve homeostasis. With repeated successes at achieving homeostasis, the brain will use the map to guide future situations (2019). Participants who INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 50 continually returned to helpful coping strategies utilized their IA maps to reduce stress appropriately. Schuette et al. (2020) suggested distraction could also decrease personal IA associated with stress, which affects emotional regulation and the ability to trust IA. Participants in the research study also spoke of ways of coping that were not helpful or harmful to them. Participants reported sleep, social media, or binging a television program became an escape to avoid thinking about the stressors. The participants admitted these coping strategies only worked temporarily and might lead to more stress. Substance use has been a common means of coping with stressors among college students as a means of escape and avoidance (Boke et al., 2019; Pedrelli et al., 2015). Paulas and Stewart (2014) proposed the concept that IA and substance use were connected in that the individual was using the substance to either enhance or decrease their physiological state. The authors discussed how this would be evident in the use of depressants to decrease arousal or stimulants to increase arousal (2014). As previously discussed, the avoidance of stress includes the dulling of the physiological IA signals associated with stress. The decrease of arousal with alcohol also dulls IA (Paulas & Stewart, 2014). Another means of distraction was nonsuicidal self-harm. Young et al. (2021) studied the connection between nonsuicidal self-harm and IA. The researchers proposed the behaviors were due to decreased IA but admit more research is needed to understand the breadth fully. The researchers also reported participants in their study who engaged in nonsuicidal self-harm found tracking their heart rate an uncomfortable experience (2021). Since pain is a component of IA (Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020; Schuette et al., 2021), the participants engaging in nonsuicidal self-harm may be using the signal of pain to distract from other IA signals associated with stress. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 51 IA is very personal and requires individuals to understand their own bodily interpretations (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al, 2015; Khalsa et al., 2017; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). Helping individuals notice and then become aware of interoception can then lead to adequate and accurate IA maps to assist with coping (Schuette et al., 2020; Spira 2019). Using IA to recognize and manage emotions leads to an improved sense of self (Quigley et al., 2021; Schuette et al., 2020). Left unmanaged, stress can become a barrier to college students (Bistricky et al., 2018). Connecting IA to Undergraduate College Students Lived Experience with Stress The WHO defines stress as the bodys response to something physical, emotional, or psychological that requires action or attention from the person (WHO, 2021). Bistricky et al. (2018) identified everyday stressors for college students as finances, moving away from home, relationships, and coursework. Most, if not all, participants could identify ways in which the transition to college was stressful. The participants commonly had issues with roommates, friends, and resident advisors. Participants noted that transitioning from living at home to independent living caused stress. Learning to manage time and schedules and figuring out how to study effectively became barriers they did not expect. Boke et al. (2019) noted that students in courses with higher math and science requirements reported higher stress levels. Almost all participants took a course load of 16 credit hours or more, coinciding with the academic stress. More than half of the participants planned to start a post-undergraduate graduate program. The graduate programs listed were all healthcare-related fields, with coursework focusing on sciences, which is consistent with the research of Boke et al. (2019). Stress related to academics leads to greater stress levels and an increased likelihood of developing a mental health disorder (Boke et al., 2019; Yzer & Gilasevitch, 2019). Bistricky et INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 52 al. (2020) also discussed how stress affects college students. The researchers noted that diagnoses of depression and anxiety are on the rise, and living with them made it difficult for the students to function in daily life (Bistricky et al., 2020; Boke et al., 2019; Pedrelli et al., 2015; Yzer & Gilasevitch, 2019). Consistent with the literature, half of the participants self-reported diagnoses of depression, anxiety, and ADHD. Even though there was access to mental health services on campus, research showed many college students do not utilize the support provided on campus for mental health for a myriad of reasons (Amanvermez et al., 2021; Shi, 2019). Yzer and Gilasevitch (2019) noted that structural changes needed to be in place to allow students the time to practice self-care for stress management. OTPs work in a myriad of settings, with one being college campuses (Spencer et al., 2018). OTPs address the occupations of ADLs, IADLs, health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020). Stress impacts performance in all areas of occupation, but poor IA affects ADLs, IADLs, health management, sleep, education, and social participation, as noted in the results of this study. Quigley et al. (2021) reported how IA was integrated with homeostasis, hunger, memory, emotional regulation, and an overall sense of self. The occupation of health management includes coping strategies, monitoring changes in symptoms, and managing emotions (AOTA, 2020). Working with campus counseling centers, OTPs can assist students experiencing stress or at risk of developing mental health disorders in learning to improve IA and coping strategies to manage their stress. By acknowledging the importance of IA as a dimension of health (Schmitt & Schoen, 2022), OTPs can be an integral part of establishing a healthy campus (ACHA, 2020). OTPs can use their scope of practice in conjunction with knowledge of IA to assist college students with the transition and participation in college (Khalsa et al., 2018; Schmitt & Schoen, 2022; Spencer INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 53 et al., 2018). By staying occupation-focused, OTPs can support students in establishing routines to address eating and sleeping through IA (Khalsa et al., 2018; Spencer et al., 2018). Exploring the lived experience of stress from a cognitive perspective is consistent with the literature studying college students and stress management from a health behavior lens (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019;Yzer & Gilasevitch, 2019). Bringing the concept of IA to stress can bring agency to individuals in managing their stress. However, participants need to understand the concept of IA first. Overall, education on IA can help college students become more aware of their stress experience and subsequent coping strategies. Limitations This research was met with several limitations. While the participants could give a rich perspective of their lived experience of stress and interoceptive awareness, only eight participants responded to the recruitment flyers. A college setting with a more diverse population might have drawn a wider variety of participants and responses. The demographic sample was predominantly Caucasian and female, which limits the diversity and transferability of the study. A drawback of snowball sampling was demonstrated by the majority of participants being in the same course of study. Real World Implications Most research on mental health conditions focuses on the cognitive implications of stress and stress management, not the bodily sensations related to stress (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Nord & Garfinkel, 2022; Yzer & Gilasevitch, 2019). Nord and Garfinkel (2022) proposed mental health conditions be treated in relation to IA. Many researchers focusing on college students addressed health behaviors through the lens of health behavior theories (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Yzer & INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 54 Gilasevitch, 2019). While these theories are vital to research, they do not take into account the role of IA in the experience of stress or coping. Helping college students become more aware of their IA signals, college students can learn to notice their stress responses and improve their abilities to cope. More importantly, using personal IA to manage stress effectively could assist college students' overall health and wellbeing. Becoming attuned to IA helps the individual recognize how heart rate, awareness of hunger, and sleep patterns are influenced by stress. Better awareness of IA leads to better mood and emotional regulation. Using personal IA allows individuals to return to helpful coping strategies in times of stress. When students can manage their stress, they can attend classes, focus in the classroom, and are more likely to complete daily functional tasks. Occupational therapists can implement interventions that address IA as well as participation in daily occupations on college campuses. Future Research A large portion of research on personal IA focuses on the specific populations like people diagnosed with autism, depression, anxiety, and PTSD. This researcher excluded articles that used the diagnosis of autism as the focus population to explore how IA can be generalizable in a college setting. Expanding the research into different groups and populations can broaden the audience and knowledge base on IA, leading to more evidence-based practice interventions. Literature suggests further research in the areas of college students mental health and stress management, as well as the role of IA in stress management (Amanvermez et al., 2021; Arora et al., 2021; Nord & Garfinkel, 2022; Stevenson et al., 2023; Yzer & Gilasevitch, 2019). Arora et al. (2021) stated more research on IA could help improve understanding of the mind-body connection. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 55 This researcher recommends future studies exploring the coping behaviors of participants post-interview. This study would have benefited from a follow-up survey that explored IA and any changes or adaptations participants made in response to their personal IA. A survey could help determine if education on ways IA could identify when a person is experiencing stress. Furthermore, the survey could also determine if being more attuned to personal IA improved coping strategies or not. Increased understanding and addressing IA in college students may positively influence retention rates and improve overall campus mental health. Conclusion The concept of interoception has been studied for decades but still needs to be understood more clearly by the general public (Craig, 2002). The basis of this research was to determine if undergraduate college students' personal IA impacted the experience of stress and chosen coping strategies. For the most part, the participants did not understand what the term IA meant or the impact of IA on their experience of stress and subsequent coping strategies. Education on IA, in general, can improve how individuals understand their bodily signals. Learning to interpret personal IA appropriately can improve stress management, coping strategies, social participation, emotional regulation, and academic performance. Improved IA and coping strategies can help college campuses improve students' overall health and wellness. OTPs are skilled practitioners with the education and abilities to assist students with IA and improved participation in daily life. Researchers Self-Reflection Statement The process of understanding the undergraduate college students lived experience of stress required the researcher to be mindful of biases that created the initial research topic. The researcher noticed many of the graduate students she was interacting with complained of increased stress and anxiety related to academics. The researcher was curious if environmental or INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 56 sensory input was contributing or increasing stress levels. As the researcher conducted more literature reviews into the topic, IA became more interesting as a research topic. Exploring the research of Dr. Kelly Mahler and her contributions to the field of occupational therapy and IA, it became clear to the researcher IA and college students experience of stress was a viable research topic. The researcher became curious about whether or not this population was aware of how interoception appeared when experiencing stress or choosing coping strategies. Trustworthiness was established through credibility, dependability, confirmability, transferability (Creswell & Poth, 2018; Henderson & Rheault, 2004; Marshall & Rossman, 2011). As someone who worked in the field of mental health and educated individuals on coping strategies, the researcher made sure to bracket any preconceived notions of what stress and coping mean to her. The researcher acknowledged the participants might engage in substance use but were more likely to engage in physical activity due to their chosen college majors. Being able to separate preconceived ideas allowed the researcher to focus on the lived experience of the participant. For credibility, the researcher listened to the recordings several times, initially marking recurring words or phrases in each individual interview. The researcher did not move on to the next interview until the essence and lived experience of each participant was noted and summarized. Another step to ensure credibility occurred through the researcher sending the transcripts and descriptive summaries to the participants. After reading the transcripts and summaries, none of the participants requested corrections. One participant even commented the summary was very accurate of her lived experience. Confirmability and credibility occurred through the researcher bracketing and taking detailed memos. A review of the initial coding for themes in the data by Dr. Kelly also addressed confirmability (Creswell & Poth, 2018). The committee members reviewed the results accurately INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 57 reflected the research questions and the participants' lived experiences. The process of coding for themes took time and effort from the researcher and the research committee. The concept of IA was very familiar to the studys content expert, but the researcher needed to make sure others not as familiar with the concept on the committee could also understand the themes associated with the study. The review and revision process not only allowed the researcher to describe the phenomenon the participants experienced accurately, but also allowed for the transferability of the study. Using the interview guide in future research at colleges and universities with similar demographic information could demonstrate the dependability of the research questions and lived experience of college students in regards to personal IA awareness with stress and coping. The researcher learned the concept of IA is very important to ones overall health, but not widely known or understood. Throughout this process, the researcher learned more about the importance of IA in identifying emotions and choosing coping strategies. The researcher hopes to continue to explore the concept of IA in order to understand the lived experiences of her students and improve the quality of life for college students. Human Subjects Statement The Institutional Review Board permitted the researcher to collect data in March 2023. The study was reviewed and approved as exempt. All participants were provided informed consent. 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Journal of American College Health, 67(2), 153160. https://doi.org/10.1080/07448481.2018.1462828 66 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Tables Table 1 Demographic Information on Participants Participant Gender identity Age Year in undergraduate study Ethnicity Degree path A Female 19 Sophomore Caucasian Working towards getting accepted to a DPT program B Male 22 Senior Caucasian Communications C Female 22 Senior Caucasian Exercise Science D Female 21 Junior Caucasian Exercise Science E Female 21 Senior Caucasian/ Latina Exercise Science + Human Performance and Fitness F Male 19 Freshman Caucasian Communications G Female 19 Freshman Caucasian Psychology & Sociology H Female 22 Senior Caucasian Human Performance and Fitness 67 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 68 Table 2 Sample of Themes Emerging from the College Students Perceptions of Personal Interoceptive Awareness Regarding Stress and Coping Interviews Theme 1 Definition & Terms Used by Participants IA & How the interviewees identified knowing they Experience of were stressed and what was listed after being Stress given a handout defining interoceptive awareness. This includes IA, their interpretations, and perceptions of what they feel in their body in times of stress. Also included are sources of stress and how stress impacts habits and routines. Terms: anxiety, racing heart, more awake, more aware of what is going on, harder to think, boredom and tired with studying, sweating, don't notice hunger or the need to use the bathroom, feels burnout, not aware of them happening, hunger increases Example Quotes "(Nodding) Yeah, I definitely feel like anxiety. It's like take oneumlike, racing heart ratePA: Um, yeahI feel like not really tiredness (sounding thoughtful)more like being awakeand yeah(PA, page 8, lines 206210). I don't know if this is like a physical or like a mental, but like. If I'm really stressed about something and I haven't had time to like think it through or like identify the issues, I'll have a hard time focusing. So like in class,...practice. Like I'll still think about it like it'll like it could be like mid conversation with someone and I'm not like really listening. Like I'm listening enough to respond (pointing to ears and then towards the window for emphasis), but I'm thinking about the other thing and it's. It's terrible, I would say. Maybe a little more like grumpy, I guess (PF, pages 5-6, lines 113-121). Theme 1 Sub Themes Physiological Terms used to describe their experience of Experiences stress in their bodies. Terms: being alert, increased heart rate, hunger, loss of appetite, restlessness, tension, sore muscles, thirst, tired, tremor, increased startle reflex, I get really sweaty. Or...I. I feel, like, racing thoughts as well as, like, a...an increased heart rate It's, for a lack of a better term, like, I can feel my INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS physically hot, nervous stomach, lightheaded, sweating, mood swings 69 heart kind of pounding, and I'm sweaty, and I'm just kind of, like, jittery. (PD, page 5, lines 101-105) I definitely think I have upper back tension (moving hands towards upper back). For sure. And neck pain too, just from like sitting and just staring at a screen and doing things constantly. It's not(PG, page 7, lines 146-149). Um...I don't know about temperature. I feel like that would also have to kind of go with sweating, like probably like those two kind of go hand in hand. Ummm (thinking) Honestly, I don't really feel like I notice hunger or going to the bathroom at all. Like I just even if it is like a present situation...P1: OK. P42723: Like I just it's an ignored almost or it's like pushed to the back of my mind (PD, page 7, lines 124-127). Impact on Appetite and Eating Behaviors Ways in which participants described their appetite and eating habits when experiencing stress. Terms: grumpy, annoyed, "hangry," stress eating, not hungry, force to eat. Well, definitely...So, it's kind of, like, a hit or miss. Like, sometimes if I'm stressed, I'm hungry. Other times, it's I have no appetite at all. Um, So... I don't really know, like, what's the difference, like, what causes the difference between, but sometimes it's, like, either one of those. (PC, page 8, lines 181-185). "Um, I haven't tried it, like purposefully, but sometimes I do catch myself kind of stress INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 70 eating. (PD, page 8, lines 174180). Impact on Levels of Arousal Ways in which participants described their experiences with levels of arousal when stressed. Terms: stress zaps motivation, no motivation, more alert, baseline stressed all the time, stressed all the time, hard to sleep or sleep all the time. "Oh, I get. I definitely get like tired. (PF, page 5, line 113). "Everything just kind of gets, like, heightened almost. Because like as soon as you said like tired like I...I feel just like drained, like, but like both physically but also mentally (PE, page 7, lines 146-147). Uhhgg (making a sound in agreement and exasperation) Um, And then I get alert. Like I'm just kind of more wary of what's going on (PB, page 7, lines167-168). Impact on Daily Life Ways in which the experience of stress impacts participants daily life. Terms: skipping or missing class, delays with turning in assignments, not being able to stay organized or plan out school work, missing practices, poor social participation, quitting clubs or sport teams, poor ADL/IADLs "Um, So I guess like on the negative side of stress. It just makes me kind of like, I guess we could say crabby (being thoughtful then matter-of-fact and smiling). It just like, I just am very like I'm hard on myself. So when I feel start feeling stressed, I kind of just shut down and I become very zoned in on like the things that I have to accomplish (stressing I have to accomplish) (PC, pages 6-7, lines 143- 148) "Um, yes. I would say my motivation drops. Oh, I definitely missed class, just due to stress. I did not even go to practice one time just due to stress. (PF, page 6, lines 123124). No Longer Experiencing Stress How they are aware of no longer being stressed or their interoceptive awareness of not being stressed. Terms: feel relaxed, calm, Oh, I'd just I definitely am not really then tired. Um...Like I, I wanna go do something fun INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 71 normal, feels like a weight has been lifted, feel like being around others, more comfortable in body, don't feel the need to move, able to focus on things, always stressed so harder to know why not stressed, sleep is better, at ease, know when actually hungry, feeling motivated again, feel like getting stuff done, don't really know when no longer stressed, least stressed when less alert, normal hunger, heart rate is normal, IA cues are less intense, normal temperature then usually. And then I guess like I'm usually. I know that I'm not like, stress eating, likeThat's...it's like a normal hunger? It's like, Im not that... I'm just gonna sit here and eat this because I'm like, trying to crank out like a paper (PC, page 9, lines 197-203). "Definitely calm. Um...I would say heart rate, temperature probably back to normal. And then boredom, I would say kinda is the opposite. Like I, I want to do more things(PD, page 7, lines 150-152). "Yeah, exactly (smiling and nodding). I like, I definitely forget to eat sometimes because of that business and kind of balancing factor. But like it's easier to know that I have to eat or like that, like to remind myself instead of like someone reminding me when I'm like not stressed or something like that. (PE, page 7, lines 159-161). Theme 2 Definition & Terms Used by Participants Example Quotes Coping Strategies Anything the person engages in to relieve stress or relax Theme 2 Sub Themes Helpful Coping Strategies Anything that is adaptive or proactive in managing stress. Terms: Sensory, self-cares, friends, yoga, walking, running, lifting weights, swimming, television, reading, music, spa days, fidget use, showers, resting/sleep, prayer, journaling/devotional, pets, crying, therapy, medications. "Yeah. I think a big one is like, being with other people, like, my friendsjust to distract myselfto get out of my own head and, you know, go to target and go get dinner and you know, just like kind of distract myself. Listen to music. Really, just like INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 72 something else (stressing something else) other than just being alone with my thoughts. PA, page 9, lines 238-241)." I go to the gym quite often. Um, I like exercising. Mainly. I like lifting more so than cardio, but I do both. Um, I talked to my family. Watch TV sometimes I read (PD, page 7, lines 158-160). Not Helpful Coping Strategies Anything that is maladaptive or harmful to the participant. Terms: Substance use weed/EtOH, self-harm, cutting, nail biting/chewing, avoidance - tv, video games, sleep, stress eating, therapy, some medications. So I, Ive cut myselfBut, I don't remember if it was or not, but chewing on my skin, apparently around my fingernails is self-harm? And I didn't realize that. I think that was more for me, a habit (PG, page 14, lines 336-338). "Being a 22 year old, I dabble in drinking. (PH, page 9, line 211)." "Drug usage is a thing...that a lot of college students use to escape...a lot of these symptoms that I feel like we have constantlyIt is, uh, something I engage inEvery now and then... uh...weed (saying weed in a matter-offact tone) (PG, page 11, lines 250-260). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Figures Figure 1 Interoceptive Awareness in Regards to Stress and Coping 73 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 74 Appendices Appendix A Informed Consent Document for Research Study Participation Title of Project: College Students Perception of Personal IA Regarding Stress and Coping For Research Conducted at: Research will be conducted to complete the degree requirements for a Doctor of Health Science degree through the University of Indianapolis. Principal Investigators: Dr. Jennifer Fogo: jfogo@uindy.edu Stephanie Phares: pharesstephaniel@sau.edu or pharess@uindy.edu WHAT IS THIS FORM? You are invited to participate in a research study. The purpose of this consent form is to describe the research study to help you decide if you want to participate. It also tells you about why the study is being done, about the risks and benefits of the study, and your rights as a research subject. You are being asked to participate because you are an undergraduate college student aged 18-24 living on campus and understand written and spoken English. You can choose if you want to be in the research study. If you wish, you can discuss it with other people before deciding. You should not feel pressured to participate. If you decide to participate in this research study, you will be asked to check the YES box on the form indicating informed consent and agreement to participate in this research study. You will be given a copy to keep. WHY IS THIS STUDY BEING DONE? INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 75 How a student chooses to cope with stress will affect their behaviors, emotions, relationships, physical well-being, and academic endeavors (Boke et al., 2019). Prior research has shown the link between IA and emotional regulation (Price & Hooven, 2018; Schmitt & Schoen, 2022). Consideration of the student stress experience is key in understanding their stress profile and subsequent treatment strategies (Boke et al., 2019). Without addressing IA, students may not realize they are under stress until they are overwhelmed and in academic distress, presenting as poor attendance, an inability to maintain an appropriate grade point average, or struggling to complete daily tasks. Current research addressing college students lived experience with stress does not explore the relationships between IA, stress management, and coping (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Rodriguez & Provident, 2018; Sapadin & Hollander, 2021; Shi, 2019; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). An opportunity exists to understand how IA influences stress and coping abilities in college students. WHAT IS THE PURPOSE OF THIS STUDY? This research aims to understand whether undergraduate college students aged 18-24 who live on campus use IA to identify when they experience stress and engage in chosen coping strategies. HOW MANY PEOPLE WILL PARTICIPATE? We anticipate that about eight to ten people will be invited to participate in this study. HOW LONG WILL I BE IN THIS STUDY? Participants will be asked to participate in one 45-minute interview session. WHAT WILL HAPPEN DURING THIS STUDY? INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 76 If you agree to participate in this study, you will be asked to participate in one interview and then read a summary of the data analysis upon completion of the analysis to ensure the information is an accurate reflection of your experience. WHAT ARE THE RISKS OF THIS STUDY? There are minimal psychological risks associated with this research due to the interview guide asking questions directly related to personal stress and coping. The research will not cause a level of either harm or discomfort to participants that is greater than what they encounter ordinarily in their daily lives. Participants will be given information regarding counseling services available to them on campus. WHAT ARE THE BENEFITS OF TAKING PART IN THIS STUDY? Students participating in the research study may benefit from understanding what IA is and how they can apply it to their personal lives. A deeper understanding of how to use IA can improve emotional regulation (Price & Hooven, 2018; Schmitt & Schoen, 2022). College campuses and student body populations may benefit in some way. By understanding students' perspectives on personal IA with stress and coping, college campuses can explore integrating IA into mental health interventions. Studying the link between IA and stress management in college students may have an impact on overall student wellness, academic performance, and coping strategies. Additionally, occupational therapy practitioners may expand services on college campuses to address students interoceptive needs. Thus improving college students stress management and overall quality of life. HOW WILL MY PERSONAL INFORMATION BE KEPT CONFIDENTIAL? We will do our best to keep your information as confidential as possible. We will not tell anyone you are in this study. Your name will not appear on any of the paper or electronic forms INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 77 that are used to collect data. All of your forms will be labeled with a code number and kept in a locked file cabinet in the Center for Health Sciences Education building behind a locked door. The same code will be used to label any computer files where your data are stored. In addition, all electronic data will be stored on a computer that is protected with a password. Only Stephanie Phares will have access to the information contained in your paper or electronic records. Information collected from you will be deleted or destroyed no later than December 2026. No information that would reveal your identity will be included in any publication or presentation resulting from this study. WHAT ARE THE COSTS OF BEING PART OF THIS STUDY? There is no cost to you for being in this research study. WILL I BE PAID FOR PARTICIPATING IN THIS STUDY? You will not be paid for being in this research study. WHAT IF I AM INJURED BECAUSE I TOOK PART IN THIS STUDY? Although I believe that the risk of being injured during the course of this study is minimal, if you are injured, notify Stephanie Phares immediately. We will call for medical assistance if you require medical care for your illness or injury. Any medical care that you receive will be billed to you or to your insurance company in the same manner as your other medical needs are addressed. Neither the investigators nor St. Ambrose University can assume responsibility for any additional medical costs you may incur due to your participation in this research. WHAT ARE MY RIGHTS IF I TAKE PART IN THIS STUDY? Taking part in this research study is completely voluntary. You do not have to be in the study if you do not want to. If you decide to be in this study, but later change your mind, you INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 78 may stop participating at any time. If you decide not to be in this study, or if you stop participating at any time, you will not be penalized or lose any benefits to which you are otherwise entitled. WHAT IF I HAVE QUESTIONS? We encourage you to ask questions and to take as much time as you need to make a decision. We will be happy to answer any questions you have about this study now or at any time during the study. If you have further questions about this study or a research-related problem, you may contact one of the principal investigators: Stephanie Phares: (563) 333-6083 or (563) 370-3706. pharesstephaniel@sau.edu or pharess@uindy.edu INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Appendix B Recruitment Flyer 79 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Appendix C Information Sheet 80 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Appendix D Google Form 81 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 82 Appendix E Interview Guide Hello, my name is Stephanie Phares, and I am currently a student at the University of Indianapolis working towards a Doctor of Health Science Degree. My dissertation research focuses on understanding how college students experience stress, cope with that stress, and explore the role occupational therapists may play in the college campus setting to assist students with that stress. This interview aims to hear your first-hand experiences as a college student with stress and to cope. I hope to understand the thoughts and feelings surrounding your experiences. With your permission, I would like to record this interview. I will use that recording to produce a transcript that will be sent to you to ensure all the information gathered is correct and accurate. You will have two opportunities to provide corrections and feedback. The first is following the initial transcription of the interview, and the second will be following the initial analysis of your transcript. You can make corrections and return the corrected materials to me. If you have questions throughout this process, please email me at pharesstephaniel@sau.edu. Once the dissertation process is complete, the interview recording will be deleted. Now that I have started the recording, I want to tell you what you can expect regarding how the information from this interview will be used. The information obtained will be confidential, and no identifying information will be used to report this research. The information will inform current services provided on campus for student mental health. The interview is expected to last about 30 minutes. This interview is voluntary, and you have the right to refuse to answer any questions asked, take breaks as needed, and you may terminate the interview at any time. Before asking questions from the interview guide, Id like to confirm the demographic INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS information you provided on the Google Form. Thank you, I appreciate your time and information. Interview Guide Questions 1. Tell me about your college experience so far. a. What has been the most rewarding part of college? b. What has been the most difficult part of college? 2. What is your definition of stress? 3. How does stress affect you? a. How does stress impact your habits and routines? 4. How do you become aware that you are stressed? a. What specific sensations do you notice when you are stressed? b. How does your body feel when you are stressed? 5. The following sensations refer to your interoceptive senses: tiredness, hunger, temperature, toileting needs, and heart rate. How do you experience these sensations when you are stressed? a. If you notice these sensations, how do they change in response to stress? 6. How do you know you are no longer feeling stressed? a. Earlier, you mentioned (x, y, z) is how you experience stress. How do those change to let you know you are no longer feeling stressed? b. How aware are you of your interoceptive needs when you are not stressed? 7. How do you deal with or manage your stress? a. What about that (x, y, z) helps you notice your stress decreasing or becoming more manageable? 83 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS b. How does your body feel when you do those things? 8. Have you ever tried to do things to manage your stress that was not helpful? a. What let you know they were not helpful? b. How did your body feel when you did (x, y, z)? 9. What types of support do you have in place to manage stress? a. Who are the people that are helpful to you? b. How do your support systems help you manage your stress? c. When do you know you need to seek their support? 10. What supports do you wish you had more of to help you manage your stress? a. What is your understanding of campus support available to you? 11. Is there anything else you would like to tell me about your stress and coping strategies that would be helpful to this research? 84 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 85 Appendix F Interview Descriptive Summaries A Participant A (PA) is a 19-year-old Caucasian female who is a sophomore working towards a Doctor of Physical Therapy degree at a mid-sized, private Midwest college. PA was initially nervous, slightly rocking back and forth in the chair. The interview began with the overall college experience, both difficult and rewarding experiences. PA began the interview by discussing the difficult decision to quit the cross-country team. PA spoke softly and looked down while discussing this initially but became more animated as the interview progressed. She expressed frustration with the coachs attitude and lack of empathy with PA becoming injured and a teammates mental health. She likened the experience of interacting with this person to an abusive relationship (personal communication, April 18, 2023, line 116). The interview's tone shifted when PA discussed the positive experience of mission trips with the campus ministry. Campus ministry offers PA spiritual guidance, opportunities for personal growth, and a base for friendships. Worry or anxiety about your life, things going on (personal communication, April 18, 2023, line 143) is the definition of stress that PA provided. Physiological sensations associated with stress include feeling nervous, anxious, butterflies in the stomach, racing heart rate, fidgeting, needing to move or not being able to sit still, poor sleep, and sweating. She tends to get into her head and isolate herself when stressed, as well as take on the stress of others. When no longer feeling stressed, she reports feeling calm and less of the aforementioned sensations (personal communication, April 18, 2023, lines 220-222). PA reports only sometimes being fully aware of how those sensations appear when stressed. Specific physiological IA when INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 86 stressed presents as not wanting to eat, having a racing heart rate, or not being able to sleep. She does notice a need to move her body when anxious, especially before a race. PA only realized she had a pre-race routine once her teammates made her aware of her behaviors (personal communication, April 18, 2023, lines 256-259). Additional coping strategies are listening to music, going shopping, going out to eat, and talking to friends, family, and her priest. She reports looking to get out of her head with positive distractions (personal communication, April 18, 2023, lines 236-239). Support and spiritual guidance are the biggest means of coping for her. A theme in discussing coping strategies is the top-down approach to being aware of stress in a more cognitive capacity. She focused more on how she will fixate on the stressor, catastrophize (line 272), and need to get out of her head. There was no connection between IA and the stress level experienced except with running or before a test. PA stated her nerves before a race could even make her throw up (personal communication, April 18, 2023, line 182). The overall essence of the interview focused on personal growth and the changes since starting college. The decision to quit the cross-country team, going on mission trips, and awareness of emotional maturity (personal communication, April 18, 2023, lines 261-262) have been cited as areas of huge growth in the last year (personal communication, April 18, 2023, lines 341-342). All in all, PA has enjoyed the college experience and has developed healthy coping strategies to manage her stress. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 87 B Participant B (PB) is a 22-year-old Caucasian male who is a senior working towards a Communications degree at a mid-sized, private Midwest college. PB begins by expressing his frustration with the college that he will need to extend his credits into a fifth year of college due to the college eliminating theater as a major. This affected his credit load as a double major. He speaks slowly and chooses his words carefully. His tone of voice, body language, and facial expressions depict his frustration and annoyance throughout the interview with various aspects of his college experience. He does smile easily and uses a sarcastic tone to make his point at times. He reports not being pleased with some of the teachers and administration (personal communication, April 24, 2023, lines 36-37), not getting support from the university (personal communication, April 24, 2023, lines 340-348), and not finding a solid group of friends or peer support while in college. Struggling to find a friend group or support system is a theme in this interview. He states, Making friends is not that easy (personal communication, April 24, 2023, lines 299-300), and having anxiety makes social participation difficult (personal communication, April 18, 2023, lines 83-84). He was active in the tabletop role-playing gaming club but reports he did not gel with that club (personal communication, April 24, 2023, line 320). He enjoys going to sporting events but typically will go alone (personal communication, April 24, 2023, lines 322-323). He attempted to reach out for help from the campus while struggling with mental health issues during COVID-19. He felt he was not taken seriously and dismissed (personal communication, April 24, 2023, lines 340-348). He also feels dismissed when people offer solutions or coping strategies such as yoga, a planner, meditation, and journaling (personal communication, April INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 88 24, 2023, lines 282-283), as indicated by his tone of voice and body language while discussing these suggestions. He does find support from his mom, his therapist, and his psychiatrist. Another theme that emerged is the prevalence of stress in his life. PB was diagnosed with anxiety in 7th grade (personal communication, April 24, 2023, line 74) and reports additional diagnoses of depression and ADHD (lines 356-357). He feels as though there is always a stress level in his life, and it is hard to know or recognize when he is not feeling stressed (lines 192194). His symptoms of stress include becoming physically hot, getting upset, a hand tremor, increased heart rate, feeling more alert, sensitive startle response, struggling to think clearly, and shutting down. There is a decreased IA of hunger when stressed or playing video games. PB expressed frustration with being late and how being late impacts his stress levels, habits, routines, and participation in daily occupations. PB reported feeling frustrated at a Model UN event in which going to dinner would make them late, which elevated his physiological stress symptoms, and others downplayed his acute stress symptoms (personal communication, April 18, 2023, lines 96-104). He went on to identify how he would skip activities of daily living (ADLs) to avoid being late (personal communication, April 18, 2023, lines 113-115) or not attend class if he thought he would be late (personal communication, April 18, 2023, line 119). PB is aware that his main coping strategies are avoidance and distraction. He reports, I feel so bad Im just gonna go to sleep (personal communication, April 18, 2023, lines 184-185). He reports using video games, TV, or other media to distract himself in addition to sleeping. When playing video games, he can go for hours without eating and not feel the interoceptive cues of hunger (personal communication, April 18, 2023, lines 376-377). He also reports not being aware of that affecting his emotional regulation (line 388), another component of IA. He INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 89 does use sensory input to address stress, as demonstrated by his fidgeting with a baseball during the interview (personal communication, April 18, 2023, line 400). The overall essence of the interview is that PB is disappointed in his college experience and lack of understanding surrounding his mental health. He is aware of his stress levels but not necessarily the impact that IA plays in his reactions to stress or chosen coping strategies. While avoidance is used as a coping technique, it also interferes with his IA, namely hunger. He reports that sleep is not for being tired but for avoidance or distraction (personal communication, April 18, 2023, lines 205-206). To take care of his mental health, PB has professional help built into his routine. He also adjusted his schedule and made arrangements to address his mental health throughout his college career (personal communication, April 18, 2023, lines 43-44). He looks forward to actively participating in media platforms and enjoys the radio show he hosts (personal communication, April 18, 2023, line 66). Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. C Participant C (PC) is a 22-year-old Caucasian female who is a senior working towards an Exercise Science degree at a mid-sized, private Midwest college. She plans to pursue a Masters Degree in Exercise Science to work in cardiac rehabilitation. Going away to school was a big decision, but she is grateful her sister is at the same college, making it less overwhelming and scary (personal communication, April 27, 2023, line 28). PC discusses the awareness of her growth over the last four years. She describes herself as someone who enjoys the challenge of school and is driven. Throughout her journey, she feels she found ways to allow herself to INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 90 explore her interests instead of stressing about picking a major (personal communication, April 27, 2023, lines 62-70). She has allowed herself some grace with not needing to have everything planned out. Overall, PC is proud of her academic and athletic achievements in college. Being an active swimmer and making great friends have been the most rewarding elements of college for her. Being away from her mom and her coursework has been the most difficult. PC can see how taking more challenging classes has pushed her to work harder and recognize when to get help. Asking for help was difficult, and she is glad that she finally did reach out in some of her classes (personal communication, April 27, 2023, lines 108-118). When asked about a definition of stress, PC initially stated it was a difficult question but was able to identify both sides of stress. She stated that stress can be good at times but thinks of stress as something that is a negative, draining, kind of overwhelming feeling (personal communication, April 25, 23, lines 135-137). Signs of stress for PC include feeling crabby or grouchy, shutting down or zoning out, and feeling exhausted or with no motivation. When feeling grouchy, she reports her sister will ask her if she has eaten (line 157). The physiological interoceptive sensations she experiences are tiredness, tense muscles, and hunger. With hunger, PC reports going between stress eating and having no appetite but not being aware of what triggers one or the other (personal communication, April 27, 2023, lines 181-183). Stress eating seems to be the most distressing for her. She feels full and sluggish after eating what she perceives as too much (personal communication, April 27, 2023, lines 238-244). She does not seem to mind that she is more alert when stressed, as indicated by her tone of voice and facial expressions (line 184). PC appears to struggle more with physiological interoceptive sensations when not stressed. She can identify that she is calm and relaxed but has difficulty INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 91 describing those sensations in her body. She is aware she is more active, feels less tired, and has normal hunger (personal communication, April 25, 2023, lines 197-200). Coping strategies include physical activity, movies, family, friends, and her sisters dog. Physical activity tends to be the most effective means of managing stress, as demonstrated by the awareness of how calm she feels after swimming, going to the gym, and walking the dog. She mentions physical activity four times and how much that helps to calm her. PC also mentions talking to family and friends several times as a coping strategy and a huge help. She also recognizes the need to talk to others before she is at the point of crying to better manage her stress (personal communication, April 25, 2023, lines 262-263). The overall essence of the interview is that PC is a high-achieving person who values hard work in academics and athletics. Her family, especially her mom and sister, are a valuable support system to her. The personal growth PC experienced over the last four years is something that she finds cool (personal communication, April 27, 2023, lines 63-70). She is aware that being a high achiever can be a source of stress, but she sought help and allowed herself time to choose a major she really enjoys. Her physiological interoceptive sensations are more intense when stressed, and she chooses coping strategies that decrease those sensations. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. D Participant D (PD) is a 21-year-old Caucasian female who is a junior working towards an exercise science degree at a mid-sized, private Midwest college. She has plans to pursue a Doctor of Physical Therapy degree, but the admission process is a source of stress and one of the INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 92 most challenging parts of college for her (personal communication, May 4, 2023, lines 78-82). PD reports being a pessimistic person and tends to struggle with confidence in her abilities (personal communication, May 4, 2023, lines 224-226). She is thankful for the support and encouragement she receives from her mother. PD reports her college experience was rough to begin with, identifying being distraught when she first started school due to COVID restrictions, not knowing her roommate, and feeling lonely (personal communication, May 4, 2023, lines 236-241). However, joining the soccer team increased her social participation and gave her an outlet for her stress (personal communication, May 4, 2023, lines 68-72). While PD refers to her college experience as a little different several times, she does not necessarily see that as a bad or negative experience (personal communication, May 4, 2023, lines 47-63). PD defines stress as sort of like having this apprehension or anxiety towards something youre currently dealing with or something that is like coming up (personal communication, May 4, 2023, lines 85-86). PD can recognize how stress can be both detrimental and motivating. She feels the stress of maintaining a specific GPA and getting good grades allows her to work harder toward her goals (personal communication, May 4, 2023, lines 93-96). While exploring the concept of stress, PD discussed racing thoughts, worrying, and having nagging thoughts. The physiological interoceptive sensations she experiences when stressed, are increased heart rate, feeling tired, getting sweaty, fluctuating hunger, and feeling jittery (personal communication, May 4, 2023, lines 101-105). Although she could identify her physiological interoceptive sensations, she had not heard of interoception before this interview. PD brought up stress eating and views the negative feelings that result from stress eating as I couldnt control my INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 93 psychological appetite instead of actual hunger or drive for hunger (personal communication, May 4, 2023, lines 189-191). PD engages in many positive coping strategies, such as going to the gym, reading, watching TV, and reaching out to her support system. The support system includes her mom, boyfriend, friends, roommates, teammates, and the pet cat in the apartment. She can identify that she feels calm and comfortable when relaxed but struggles to identify specific physiological interoceptive sensations related to no longer feeling stressed (personal communication, May 4, 2023, lines 166-168). Her support system helps her feel less overwhelmed by talking her thoughts through (personal communication, May 4, 2023, lines 215-220). The overall essence of the interview is that PD can use her stress as a motivator for success. She uses several positive coping strategies and can connect with others when feeling overwhelmed. PD focuses more on the top-down concepts of stress, such as worry, nagging, and racing thoughts. Being tired and bored Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. E Participant E (PE) is a 21-year-old Caucasian and Hispanic female senior at a mid-sized, private Midwest college. She was accepted into a Doctor of Physical Therapy program postgraduation. PE is proud that she is in the Doctor of Physical Therapy program and credits her hard work and motivation to getting accepted. She has a bubbly personality and is engaged throughout the entire interview. She has a strong family and friend support network but is incredibly close to her mother. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 94 PE feels being active and making connections have been the most rewarding part of her college experience. She is a member of the bowling team, plays intramural sports, is a member of Phi Eta Sigma, and has participated in Green Life and the Kinesiology Club. She also does personal training, has an internship, and works in the admissions office. All of this is on top of taking 15 to 18 credit hours. While being active and engaged is a source of pride, PE also admits that maintaining a healthy life balance has been a problematic part of the college experience. PE defines stress as Probably just like high feelings or anxiety or like your minds kind of going 1,000,000 miles per minute and you have tolike constantly be keeping up with everything (personal communication, May 8, 2023, lines 71-73). PE acknowledges that she has a diagnosis of ADD (personal communication, May 8, 2023, lines 127-128), and this impacts her thinking and response to stress. The awareness of the heightened need to fidget, along with racing thoughts, is the highlight of her stress response. She feels stress can be motivating as well as debilitating. She knows that stress changes her personality from talkative and bubbly to withdrawn and not as talkative (personal communication, May 8, 2023, lines 112-115). Stress affects habits and routines by making daily tasks and occupations challenging (personal communication, May 8, 2023, lines 96-101). PE experience of stress is related to the symptoms she experiences with having an ADD diagnosis. PE reports racing thoughts and feeling an increase in the need to move her hands, using fidget tools to assist with addressing this sensation (personal communication, May 8, 2023, lines 183-187). Other physiological interoceptive sensations she experiences with stress include a change in appetite, feeling drained, and having no motivation. She reports feeling a heightened sense of her physiological interoceptive sensations when stressed. She realizes that it is easier to understand when she is not feeling stressed (personal communication, May 8, 2023, lines 153- INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 95 155). Hunger is the hardest to interpret when stressed (personal communication, May 8, 2023, lines 159-161). To manage her stress, PE enjoys watching television, using fidgets, aerial yoga, and having a spa session alone or with her roommates. She reports feeling a sense of control when using the fidgets (personal communication, May 8, 2023, lines 219-222). Many of her coping strategies are sensation-based and provide a sense of calm or relaxation. She has a positive support system in her mom, brother, boyfriend, and friends/roommates. PE is aware that her high achievement drive can lead to perfectionism, and her coping mechanisms gets me through it because it kind of brings everything back (personal communication, May 8, 2023, lines 265266). PE is also aware that her experience of stress is more cognitive, then moves to the physical realm regarding the need to fidget (personal communication, May 8, 2023, lines 270-272). She does report getting injured initially while doing aerial yoga. The overall essence of the interview is that PE is a hard worker and uses the stress of school as a motivator for success. She is an energetic and bubbly person who is positively connected to her support system. She uses several positive coping strategies and can connect with others when feeling overwhelmed. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. F Participant F (PF) is a 19-year-old Caucasian male who is a freshman working towards a Communications degree at a mid-sized, private Midwest college. PF is a student-athlete and is proud of the work he has done with the track team. Track was part of his decision to not only INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 96 attend this college, but the team has been a large part of his support system. He beams when he talks about track and does feel it has been the most rewarding experience in college thus far (personal communication, May 10, 2023, line 37). He is hard-working and is currently taking 17 credit hours. He feels the initial transition to college was overwhelming with managing his schedule, but he could manage the increased workload this semester (personal communication, May 10, 2023, lines 25-27). While he feels he can manage the workload, he does report that classes and managing relationships have been the most challenging or complex part of the college experience (personal communication, May 10, 2023, lines 60-69). He is realizing the nuances of friendships and determining what type of relationship is worth it to him (personal communication, May 10, 2023, lines 66-69). PE defines stress as being overwhelmed and spreading myself too thin (personal communication, May 10, 2023, lines 101-102). PE experiences stress cognitively by becoming too hard on himself, allowing problems to appear much bigger than they really are, and begins to feel like people do not really like him (personal communication, May 10, 2023, 104-105). The idea of people not liking him becomes a theme and source of stress for PF throughout the interview. He reports getting stressed and then feeling like his interactions with others are not as good as they could be (personal communication, May 10, 2023, lines 173-179) or feeling like others think he is a joke (personal communication, May 10, 2023, lines 354-362). He recognizes that he becomes grumpy and less inclined to socialize with others when stressed. The physiological interoceptive sensations PF experiences when stressed include loss of appetite, feeling tired, getting a headache, and poor focus. He was not aware of the term interoception before the interview and did keep the flyer at the end of the interview. The most prevalent interoceptive sensation is tiredness. PF reports missing practice or not going to class INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 97 due to listening to the cues from his body to rest, but he also attributes that to stress affecting his habits and routines (personal communication, May 10, 2023, lines 123-124). PF is aware of his need for sleep and tries to ensure enough sleep to feel focused and ready to complete his daily tasks (personal communication, May 10, 2023, lines 226-229). He reports trying to meditate but did not feel like it was too helpful. PF also acknowledged that he experienced tendonitis this year and wondered if the toll stress was taking on his body contributed to his injury (personal communication, May 10, 2023, lines 254-258). Positive coping strategies for PF include sleep, being with friends and family, and running. The overall essence of the interview is that PF enjoys the challenge and work that school and track provide. He values sleep and will listen to his physiological interoceptive sensations when tired and honor those sensations. He is a deep thinker and can get caught up in his own thoughts when experiencing stress. He acknowledges that he may be the biggest source of stress in his life by trying to do too much and then getting overwhelmed (personal communication, May 10, 2023, lines 286-289). PF also recognizes how becoming too cognitive or cerebral with his stress affects his self-perception and interactions with others. He does value communication and will express those thoughts to his family and friends for validation and support (personal communication, May 10, 2023, lines 270-274). While he was not sure of what the term interoception was initially, he was able to communicate an understanding of the concept throughout the remainder of the interview. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. G INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 98 Participant G (PG) is a 19-year-old Caucasian female who is a freshman working towards psychology and sociology degrees at a mid-sized, private Midwest college. PG is friendly and easy to talk to during the interview. PG disclosed the diagnoses of depression and anxiety and discussed how those diagnoses had been intertwined with her lived experience of stress. She feels there is never a time when she does not experience stress, which is part of her life (personal communication, May 12, 2023, lines 169-172). While taking a high credit load, she does not recognize this as a source of stress but rather a positive of being challenged while in college. She feels that having the opportunity to learn has been one of the most rewarding parts of her college experience thus far (personal communication, May 12, 2023, lines 104-105). PG defines stress concerning her experiences with depression and anxiety as constant worrytheres also, I feel like a type of burnout with stress as well that I feel like I definitely experience as well as feelings of being burnt out and having no motivation (personal communication, May 12, 2023, lines 128-138). PG did not understand the term IA and used the handout to assist with identifying physiological interoceptive sensations. The physiological interoceptive sensations she experiences are tiredness, tension, soreness, increased heart rate, and variations of hunger. She feels like she is able to experience a state of being less stressed when her heart rate is down, and she feels less alert (personal communication, May 12, 2023, lines 239-242). PG engages in a variety of coping strategies to manage her stress, anxiety, and depression. She does yoga, performs self-care tasks, tries to be with friends, and sleeps. As stated earlier, she feels less stressed when she is less alert and will engage in cannabis use occasionally to escape the alertness (personal communication, May 12, 2023, lines 257-261). In the past, PG used cutting as a means of coping but was able to end that behavior with the help of her INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 99 support system, medication, and therapy (personal communication, May 12, 2023, lines 331370). She currently still chews on the skin around her fingernails, but does not engage in cutting (personal communication, May 12, 2023, lines 337-344). The overall essence of the interview is that PG works hard at school but tends to ignore or want to escape her feelings regarding stress. PG grew up in an abusive household and feels she always has a degree of stress but tries not to pay attention to or recognize those signals within herself (personal communication, May 12, 2023, lines 434-436). Interestingly enough, PG did not think she was experiencing any stress until she came to the interview and began to discuss her physiological interoceptive sensations (personal communication, May 12, 2023, lines 440-442). Her coping skills focus on soothing her sensory system, as indicated by her need to take breaks from socializing, engaging in spa sessions, and the use of cannabis. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post interview. This may determine if PG is able to recognize her physiological interoceptive sensations sooner and manage her stress levels better in the future. H Participant H (PH) is a 22-year-old Caucasian female who is a senior graduating with a degree in Human Performance and Exercise from a mid-sized, private Midwest college with a plan to transfer to a Masters of Therapeutic Recreation program. PH appears nervous at first, fidgeting with her hair and skirt initially, then becoming more animated and talkative as the interview progresses. PH describes an overall positive college experience, especially after switching her major from exercise science to her current major. She reports having a total INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 100 mental breakdown her junior year, which led to her switching, and feels it has been the best decision for her (personal communication, May 15, 2023, lines 22-28). Her mental health is a theme throughout the interview, along with her ability to grow from her lived experiences. PH reports coming to college and making that transition alone was one of the most difficult experiences, along with learning how to manage her time and stay organized (personal communication, May 15, 2023, lines 57-77). She describes various instances where relationships with roommates have been difficult, but overall feels she has created some rewarding relationships (personal communication, May 15, 2023, lines 54-55). Another part of her lived experience that she finds rewarding is watching her personal growth. She reflected on how her growth as an individual and all the experiences she had (personal communication, May 15, 2023, lines 48-52) allowed her to feel ready to move on to her next college experience (personal communication, May 15, 2023, lines 452-453). PH discusses her lived experience with stress in relation to her diagnoses of anxiety and depression. She defines stress as just likefeeling overwhelmed. I guess, not being able to handle the situations presented to mein a more relaxed manner? (personal communication, May 15, 2023, lines 91-93). The result of the stress is panic attacks, anxiety attacks, feeling overwhelmed and emotional, crying, increased crying, and stress eating (personal communication, May 15, 2023, lines 101-128). She reports being aware of how much stress affects her sleep and how that impacts the rest of her day. Some other physiological interoceptive sensations are an increased heart rate and shaking hands (personal communication, May 15, 2023, lines 141-150). She did not connect stress eating to interoception and stress until looking at the handout, wherein she stated, Thats interesting several times while discussing her eating habits (personal communication, May 15, 2023, lines 159-163). However, PH may benefit from INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 101 further exploration of the physiological interoceptive sensation of hunger because there was a contradiction in how she experiences hunger. At one point, she discusses feeling hungry all the time and not getting enough to eat, then states that she struggles with stomach problems and needs to force herself to eat (personal communication, May 15, 2023, lines 159-169). Cueing into those varying sensations may assist her with identifying hunger needs. PH enjoys a variety of coping mechanisms, but combining music with spiritual care seems to be her main source of calming herself (personal communication, May 15, 2023, lines 182-203). She reports listening to spiritual music, or Jesus Music (personal communication, May 15, 2023, lines 182-187), helps her calm down, focus, and sleep better (personal communication, May 15, 2023, lines 201-205). She also engages in self-care activities (personal communication, May 15, 2023, lines 216-226) and any type of interaction with animals (personal communication, May 15, 2023, lines 333, 336-339, 347-350, 354-355, 359-361, 456-470). Communicating with her mother through talking and journaling has been especially helpful in dealing with negative thoughts of self-harm and overall mental health (personal communication, May 15, 2023, lines 270-304). Therapy has also been beneficial (personal communication, May 15, 2023, lines 270-272). PH can recognize that she is calmer after engaging in these coping strategies, noting her sleep and focus are improved. She does engage in alcohol use occasionally as a means of giving herself a hard mental reset (personal communication, May 15, 2023, lines 211-216). The overall essence of the interview lies in the fact that PH is proud of the accomplishments she has made despite having depression and anxiety that can interfere with her life. She wishes more people understood what it means to have anxiety, as that misunderstanding has been a source of stress with former roommates and her dad (personal communication, May INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 102 15, 2023, line 379-383, 393-394). She is aware of the IA of feeling calm, able to focus, and improved sleep. Still, she could benefit from paying more attention to the physiological interoceptive sensations surrounding hunger when experiencing stress. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. ...
- Creator:
- Phares, Stephanie
- Type:
- Dissertation
19. Occupational Therapists’ Perceptions of Autonomy Support During Feeding Interventions with Young Children: An Exploratory Qualitative Study
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- ... Occupational Therapists Perceptions of Autonomy Support During Feeding Interventions with Young Children: An Exploratory Qualitative Study Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Melissa R. Mattner MS, OTR/L Copyright October 24, 2023 By: Melissa R. Mattner MS, OTR/L All rights reserved Approved by: Lisa Borrero, PhD, FAGHE Committee Chair ______________________________ Christie Boxer, PhD Committee Member ______________________________ Michelle Suarez, PhD, OTR/L Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ OT PERCEPTIONS OF AUTONOMY SUPPORT 1 Occupational Therapists Perceptions of Autonomy Support During Feeding Interventions with Young Children: An Exploratory Qualitative Study Melissa R. Mattner Department of Interprofessional Health and Aging Studies, University of Indianapolis OT PERCEPTIONS OF AUTONOMY SUPPORT 2 Abstract Background: Feeding therapy is a complicated area of occupational therapy practice. A critical consideration in pediatric practice is developing and respecting a childs autonomy and sense of control during treatment sessions. Research on how therapists working in feeding consider this during feeding therapies is limited. Objective: This study examined the perceptions and intentionality in support of autonomy with occupational therapy practitioners who complete feeding interventions with children three and under. Specifically, in how they consider autonomy, as well as elements of the just right challenge when planning and implementing these interventions. Methods: The researcher utilized a basic interpretive approach. Participants were selected through social media recruitment through purposeful sampling. Audio-recorded, semi-structured interviews took place to collect data, then were transcribed. Transcriptions were analyzed using elemental coding methods, including structural and descriptive; overarching themes were then developed. Results: Three themes were identified within the data: High Intentionality of Autonomy Considerations, Conditional Intentionality of Autonomy Considerations, and Least Intentionality of Autonomy Considerations. Discussion: This research highlighted that occupational therapists' have varying degrees of intentionality when considering a childs autonomy in their clinical reasoning processes. It also highlights that this is a complicated subject with no clear-cut correct answer. Future research should address further inquiry into the occupational therapists development of knowledge on the subject, their beliefs, and biases in the area, as well as how graduate occupational therapy programs are teaching autonomy considerations to students. Keywords: occupational therapists, feeding therapy, autonomy, just right challenge, self-determination theory, responsive feeding, infant, toddler OT PERCEPTIONS OF AUTONOMY SUPPORT 3 Acknowledgments As the end of my program draws to a close, I want to acknowledge those who have been a part of one of the hardest years I have pushed through and survived. To my committee: Dr. Lisa Borrero, Dr. Christie Boxer, and Dr. Michelle Suarez - I will forever be grateful for your support. I was ready to throw in the towel and push my defense date back at several points in this process. While each of you stated you would support whatever decision I made, you kept me positively moving forward. I have saved screenshots of several emails I have read back to myself when I felt low. I would not have made it to this point without you behind me. I also want to acknowledge and thank my partner, Eric, for his unconditional love and assurance during this time. You have never let me give up and are constantly reminding me that you have watched me time and time again accomplish what I set out to do, not letting anything or anyone get in my way. Im sure youre so very ready for me to stop worrying about it once and for all. Thank you to my fellow faculty in the MSOT Program at Colorado Mesa University - Dr. Jennifer Fortuna, Dr. Sarah Gray, Dr. Tori Hibler, and Dr. Carla Wilhite - for allowing me to stop in and chat when I was feeling overwhelmed. I am in awe of the way we all lift each other up when one of us is down. I look forward to being able to continue to support each of you in this journey called life. Last but certainly not least, many thanks to my daughter, Avery. For all the weekends and evenings that you struggled to understand why I was once again busy with homework and writing. . . I hope you know the path I was paving was all for you. I love you more than anything in the world. Thank you for being patient with me. With love Mel (aka Mom) OT PERCEPTIONS OF AUTONOMY SUPPORT 4 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgments........................................................................................................................... 3 Occupational Therapists Perceptions of Autonomy Support During Feeding Interventions with Young Children: An Exploratory Qualitative Study ...................................................................... 7 Problem Statement ...................................................................................................................... 9 Purpose Statement ....................................................................................................................... 9 Research Question .................................................................................................................... 10 Significance of the Study .......................................................................................................... 10 Definition of Terms................................................................................................................... 10 Literature Review.......................................................................................................................... 10 Prevalence of Feeding Difficulties............................................................................................ 11 Parental Influence on Feeding .................................................................................................. 12 The Occupational Therapists Role in Feeding ........................................................................ 13 Types of Feeding Interventions ................................................................................................ 14 Autonomy ................................................................................................................................. 17 Conclusion ................................................................................................................................ 19 Method .......................................................................................................................................... 20 Study Design ............................................................................................................................. 20 Participants ................................................................................................................................ 20 OT PERCEPTIONS OF AUTONOMY SUPPORT 5 Procedures ................................................................................................................................. 20 Sampling and Recruitment .................................................................................................... 20 Informed Consent.................................................................................................................. 22 Data Collection ..................................................................................................................... 22 Data Management & Analysis .............................................................................................. 24 Rigor/Trustworthiness............................................................................................................... 25 Results ........................................................................................................................................... 27 Theme 1: High Intentionality of Autonomy Considerations .................................................... 28 Theme 2: Conditional Intentionality of Autonomy Considerations ......................................... 32 Theme 3: Least Intentionality of Autonomy Considerations .................................................... 36 Discussion ..................................................................................................................................... 39 Autonomy Considerations ........................................................................................................ 40 Implications for Occupational Therapy Practice ...................................................................... 42 Study Limitations ...................................................................................................................... 43 Future Research ........................................................................................................................ 43 Conclusion ................................................................................................................................ 44 References ..................................................................................................................................... 45 Table 1 .......................................................................................................................................... 67 Table 2 .......................................................................................................................................... 68 Figure 1 ......................................................................................................................................... 74 OT PERCEPTIONS OF AUTONOMY SUPPORT 6 Appendix A ................................................................................................................................... 75 Appendix B ................................................................................................................................... 76 Appendix C ................................................................................................................................... 79 OT PERCEPTIONS OF AUTONOMY SUPPORT 7 Occupational Therapists Perceptions of Autonomy Support During Feeding Interventions with Young Children: An Exploratory Qualitative Study Feeding problems in childhood are not a rarity, as they occur in approximately 27% of children, with the highest prevalence before three years of age (Benjasuwantep et al., 2013). Prevalence is higher (42%) among children born prematurely (Pados et al., 2021). Feeding disorders and problems may present as food selectivity, dysphagia, aspiration, difficulty gaining weight, malnutrition, texture aversions, problematic behaviors at mealtimes, and atypical physical responses such as gagging and vomiting at mealtimes (Benjasuwantep et al., 2013; Kovacic et al., 2021; Pados et al., 2021; Van Dijk et al., 2021). The children that most experience feeding difficulties are between the ages of 2 and 3 (Cole et al., 2017; Sudewei et al., 2021). Feeding is an important occupation that all human beings experience throughout their lifetime (AOTA, 2017). In all cultures, infants and children rely on their caregivers to provide nourishment to ensure their development (Winston et al., 2010). However, feeding is not only an activity to sustain ones life; it is an activity that allows for the acquisition of social skills as well as the development and support of positive family relationships (Ausderau et al., 2019; Korth & Maune, 2020; Suarez et al., 2014). Without those positive feeding relationships and interactions, a childs development could be compromised (Slaughter & Bryant, 2004). Multiple diagnoses correlate with feeding disorders and problems, including ASD (autism spectrum disorder), ARFID (avoidant/restrictive food intake disorder), cerebral palsy, Down syndrome, and sensory integration disorders (Anil, et al., 2019; Estrem et al., 2022; Snider et al., 2010; Tauman et al., 2017). Treatment for feeding difficulties within these diagnoses may include but are not limited to, interventions addressing deficits in oral motor and swallowing processes, as well as sensory sensitivities (Snider et al., 2010). Psychological treatments and OT PERCEPTIONS OF AUTONOMY SUPPORT 8 behavioral methods, such as systematic desensitization, may also be included (Spettigue et al., 2018; Toomey & Ross, 2011). It is essential to proceed with caution when choosing feeding treatments for children with the above diagnoses, as some feeding practices, such as escape extinction, could be traumatic for a child (Leaf et al., 2022). Escape extinction is a method that prohibits a child from leaving the situation that they are in until they comply with the instruction given; in regard to feeding, the child may not be allowed to leave the table until they comply with eating instructions (Cormack et al., 2020). This practice is one example of harmful feeding practices that may be viewed as coercive and non-conducive to a childs autonomy or right to choose (Chazin et al., 2021). Studies have shown that parental support in developing a childs autonomy is important for successful, positive feeding experiences (Bassett et al., 2008; Cormack et al., 2020; van der Kaap-Deeder et al., 2017). Psychologically controlling tactics by parents can be detrimental to the development of autonomy. These tactics may include shaming, manipulation, and not allowing their child to make any of their own choices (van der Kaap-Deeder, 2017). However, parents who control their own emotions around mealtimes and are responsive to their childs own hunger cues are better able to support their childs development of autonomy (White, 2022). Similarly, the autonomy of the child should be considered in feeding by health professionals, such as occupational therapists, who engage in feeding therapy. Autonomy is rooted in self-determination theory (SDT), which has also been referred to as basic needs theory. (Cormack et al., 2020). SDT combines the concepts of autonomy, competence, and relatedness. Occupational therapists can support the development of these concepts through the consideration of an individuals own goals for their therapy (Ziviani, 2015). Autonomy is also an important element in occupational therapy practice as defined by the OT OT PERCEPTIONS OF AUTONOMY SUPPORT code of ethics. The American Occupational Therapy Associations (AOTA) most recent version of the code of ethics states: Freedom indicates valuing each persons right to exercise autonomy and demonstrate independence, initiative, and self-direction. A persons occupations play a major role in their development of self-direction, initiative, interdependence, and ability to adapt and relate to the world. Occupational therapy personnel affirm the autonomy of each individual to pursue goals that have personal and social meaning. (AOTA, 2020, p. 7413410005p2) Currently, limited research exists on how occupational therapists consider autonomy in children of any age with any intervention. Problem Statement The extent to which pediatric occupational therapists consider the autonomy of children three and under when planning and implementing feeding interventions is not yet understood. While there has been published research speaking to the importance of responsive parental support of autonomy in the area of feeding (Cormack et al., 2020; Loth et al., 2022; Redsell et al., 2021; Slaughter & Bryant, 2004; Sudewei et al., 2021; White et al., 2022), there is a lack of research on how occupational therapists can better support the self-determination and autonomy of children, especially in the area of feeding. Purpose Statement The purpose of this study was to understand how occupational therapists consider a client's autonomy, specifically in feeding interventions with children three and under. Increased understanding of occupational therapists knowledge and attitudes towards autonomy in feeding interventions may improve outcomes and prevent traumatic experiences in young clients. 9 OT PERCEPTIONS OF AUTONOMY SUPPORT 10 Research Question This study addressed the following question: How do occupational therapists consider the autonomy of children three and under when planning and implementing feeding interventions? Significance of the Study The information gained from this study may improve how occupational therapists view the interventions they put into practice, as well as further research and development of feeding programming that reflects the support of autonomy development. Definition of Terms Pediatric Occupational Therapist occupational therapists that address activities of daily living (ADL) with children and youth ages 0-18. (American Occupational Therapy Association, 2015). Autonomy Acting in an internally driven way, in a way that one is controlling and making decisions for themselves (Keller, 2016). Just right challenge A means of guiding the therapists choice of activities so that they were not too easy or too difficult for the child (DArrigo et al., 2020, p. 134). Self-determination theory (SDT) a perspective that encompasses human motivation, it considerings three specific areas: autonomy, relatedness, and competence (Ryan & Deci, 2000; Ryan & Deci, 2020) Literature Review As recent as 2019, researchers have had difficulty finding a complete way to define pediatric feeding disorders (PFD) and proposed that it be described as restricted oral intake that is not age appropriate and is associated with medical, nutritional, feeding skill, and/or OT PERCEPTIONS OF AUTONOMY SUPPORT 11 psychosocial dysfunction (Goday et al., 2019, p. 125). Feeding disorders can manifest in several different ways, which include but are not limited to highly selective eating tendencies, sensory or texture aversions, oral motor, and swallowing dysfunction, and in some cases, they may manifest as ARFID (avoidant restrictive food intake disorder; Anil et al. 2019; Benjasuwantep et al. 2013; Engel-Yeger et al., 2015; Miller, 2014). ARFID is a condition described in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) as a feeding disorder that is not otherwise explained by any other mental health issue; it is characterized by a severely restricted diet that leads to weight loss, loss of nutritional intake, and the potential for requiring nutritional supplementation and enteral feeding methods (Katzman et al., 2019; Spettigue et al., 2018) Prevalence of Feeding Difficulties According to Benjasuwantep et al. (2013), the prevalence of pediatric feeding disorders is around 27% for typically developing children between 12-48 months of age. In children with developmental disabilities and those born prematurely, this number could range from 45% to as high as 80-90% (Pados et al., 2021; Kleinert, 2017). However, Estrem et al. (2022) found in a scoping review that it was difficult to accurately convey pediatric feeding disorder prevalence as few large-scale studies have been conducted to address and target a more specific number. Pediatric feeding disorders are considered common in children on the autism spectrum, affecting approximately 24% of children under the age of 3 with ASD (Seiverling et al., 2018). However, previous research by Cermak et al. (2010) indicated that the number could be upward of 80%. In 2021, Inoue et al. found that in children under 16 diagnosed with anorexia nervosa or ARFID, up to 16.3% of those children also had a diagnosis or traits of ASD. Sensory integration disorder and selectivity are seen as common causes of feeding difficulties in autistic children (Bourne et al., 2022; Cermak et al., 2010; Suarez et al., 2012). Cerebral palsy and Down OT PERCEPTIONS OF AUTONOMY SUPPORT 12 syndrome are other diagnoses associated with a greater likelihood of feeding difficulties (Anil et al., 2019; Nur et al., 2019). The most common problems for these children are oral motor dysfunction, including tongue movements and the ability to swallow safely (Anil et al., 2019; Nur et al., 2019). Children with cerebral palsy may have a more severe inability to take food by mouth and may have tube feeding as their primary source of nutrition (Hopwood et al., 2021). Parental Influence on Feeding Mealtimes and feeding are both significant routines for families. It is one of the most meaningful occupations that children in all cultures engage in, as it addresses both nutritional needs and the building of social skills (AOTA, 2017; Henton, 2018). Mealtimes together are vital for developing family relationships and an increased food repertoire (verby et al., 2020). However, mealtimes may also become trying times for families. When a child is having difficulties with feeding, such as food selectivity, caregivers often become stressed; this may lead to them feeling as though coercion and force-feeding are their only option for ensuring their child receive nutrition (Verhage et al., 2018; White et al., 2022; Winston et al., 2010). A significant amount of research has been done on how parenting and caregiving styles can positively and negatively influence feeding. While parents may find that their methods of encouraging a child to eat, such as bribery and the use of food as a reward, are effective in the short term, these strategies have been reported to have adverse long-term effects (Russell et al., 2015; Slaughter & Bryant, 2004; Sudewei et al., 2021; Wehrly et al., 2014; White et al., 2022). One negative long-term effect includes an inability to expand their diet as the child ages (Batsell et al., 2002; Mou et al., 2021). Parental pressure may directly increase a childs refusal to eat or failure to expand their dietary selections (Jansen et al., 2017). Parents may also inadvertently ignore their childs hunger cues (Galindo et al., 2018). OT PERCEPTIONS OF AUTONOMY SUPPORT 13 Issues like force-feeding and pressure by parents and other caregivers can cause significant mental and behavioral consequences, as well as a worsening of food difficulties and refusals and decreased development of autonomy (Black & Aboud, 2011; Jansen et al. 2017). For some children, the effects of pressure continue through adulthood (Batsell et al., 2002). Not only may they continue to dislike items that they were forced to eat, but they may develop further food aversions based on the actions of their caregivers. Specific actions such as punishment, deception, and threats cause tearful episodes and could even result in the child vomiting from the distress. Eventually, there is a risk of developing neophobia, which is characterized by avoidance of most new and unknown foods; they also may choose to eat predominately unhealthy foods as adults (Batsell et al., 2002; Mou et al., 2021; Wadhera et al., 2015). Research has shown that responsive feeding and mealtimes that include frequent exposure, modeling, encouragement, and family engagement are most effective in improving a childs feeding difficulties and overall nutritional well-being (Finnane et al., 2017; Wadhera et al., 2015). Parents report less stress when they focus on the promotion of autonomy during mealtimes (White et al., 2022), and they welcome strategies from their childs healthcare team on how to make mealtimes more successful (Caldwell et al., 2018; Caldwell et al., 2020; Slaughter & Bryant, 2004). These strategies, including structured meal plans and setting specific times and places for feeding, successfully promote positive feeding behaviors. (Mallan & Miller, 2019). The Occupational Therapists Role in Feeding Both occupational therapists (OTs) and speech and language pathologists (SLPs) are qualified to treat feeding difficulties. While SLPs have more training in oral motor and OT PERCEPTIONS OF AUTONOMY SUPPORT 14 swallowing, OTs are uniquely positioned to address sensory processing difficulties related to feeding. This can be a strong focus for evaluating infants and children with sensory sensitivities and over-responsivity. (Subramaniam & Reid, 2003). They also have a holistic perspective of recognizing and assessing not only the physiological factors but also the psychosocial, cultural, and environmental factors involved with these aspects of daily performance (American Occupational Therapy Association, 2017, p. 7112410015p1). The role of OT in feeding therapy has grown significantly; the position paper released initially in the late 1980s by the American Occupational Therapy Association (AOTA) was a one-page document focusing primarily on seating, social interaction, and physical impairments such as oral motor dysfunction (American Occupational Therapy Association, 1989). This has evolved today into a 13-page document with guidance on the knowledge required for entry-level and advanced practice in feeding (American Occupational Therapy Association, 2017). While occupational therapists have been a part of feeding therapies for the last several decades, there does not seem to be an agreement on what approach is the most optimal for interventions with children with pediatric feeding disorders (Hamre et al., 2017; Howe & Wang. 2013). Types of Feeding Interventions Feeding interventions that OTs may include when planning may involve techniques from several approaches, including oral motor, sensory/sensorimotor and behavioral (American Occupational Therapy Association, 2017; Barton et al., 2017; Caldwell et al., 2018; Cormack et al., 2020; Howe & Wang, 2013; Paul & DAmico, 2013; Zobel-Lachiusa et al., 2015). It is recommended that entry-level therapists or those with minimal experience in feeding spend time with a mentor with an advanced level of expertise and complete other formal training (American Occupational Therapy Association, 2017). While these guidelines are recommended to be OT PERCEPTIONS OF AUTONOMY SUPPORT 15 followed, there are no set requirements for occupational therapists who would like to participate in feeding interventions. Oral motor skills are the foundation for feeding. Oral motor interventions are among the most important, with therapists completing these interventions in children as young as newborns with difficulty with bottle or breastfeeding (Hardy et al., 2018; Paul & DAmico, 2013; Subramaniam & Reid, 2003). Children with developmental delays, including children with cerebral palsy, Down syndrome, and ASD, frequently experience delays in this area (Anil et al., 2019; Chaware et al., 2021; Gisel et al., 2003; Nur et al., 2019; Widman-Valencia et al., 2021). Interventions for oral motor may address sucking and swallowing patterns, tongue movement, as well as tongue and jaw strength, with an end goal of increasing oral feedings, reducing tube feedings, or advancing the texture of foods for children who have not had the endurance to tolerate more than pureed foods (Arora et al., 2018; Manno et al., 2005; Widman-Valencia et al., 2021). Oral-motor delays and oral sensory sensitivities may overlap, but it is difficult to pinpoint which is the cause of the other (Benson et al., 2013). Several protocols have been designed for sensory feeding difficulties, but many rely on the same concept of systematic desensitization to address sensory over-responsivity to certain foods and food textures (Benson et al., 2013; Elliot & Clawson, 2010; Suarez, 2020). Systematic desensitization involves gradually exposing a child to new foods through interactions that include tolerating it being near them, touching it, and eventually tasting it, which may consist of several steps in between (Benson et al., 2013; Tanner & Andreone, 2015). While systematic desensitization may take some time to be implemented and accepted by the child, some studies have shown it to be successful in increasing food acceptance (Suarez, 2020; Suarez, 2022; Tanner & Andreone, 2015). OT PERCEPTIONS OF AUTONOMY SUPPORT 16 Behavioral techniques are often combined with both types of feeding interventions described above. Some common behavioral techniques that may be seen in feeding interventions include escape extinction, positive reinforcement, and antecedent manipulation (Edwards et al., 2015; Gibbons et al., 2007; Howe & Wang, 2013; Suarez, 2020; Williams et al., 2007). In feeding, escape extinction restricts the child from leaving or escaping a situation until they comply with the goal of the day is accomplished, which may be something as simple as interacting with a food by touch or by taking a bite (Peterson et al., 2016; Suarez, 2020). Positive reinforcement is a response given after a child has taken a bite, which may include a reward such as playing with a toy or choice or a positive verbal response (Edwards et al., 2015; Gibbons et al., 2007). Lastly, there is antecedent manipulation which may include changing how mealtimes are structured, how food is presented, and even how the environment can be adjusted to increase the likelihood of a successful feeding session (Edwards et al., 2015). When done with attunement to the childs feelings and cues, these behavioral techniques have been shown to be successful and have a positive effect on increasing a childs oral food intake. An essential concept in the planning and implementation of pediatric intervention, including feeding therapy, is the idea of providing a just right challenge to move a child beyond their comfort level with food (Suarez & Bush. 2020; Suarez. 2022; Trewin et al. 2022; ). The concept of the "just right challenge" in pediatric occupational therapy is a fundamental principle that guides therapists in tailoring interventions to meet the specific needs of children (Bundy et al., 2002). It refers to finding the optimal level of challenge that is neither too easy nor too difficult for a child, aligning with their current abilities and promoting growth, development, and skill acquisition (Ayres, 2005; Canadian Association of Occupational Therapists, 1996). The OT PERCEPTIONS OF AUTONOMY SUPPORT 17 goal is to create an engaging and motivating environment where children can succeed while still being challenged enough to make progress (Lindquist et al., 1982). Autonomy Considering a childs autonomy is integral to any pediatric rehabilitation treatment plan (Hilberink et al., 2020; Meyns et al., 2018). It can be difficult to respect autonomy when a child refuses care, particularly when this conflicts with the parents goals/wishes (Wasserman et al., 2019). There is a continued debate on the ethical and legal aspects of maintaining appropriate boundaries while allowing children more volitional control of their treatment (Beach & Proops, 2009; Chenneville et al., 2021). All children are working to build their autonomy, self-regulation, and sense of self, a process that begins in infancy (Black, 2021; Chang et al., 2014; Gilmore et al., 2016; Hilberink et al., 2020). Toddlers specifically demonstrate the development of their autonomy with spontaneous play and exploration of their environments (Ct-Lecaldare et al., 2016). Adults should [engage] in a reciprocal and collaborative relationship with the child (Ct-Lecaldare et al., 2016, pg. 23) to best support this development of autonomy. This may be especially important for children with PFD because nutritional intake is necessary for survival. An aspect of autonomy consideration is at what age pediatric patients should have a say, with the consensus being around 11-16 years old (Chenneville et al., 2021; Duncan & Sawyer, 2010). Medical professionals are less likely to allow a child to make decisions on their medical care, dependent on their prognosis (Duncan & Sawyer, 2010). Most existing research focuses on how to respect the development of autonomy in adolescents. Collaboration between adolescents and their caregivers is important to give the patients a feeling of personal responsibility for their care (Partridge, 2014). Parents and caregivers may not understand the development of autonomy and, therefore, may have inappropriate expectations and exhibit high levels of psychological OT PERCEPTIONS OF AUTONOMY SUPPORT 18 control of their relationships with their children (Sudewei et al., 2021; van der Kaap-Deeder, 2017). When there is a concern for the childs health, safety, and level of competence for making their own decisions, parents often return to an authoritarian approach, attempting to take control of the situation (Beach & Proops, 2009; Duncan & Sawyer, 2010). Supporting and facilitating autonomy in young children is vital in establishing competence in adolescent decision-making. Autonomy develops best with moderate levels of autonomy support, low levels of psychological control and relatively high levels of need satisfaction and well-being in place (van der Kaap-Deer et al., 2017, p. 242). Children of many ages appreciate trusted individuals to speak with about their needs and skills development. (Bath, 2013, Hilberink, 2020). While children may not be capable of complete control of their medical decisions, they want to be listened to and participate in the goal-setting process (Dunn & Thrall, 2012; Kolehmainen et al., 2012; Wangmo, 2017). Infants and toddlers cannot voice this same desire, but it can be inferred that the same consideration toward them in treatments would also be necessary. Healthcare workers have an ethical obligation to complete treatments when children are refusing, but forcing treatment on an unwilling participant is also a moral concern (Zutlevics & Henning, 2005). Autonomy is an essential piece of self-determination and self-determination theory (SDT), which also considers motivation (Cormack et al. 2020). SDT is a growing area of healthcare research, and it examines autonomy, relatedness, and competence and their connection to intrinsic and extrinsic motivation (Ryan & Deci, 2000). It is also a growing area in occupational therapy, with researchers making the connection that self-determination is related and vital to occupational performance as it looks in depth at psychological needs (Bray and Capilouto, 2021; Ziviani, 2015). OT PERCEPTIONS OF AUTONOMY SUPPORT 19 Self-determination theory (SDT) states that for an individual to succeed best and to be intrinsically motivated, their environments should meet their needs for autonomy, competence, and relatedness. A study by Stanton et al. (2020) found that meeting these three needs increased feelings of safety and well-being among children and adolescent mental health patients, increasing their motivation to participate in treatment. The principles of SDT work closely with goal-setting theory, which emphasizes the importance of ensuring the level of goals is appropriate and attainable and that clients find motivation (Cormack et al., 2020; Pritchard-Wiart et al., 2019). It also aligns with the occupational therapy concept of the just-right challenge in assisting children in finding what helps them feel safe, motivates them, and moves them along from a clinical standpoint (DArrigo et al., 2020; Poulsen et al., 2006). Conclusion There has been little research on autonomy as a part of intervention planning in pediatric occupational therapy, specifically as it relates to the treatment of feeding disorders in young children. When considering the needs of young children, goal setting has typically been based on family autonomy, needs and routines (Caldwell et al., 2018; Lage et al., 2022; Pritchard-Wiart et al., 2019). In recent literature on goal setting, autonomy, and shared decision-making with children and adolescents themselves in healthcare settings, there is an overall recommendation that this area is further researched and considered (Delany & Galvin, 2013; Kon & Morrison, 2018; Levy et al., 2016; Park & Cho, 2018; Wyatt et al., 2015). Allowing a child to participate in the intervention process on their own terms may increase motivation in therapeutic activities and interventions, potentially improving feeding intervention participation and success (Cormack et al., 2020). This research study will examine how occupational therapists consider a childs autonomy when planning and implementing feeding interventions in children ages 3 and under. OT PERCEPTIONS OF AUTONOMY SUPPORT 20 Method Study Design This qualitative study utilized an interpretive approach to explore the experiences and perceptions of occupational therapists (OTs) that address feeding difficulties in children three years of age and younger. This approach was chosen as the overall purpose [of the interpretive approach] is to understand how people make sense of their lives and their experiences (Merriam, 2002, p. 38). This researcher was explicitly interested in how these OTs consider the development of autonomy in this age group when planning and implementing feeding interventions. Participants An individual was considered eligible for participation in this study if they 1) lived in the United States and were either a licensed occupational therapist or licensed occupational therapy assistant in any pediatric setting; 2) had completed feeding interventions (including but not limited to oral-motor, sensory, or behavioral approaches) with children ages three and under for a minimum of 6 months; 3) children ages three years and younger consisted of 25% of their feeding caseload at minimum; and 4) speak English. Individuals who did not meet these criteria were excluded from participation. Procedures Sampling and Recruitment A purposeful criteria sampling was utilized, selecting participants based on a predetermined criterion of importance (Patton, 1990). The goal was to recruit fifteen to twenty individuals for one-on-one interviews. This number was decided upon based on Malterud et al.s (2016) model related to the concept of information power, which states, the larger OT PERCEPTIONS OF AUTONOMY SUPPORT 21 information power the sample holds, the lower N is needed, and vice versa (p. 2). Their model states that the narrower and stronger a study design is, the fewer participants are required. This study had a narrow aim, and the plan for interviews was a robust and in-depth conversation. Thirty-five individuals responded to the initial survey, eight of which were not eligible for participation. A total of sixteen participants were interviewed for this study. The remaining eleven eligible respondents either did not respond to further communication or emailed the researcher back to state they were unable to participate at this time. Participants were recruited through posts within social media groups, including Facebook pediatric OT and feeding therapy groups, as well as AOTA CommunOT forums (see Appendix A). The CommunOT forums the survey will be published in include the General Forum, the Developmental Disabilities Forum, and Special Interest Sections for Children & Youth, as well as Sensory Integration & Processing. The researcher first ensured that the research solicitation posting was within a Facebook community or group's rules and obtained any necessary permissions before posting. If the Facebook group did not have a rule one or another, the researcher contacted the group/community administrator via Facebook Messenger before proceeding. Some of AOTAs CommunOT forums request that research study and survey information be placed in specific, designated threads on a board. When the researcher was ready to post, they verified this before posting a new thread in the forum. Snowball sampling was also used by the researcher, requesting that participants assist in recruitment if they know of others who would be interested in participating (Marshall et al., 2022; Oregon State University, 2010). Because the researcher did not request referral information in the initial Qualtrics survey, it is not known what percentage of participants came from each source. OT PERCEPTIONS OF AUTONOMY SUPPORT 22 Posts included a link to a confidential Qualtrics survey that explained the basic tenets of the study, as well as the consent information. To screen for eligibility, it also collected participants' basic demographic and job information, including their discipline, experience level, and general feeding caseload percentage. It further requested contact information, such as email and phone number, contact preferences (time of day to best contact and interview them), and permission to be contacted directly by the researcher to discuss the study verbally, establish that eligibility criteria are met, and schedule an interview if they wanted like to move forward with participation in the study. To keep this information confidential, the researcher kept survey data on the Qualtrics site without exportation. Informed Consent Participants were informed at all stages by the researcher that their participation was voluntary and that they were allowed to withdraw or refuse to answer at any time. A study information sheet was available as an attachment as a part of the Qualtrics survey, and they were required to check a box to acknowledge the review of this information. This study information sheet included details on the purpose of the study, including the approximate duration of study participation; information on voluntary withdrawal; the rights and responsibilities of the participant; and a statement of confidentiality (see Appendix B). They were reminded of these rights by the researcher at each stage in the process, including at the time of interview scheduling and interview participation. The researcher requested verbal consent at the start of the interview, which was recorded with the participant's permission to participate by audio and video recording. Participants were also reminded that they would be contacted via their contact method of choice within 2-4 weeks after their interview to verify the themes interpreted by the researcher. Data Collection OT PERCEPTIONS OF AUTONOMY SUPPORT 23 The researcher collected data through one-on-one, semi-structured interviews that took place between January 2023 and March 2023. Interviews were scheduled at the interviewees convenience. They were conducted and recorded via the Zoom web conference platform; both audio and video were automatically recorded and saved, as per the Zoom functionality. All video was deleted from Zoom, as only the audio was used for analysis. The audio was initially placed in a password-protected cloud storage account before also being deleted from Zoom. Temi, an audio-to-text transcription service, was used for transcription. All identifying information, such as names, was removed during transcription editing in Temi. All audio and transcription files were labeled by participant number to protect participants privacy. Transcription files were removed from Temi and uploaded to the same password-protected cloud storage account. Before the interviews, the researcher collected general demographic information, including discipline (OT or OTA), level of education, and years of experience as an occupational therapist or occupational therapy assistant. Participants were also asked to specify their primary practice setting. This information was gathered during the completion of the initial interest survey. With each interview, the researcher used a semi-structured interview guide developed by the researcher (see Appendix C) to explore topics such as the participants experience in feeding therapy, training in feeding approaches, and how they choose feeding interventions. Interviews lasted between 30-70 minutes. Interview questions examined the participants experiences as occupational therapists, the diagnoses they work with, feeding training in their occupational therapy programs, and additional feeding continuing education they may have completed. The researcher also asked how the participants chose their approaches to feeding interventions and how they built rapport with children before or during intervention. The researcher built on this OT PERCEPTIONS OF AUTONOMY SUPPORT 24 question, asking about the importance of and consideration of topics such as a childs ability to control their session and the development of autonomy. The researcher utilized memoing throughout data collection and analysis, which is a reflexive method by which researchers take note of thoughts and feelings that may arise during the research process, e.g., during qualitative interviews, to monitor the researcher's biases throughout the interviews (Birks et al., 2008). At the end of the interviews, participants were asked if they would like to add any additional thoughts on feeding or advice for other occupational therapists moving forward. The researcher then ensured that participants had the researchers contact information to add any additional information later as necessary. The participants were then reminded that the researcher would be completing member checking following data analysis to ensure the participants experiences and perceptions have been appropriately interpreted by the researcher. Data Management & Analysis After each interview, the researcher uploaded audio recordings to their passwordprotected university cloud drive for storage and then temporarily to Temi, the transcription service. The researcher listened to the recordings in Temi and read through them to ensure they had been accurately transcribed. The transcripts were edited if the service misinterpreted any of the audio. Other edits were made to enhance readability, including the removal of excessive repeated use of phrases such as um. Transcripts were downloaded from Temi in the form of Word.docx files and placed in the password-protected drive; all recordings and data were immediately deleted from Temi when this download occurred. Transcriptions were then uploaded to Dedoose OSX 9.0.90, a qualitative data analysis software that ensures a secure platform through encryption (Dedoose, n.d.). OT PERCEPTIONS OF AUTONOMY SUPPORT 25 In the first step of coding, the researcher, with the assistance of a second researcher, an expert in qualitative analysis, applied elemental coding methods from Saldana (2021), including but not limited to structural, descriptive, and in vivo coding. All transcript reviews and coding by the researchers took place in Dedoose. The first read-through by the researchers primarily focused on in vivo coding, which uses a participants own wording (Saldana, 2021), as well as descriptive or topic coding. On subsequent read-throughs, structural coding was used based on sections of interview questions. Structural coding both codes and initially categorizes the data corpus to examine comparable segments commonalities, differences, and relationships (Saldana, 2021, p. 130) and was used to maintain a similar coding process and approach across the participant transcriptions. Overarching themes were developed from patterns or commonalities with the identified codes following these final read-throughs by the primary and secondary researchers. When initial themes were identified, member checking was conducted whereby the primary researcher followed up with participants via email to clarify interview themes and coding to support the studys credibility. Two participants emailed the primary research in response with additional clarifying information that did not affect interpretation. Theme tables were then created by the primary researcher, with noted interview quotes and a visual representation of the themes, both of which were inserted into the final manuscript (See Table 2 and Figure 1). Rigor/Trustworthiness Rigor and trustworthiness were addressed utilizing Gubas four components of trustworthiness, which include credibility, transferability, dependability, and confirmability of a qualitative study (Henderson & Rheault, 2004). To support the credibility of this research study, the researcher applied reflexivity to the data collection process using memoing during the data OT PERCEPTIONS OF AUTONOMY SUPPORT 26 collection process. Credibility reflects the extent to which the results accurately represent the experiences and stories shared by the participants (Henderson & Rheault, 2004). During data analysis, member checking was used to improve the validity of participants data. Each participant was initially contacted via phone or email based on contact preference. Initially, in the study information sheet, participants were informed that member-checking phone calls would take place; however, email was more convenient for participants. They each received a 12-page Word document by email with compiled interpreted information from their interviews that they could take their time to review. The primary researcher created a Word document for each participant that included the following sections: practitioner profile, a summary of practice, treatment sessions, incorporation of child views in session, and additional practitioner views. In each section, the researcher had written their interpretation of the member statements and views, backing these statements up with quotes from their interview. Ten of the sixteen participants responded to member checking. Credibility was also supported by having a second researcher involved in the data analysis process and the final solidification of identified themes. Transferability refers to the degree to which the results of qualitative research can be transferred to other contexts or settings with other respondents, which supports the ability to generalize study results (Henderson & Rheault, 2004; Korstjens & Moser, 2017, p. 121). During data collection, the researcher collected as much relevant background information as possible from participants, including their degree (Bachelor/Master/Doctorate level), practice setting, years in practice as a feeding therapist, and educational/training status. The researchers specific reporting and thick description ensured transferability during the analysis process. Dependability relates to the consistency of the study's results (Henderson & Rheault, 2004), whereby similar results would emerge if the study were replicated with the same OT PERCEPTIONS OF AUTONOMY SUPPORT 27 participants. To support this, before data collection, the committee served as the reviewers for the survey and interview guide. During the data analysis process, code-recode procedures were put into place, and a second researcher assisted with the process. A detailed description of the methods in the finalized manuscript also supported dependability. Lastly, confirmability, which is the effort to remove any research bias (Henderson & Rheault, 2004), was used. During data collection, as with credibility, reflexivity was addressed with memoing. During data analysis, a secondary researcher with experience in qualitative research outside of the occupational therapy discipline reviewed the analysis of the transcripts to ensure that bias was mitigated. Results Sixteen participants were interviewed for this study in order to explore how occupational therapists consider autonomy in the planning and completion of feeding interventions, specifically with children three and under. All participants were licensed occupational therapists with a range of feeding experience from one year to forty years of feeding experience (mean = 17.53 years; SD = 13.62 years). Demographic information can be reviewed in Table 1. Education levels were found to be similar between each group. Most participants reported taking similar continuing education courses and being current on feeding therapy approaches. Some reported courses include the SOS Feeding Therapy Approach training, Beckman Oral Motor, and AEIOU: An Integrated Approach to Feeding, as well as courses that address ARFID (Avoidant Restrictive Food Intake Disorders) and gastrostomy-tube feedings. Two of the participants, the two with the least professional and feeding experience, had not taken any formal feeding continuing education courses at the time of their interviews. OT PERCEPTIONS OF AUTONOMY SUPPORT 28 The responses varied when participants discussed the considerations of a childs autonomy and ability to feel a sense of control in their sessions. Many participants felt that these concepts were vital to the success of feeding interventions (10 out of 16 total). Based on participants reports of their experiences, a varying degree of support and intentionality of these concepts emerged. Structural and descriptive coding revealed three predominant themes around which respondents can be grouped: 1) High Intentionality of Autonomy Considerations, 2) Conditional Intentionality of Autonomy Considerations, and 3) Least Intentionality of Autonomy Considerations. Subthemes within each topic were also identified and can be reviewed in the concept map (Figure 1). Theme 1: High Intentionality of Autonomy Considerations Autonomy & Control Considerations Participants considered to have high intentionality of these considerations made strong statements in support of a childs autonomy and sense of control during feeding interventions. They also gave examples to reinforce their opinions. This group made no statements to indicate that their support was conditional or based on situational factors. Instead, their responses suggest that allowing child-led sessions and monitoring childrens feedback cues were crucial to every intervention planned. The number of participants that fell into this category was 7 out of 16. Nearly all participants in this group discussed the importance of watching a childs body language and cues for whether to proceed or switch directions during interventions in order for the child to feel safe. Participant 1 (P1) explained: A lot of times, I have to look at their cues because they're not going to tell me necessarily. Sometimes they're lovely to be vocal about it, but really no matter what age, I've found you really have to look at their cues, their eyes, their eyebrows, facial OT PERCEPTIONS OF AUTONOMY SUPPORT 29 expressions, and hands. They're really going to tell you what they do and do not want. So, I go off of what their comfort level is, see what they react to. Participant 9 (P9) expanded on how watching those cues is part of respect for the child as a person, explaining: I think it's everything. We have to listen to what they're saying. They're little tiny beings that have few ways to let us know what they're feeling. And just because they're really little doesn't mean their emotions are really little. More than half of the participants in this group emphasized they not only respected cues but also worked to educate families on how to read cues to be more responsive to their children. Participant 4 expressed: I do teach parents how to look for when their child is giving them a green light or a red light in terms of their readiness to eat. . .Are they going to verbally or gesturally, or expressively show interest or protest? And to honor that voice early. Many participants in this group agree that there may be something happening that the child is unable to verbally communicate about things happening in their bodies, no matter the age. P13 discussed: I would say, for a child, we need to understand that they are making choices sometimes for a reason. And we need to really understand why they're making those choices, you know, and respect sometimes the choices they're making, that it cannot be a battle. Factors Influencing Intervention Approaches Every participant in this group explained that child factors were their primary intervention consideration. The most discussed factors were child safety (health and relational safety), skill level, and age. Participant 2 (P2) expressed that it is vital to look beyond the most obvious deficits: I think, sometimes, like when we just focus on things like, oh, sensory motor, OT PERCEPTIONS OF AUTONOMY SUPPORT 30 what you're putting into your mouth, the texture of food, things like that. . .And you don't take into account how's the child breathing, how's the child digesting. Three participants discussed incorporating family culture and preferences since this buyin from families is important to the interventions success. Participant 2 (P2) stated, I always try and get a picture of what the family's culture is around eating and food and feeding. Participant 9 (P9) reported, I think what influences me because I'm working with these babies, a lot of it has to do with the families and what the family's approach is like. Another factor that is in consideration for most participants is safety. All participants discussed health-specific safety factors, but 4 out of the 7 participants in this group specifically discussed the importance of a child feeling a level of trust and safety, particularly during treatment and before advancing to the next step in the intervention plan. Participant 4 (P-4) shared, My first and most highest priority is safety. And when I say safety, I don't just mean prevention of aspirating, I mean relational safety, felt absence of threat, and felt presence of connection for a child. Participant 12 discussed challenging a child to try or touch a new food, while also keeping in consideration what they may be able to tolerate saying, If kids just truly can't touch it, they don't want anything sticky or slimy or watery that's going to stay on their hands, I want to pick something that they can touch and let go of so that they feel safer, at least shove it out of the way; its no longer stuck on their hand. Motivation was another consideration that was brought up. However, less than half of the participants (3 of 7) in this group discussed using or finding out what is a motivator for the children when they are working on increasing the challenge during treatment. Participant 12 discussed the use of other foods with older children, Typically with older kiddos that as I build OT PERCEPTIONS OF AUTONOMY SUPPORT 31 the rapport and feeding therapy gets more established, those preferred foods can be used as motivation when appropriate. Actions When Interventions are Not Working It was common for participants to report that there are times when intervention plans and sessions may not go as expected. While each participant reported their own process of reflecting on what needs to be done next, the general process amongst all was to step back and review as many factors as possible before deciding on a change to their approach. These factors included medical conditions, family participation, environmental factors, and reflecting on their own flexibility. Participant 12 (P-12) described the need for flexibility within a session as follows: Depending on what's happening in the situation, usually I encourage the family to take a break for mealtime, that it's getting to be stressful and not productive, and we can always come back to it, or we can take the snack to the floor or outside or a different location if we really need to consume what's eaten. But that's also a really good time to talk about hunger cues and when and how to encourage a child to eat versus letting kind of the child determine their appetite at that time. One participant specifically discussed the possibility of referring to another discipline when things are not going as expected and changing approaches has not been successful for them. This primarily happens when a problem arises that may not be within the scope of occupational therapy practice. I try different dynamics. I try and change it up. If I don't feel like it's getting somewhere, I'm very open to asking the family, saying it's not about what we've tried with it. However, there's a bigger need in a different area than my scope (P-1). Those in this category have a high level of intentionality in their considerations for incorporating autonomy and control into their treatment planning. They verbalize their support of OT PERCEPTIONS OF AUTONOMY SUPPORT 32 autonomy and demonstrate it through their actions. They understand that a young child cannot always explain what is bothering them and pay close attention to physical cues during interventions. Some report they consider safety and motivation in their intervention planning, which are important tenets of finding a just right challenge for the children they work with. They are willing to step back during sessions to adapt their interventions and consider a change of approach moving forward with their care plan. Theme 2: Conditional Intentionality of Autonomy Considerations Autonomy & Control Considerations Participants considered to have conditional intentionality of a childs right to control and autonomy may have stated they felt one or the other was important, but not always both. The number of participants that fell into this category was 7 out of 16. In this group, conditional factors such as diagnoses, psychosocial considerations, and the childs behaviors moderated their support for and ability to accommodate autonomy in intervention sessions. For example, Participant 6 expressed, Autonomy is going to look different based on the diagnosis that youre working with and the level of psychosocial support thats needed. Some participants disclosed that they would gauge if they could go beyond a child's comfort level if they felt it was necessary to accomplish an intervention goal. No participant indicated any intentional harm in their examples. Participant 5 (P-5) reported: I would like to say I never put something in a child's mouth without their permission, but that would be a little bit of a lie. There are some kids and some people who need a little push, and then they're like, oh yeah, that's not so bad. OT PERCEPTIONS OF AUTONOMY SUPPORT 33 Participant-16 stated that they turn it into more of a game, You know, just playing like, oh, I'm going to give you a kiss and something really fast so that they almost don't have time to process whether it was aversive or not (P-16). All participants mentioned the importance of perceived control when working with children during interventions. Participant 15 expressed: It is important. They need to know they have some choices. . .I use the idea of choice sometimes to drive them to pick something that might be on the newer side, but also so that they know they're safe and they're not going to be forced to eat something uncomfortable. A lot of reassurance. This idea that perceived rather than actual control is one that defines this theme of conditional support. It was common among these respondents to express the importance of control as long as it was within certain conditions. Participant 10 exemplifies this in the context of the treatment plan for the day, suggesting: I mean, that is really, really important. And that's kind of always my goal. I never like to force-feed a kid; I never force them to do something they don't want to do. They definitely need to feel like they're in control. . .I usually try to give them control along the lines of This is what we're going to do, so you can have some control. You know, you can do it this way, or you can do it this way. You can do it before we do this or after. You know, control within what I want them to do (P-10). Some participants in this group discussed a shared approach to control within sessions. When asked about the importance of a child feeling in control of a session, Participant 5 (P-5) shared, It's critical. Like, at least maybe co-control, like be a team about it. Participant 6 (P-6) stated, OT PERCEPTIONS OF AUTONOMY SUPPORT 34 "I call it shared control, is how I term it with the parents because I kind of want to represent that both people are equal partners, and they have equal influence over each other's actions. Factors Influencing Intervention Approaches In this participant group, 5 of the 7 participants discussed being influenced by both child and family factors. Participant 15 (P15) explained that both are important for developing interventions they are planning: I break down the systems. I'd say oral motor function, oral sensory defensiveness, swallow function, self-feeding is part of it. Also, looking at like mealtime routines, mealtime behaviors, the stressors on the family, really looking at what the barriers are. In some cases, for Participant 10 (P-10), while they take into account a childs factors, they state that family factors may be most important, explaining, I think the family dynamics are probably the biggest determining factor in my opinion, of success with feeding therapy if it's really sensory and behavior. One participant stated they focus primarily on a childs factors and specifically spoke about the use of the ICF (International Classification of Functioning, Disability, and Health) and OTPF (Occupational Therapy Practice Framework) to look at a child holistically. They report that they are not only looking at obvious deficits but at all parts of a child, including the contexts and factors in their life: Feeding is a heterogeneous population, so I have not found in my practice that one intervention approach is a one size fits all. And I really try to avoid that mentality, instead going back to the occupational therapy framework and looking at activity analysis and using the ICF. So I would say I'm a heavy ICF person where you're looking at, you know, the contextual factors as well as activity analysis and structure (P-6). OT PERCEPTIONS OF AUTONOMY SUPPORT 35 Some participants in this group also took into consideration safety and motivation. In comparison to the first group, 2 of 6 participants discussed ensuring a child felt safe during treatment sessions. In a discussion of building trust with the child when starting interventions, Participant 11 (P-11) stated, I may not even, like, add that in [food], and just for the first session or two that we're just kind of building connection, they're feeling safe, you know, just kind of being in my presence and, and trying new things that I might ask them to do. It should be noted that most participants in this group noted the importance of a childs physical safety. No participant noted any intent to bring harm to a child; they only did not discuss or expand on these two areas as intentional considerations. Actions When Interventions are Not Working When considering what may need to happen next when intervention plans are not going as expected, 6 out of the 7 participants espousing conditional support for autonomy take steps that are similar to the High Intentionality group. They report taking a step back, analyze the situation, and move forward with changes in their approach. Participant 15 (P-15) stated, I will change my approach. . .Sometimes I realize that the demand is too much, and we have to back up and go back to something that's very comfortable and familiar so they can reestablish feeling safe. In this group, more participants discussed referring to another discipline versus the full support group. One participant discussed referring to another discipline or to a different therapist when a family is not satisfied with their approach. Participant 5 (P-5) explained: Sometimes, I do refer out to other professionals. Sometimes I try to do a little more of a team thing. Sometimes I think more often what happens is the parent goes and seeks OT PERCEPTIONS OF AUTONOMY SUPPORT 36 something out because it seems like my approach is not really working for them and their family. Or maybe I don't know what's going on. And, like, I would've thought that would've helped, and look, it didn't. So, there's probably something else contributing to that that isn't in my scope of practice. Those in this group realistically want to do their best to honor a child and meet them where they are. These individuals are taking the time to mindfully plan interventions around what works best for the child and families. They intentionally honor a childs autonomy and sense of control, though it may be conditional based on age, diagnoses, and psychosocial components. There is no intention of harm in any of their considerations. Theme 3: Least Intentionality of Autonomy Considerations Autonomy & Control Considerations Two participants were identified as having low intentionality for considering a childs autonomy and control. They made no robust statements in support of these areas and stated these concepts were conditional. During the interview, one participant seemed unsure of how to answer some of the questions, requesting further clarification on autonomy, stating, These questions are starting to overlap a little bit. . .I guess to me, some of these are starting to really fall in the same category (P-7). Both participants in this category expressed that they like to be in control during sessions. Participant 3 (P3) expressed that they were willing to let the child believe they had some sense of control, saying, "I mean, you don't obviously want them to have complete control. I like to call it more of an illusion of control. Do you want to do this, or do you want to do this?" Participant 7 (P7) described that, at times, they experience power struggles in treatment sessions: OT PERCEPTIONS OF AUTONOMY SUPPORT 37 You know what, I'm not often the one in control. I want to be in control, but there's sometimes a struggle. I'm a little bit in control. I sometimes can get away with it, but I often have to let them hold the spoon in their mouth. I find they have to be in control and will do it. When asked specifically about autonomy considerations, P7 stated, Well, I, I'm kind of respecting them. They later described age-graded support of childrens autonomy, So I think that's really based on some of the age. Participant 3 (P3) had similar conditions, based on suspected issues in the area of behavior or sensory: I mean, a lot of it definitely depends on why they're refusing it. If it seems to be more of an I just don't want to sit down because you're telling me to, or if it's a true sensory overwhelm. If it is that like they're having a hard time just looking at the food, then you know, I'm going to respect that a lot more because I know pushing through sensory issues is not going to be the way. . .When it comes to just pure behavior, you need to sit when you eat. Factors Influencing Intervention Approaches In this group, both individuals stated they are primarily influenced by a childs presentation, developmental level, deficits, and diagnosis. Participant 7 (P7) explained, I have some that are now diagnosed with cerebral palsy. I'm working on the head control, I'm working on the trunk control, I'm working on the positioning, I'm working on the presentation. I have a child with autism. One that is not yet diagnosed with autism. That I'm definitely taking more of a sensory approach, but I'm also working on a little bit of some of the behavioral approach. OT PERCEPTIONS OF AUTONOMY SUPPORT 38 This participant did not expand on whether they were looking at the whole child or using only the aforementioned approaches with these specific diagnoses. In addition to developmental presentation and deficits, Participant 3 (P3) adds, The other thing that probably influences and makes a big difference, though, is just the families. P3 noted that they take the time to observe family dynamics, routines, and patterns around mealtime to figure out what areas need to be addressed prior to working specifically on feeding. Sometimes I find that some of those basic family dynamics you almost have to get through first before you can even begin to do anything else (P-3). Actions When Interventions are Not Working Like the previous two groups, both participants expressed taking the time to back up and change their approach. The individuals in this group did not discuss referring to other disciplines for potential further assistance. Participant 7 (P7) stated, I've had to back off and change, and if they're melting down, it's not working, then I have to change. However, they did not expand on their process of figuring out what it is they need to change. Participant 3 (P3) explained what they examined further with the child and included conversations with the family to see if there was anything that was missed when they first completed the evaluation. They stated, Got to see what, what's missing? What, you know, are we, did I miss something? Oral motor, do I need to check for a tongue tie? Do I need to try to get more information from the parent, and usually when that's the case, then you usually find out that there's something going on in the environment that you weren't aware of. While the low intentionality participants did not state that they did not support a childs autonomy, they did not discuss having these topics at the forefront of their minds during the OT PERCEPTIONS OF AUTONOMY SUPPORT 39 planning and implementation of feeding treatments. The topics of safety and motivation also were not discussed in this group. However, there did not seem to be any intent of harming the child within the processes they discussed, and their differences in view and opinion compared to the high and conditional intentionality groups should not be considered as such. Discussion Feeding therapy is a complicated area of occupational therapy intervention because it is multifaceted. Components that are often addressed include but are not limited to, sensory dysfunction and over-responsivity, oral motor delays, psychosocial elements such as behaviors, difficulties with self-feeding, and social dynamics (AOTA, 2017; Gibbons et al., 2007; Gronski & Doherty, 2020; Henton, 2018; Howe & Wang, 2013; Howe et al., 2019; Paul & DAmico, 2013). It takes a balance of responsiveness and consideration of autonomy to keep a child from further developing maladaptive behaviors around feeding (Bassett et al., 2008; Jansen et al., 2017). Non-responsive feeding therapies that ignore or miss a childs distress cues can harm a childs developing autonomy (Black & Aboud, 2011). Adult priorities sometimes take precedence, and occupational therapists who work in feeding have an ethical responsibility to consider a more child-centered approach as they work to find the appropriate just right challenge with each child they work with (Coyne et al., 2016; OConnor et al., 2021). This study examined how occupational therapists perceive the concepts of autonomy and how they intentionally consider it when planning and completing feeding interventions with children three and under. Through sixteen individual interviews, participants shared their perceptions of autonomy and a childs sense of control throughout the process. The key themes that emerged from data analysis was a spectrum of support for a childs autonomy and sense of control during feeding therapy. The three main themes are the three levels of support that the OT PERCEPTIONS OF AUTONOMY SUPPORT 40 therapists fell into based on criteria identified by the researchers: 1) High Intentionality of Autonomy Considerations, 2) Conditional Intentionality of Autonomy Considerations, and 3) Least Intentionality of Autonomy Considerations. Autonomy Considerations Participants within the high and conditional intentionality of support groups agreed wholeheartedly on the importance of honoring and respecting a childs autonomy. The majority of these two groups felt it was vital. Participants in both groups stated that they want to do what is best for the children they are working with and are passionate about the success of feeding therapies. They are intentional with their support of autonomy, which is one of the first things these participants consider during the planning and implementation of feeding treatment. Both groups also discussed topics such as safety and motivation, though it was primarily discussed by the group with high intentionality. Safety and motivation are important tenets of concepts used in practice, such as the just right challenge and self-determination theory (DArrigo et al., 2020). For most in the conditional intentionality group, their support for autonomy was typically dependent, or conditional, on criteria such as diagnosis, feeding behaviors, and age. This group did not allude to their conditions being considered negatively, and it could be theorized that their experiences with those criteria have shaped their decision-making process. As the literature reflects, these criteria are essential for clinical reasoning to ensure therapists adhere to appropriate just right challenges that align with child preferences and structure (Brown & Lynch, 2022; Poulsen et al., 2006; Schoen et al., 2018). When planning interventions, while both groups considered child and family factors, the high intentionality group spoke slightly less about the influence of parents and caregivers. While the family is an essential component of pediatric treatment planning, this groups priority was to OT PERCEPTIONS OF AUTONOMY SUPPORT 41 ensure that the child was their primary consideration. Most of the participants in this group also discussed the steps they took to educate families on how to best honor a childs autonomy, including completing education on how to be responsive to a childs cues during feeding and mealtimes at home. According to the literature, caregivers should understand how to support this to create healthy bidirectional relationships between caregiver and child (Black & Aboud, 2011; Black, 2020; Zvara et al., 2018). Research has shown that when caregivers support autonomy development in children, there is less frustration and a noted improvement in the childs overall well-being (Neubauer et al., 2021). A smaller group was identified that voiced the least intentionality in honoring a child's feelings. Like the other two groups, this group discussed very similar strategies and influences around the initial planning of what approaches they would use. Their primary focus is on the child and their developmental presentation and deficits. When interventions are not working, they take a step back to determine what may have been missed and are not continuing with an intervention plan that is not working. They are not reporting maladaptive actions such as forcefeeding that may increase feeding dysfunction (Goday et al. 2019). No considerable differences were found between any of the groups. However, when looking at the average years of experience between groups, the high intentionality group had the least, at an average of 9.64 years. In comparison, the conditional intentionality group had an average of 24 years, and the low intentionality group participants had 14 and 40 years of feeding experience, for a rough average of 27 years. With years of experience being the only difference identified between the three groups, something to consider is the time between when they graduated from their occupational therapy programs and now. In 1995, the American Academy of Pediatrics released recommendations for pediatric decision-making. While their initial OT PERCEPTIONS OF AUTONOMY SUPPORT 42 statements occurred in 1976, the 1995 release made more robust suggestions on how providers should collaborate with children and families as best practice (American Academy of Pediatrics, 1995; Katz et al., 2016). It could be hypothesized that discussions on autonomy in pediatrics within occupational therapy programs have increased since those recommendations were made. Implications for Occupational Therapy Practice One of occupational therapys main emphasis is on client-centered practice. Regarding feeding therapy, this means respecting the child's preferences, choices, and autonomy regarding food and mealtime routines. When a child's autonomy is not respected, they may feel a loss of control over their actions and experiences. This can lead to decreased self-regulation, emotional distress, frustration, and anxiety (Benoit Allen et al., 2015). By valuing and fully supporting a child's autonomy, occupational therapists acknowledge that the child is an active participant in the therapeutic process, and their needs and preferences should be central to the intervention planning (DArrigo, 2020). The findings in this study show that most participants support a childs autonomy during feeding interventions. Given these findings, occupational therapists who work in feeding, regardless of age, should take the time to reflect on whether they have gaps in their stated support and actual actions. They would also benefit from considering how their beliefs, biases, and expectations may influence their approach. Another opportunity for improvement, if they find there are gaps in their own beliefs, is to seek out professional development opportunities that are focused on how to support a childs autonomy. This may include further exploration of responsive feeding practices, which acknowledge and respect a childs cues and developmental readiness. It also reduces power struggles, improves self-regulation, and helps them develop a positive attitude towards eating OT PERCEPTIONS OF AUTONOMY SUPPORT 43 without feeling forced or coerced. By taking these steps, occupational therapists can bridge the gap between their beliefs and actions, creating a more supportive and empowering feeding therapy environment that values and respects the autonomy of the children they work with. While limited research has occurred on responsive feeding and its use by occupational therapists, there has been significant research completed on responsive parenting and feeding (Hupp et al., 2022; Ledoux et al., 2018; Mallan & Miller, 2019; Prez-Escamilla et al., 2021). Biscan et al. (2022) reported on a case study with promising results, recommending that occupational therapists become more familiar with responsive feeding techniques. Study Limitations There were some limitations noted in this study. Participants were primarily recruited from forums and groups that were explicitly feeding-focused. In this case, participants elected to participate in this study may have strong perspectives on the subject matter and research in this practice area. It is also important to note that not all occupational therapists have chosen to have social media accounts. It is not known the specific number of OTs that were recruited from these forums and groups and the number that may have been reached outside these platforms through snowball efforts. Therefore, the participants may not reflect a representative sample of all occupational therapy practitioners. Future Research Future studies should consider the further exploration of occupational therapists beliefs about autonomy. While this study looked at how they consider autonomy as a factor in feeding interventions, it did not explore further reflection on the reasoning behind these beliefs. It also did not explore whether their thoughts and feelings about this subject have changed throughout their careers. A concern for further study in this area is the potential for response bias, as OT PERCEPTIONS OF AUTONOMY SUPPORT 44 participants may feel uncomfortable giving honest answers. A quantitative, anonymous survey could be considered to gather information if feasible. A second qualitative study would also be appropriate, with interviewers who are not the primary researchers, to keep the participants' anonymity intact. Additionally, surveying occupational therapy programs to understand how topics such as autonomy are addressed within the curriculum would be beneficial. Autonomy is one of the principles of the professions code of ethics, but the question remains on how programs apply this principle to clients of all ages. Introducing discussions on pediatric autonomy could raise awareness of ethical considerations surrounding children's rights, consent, and decision-making abilities. It would also teach students how to guide parents and caregivers in supporting a child's autonomy while still providing necessary guidance and structure. Conclusion This study found that autonomy support is an intentional consideration for most occupational therapists working with young children on feeding. However, it may not be a simple, clear-cut consideration continuously at the forefront of the clinical reasoning process. Discussions on how it is considered varied amongst participants, highlighting that it is a complicated subject, and opinions on where it is considered in the occupational therapy process fall along a continuum of intention. OT PERCEPTIONS OF AUTONOMY SUPPORT 45 References American Academy of Pediatrics (1995). Informed consent, parental permission, and assent in pediatric practice. Pediatrics, 95(2), 314317. https://doi.org/10.1542/peds.95.2.314 American Occupational Therapy Association. Occupational therapy and eating dysfunction (Position Paper). (1989). 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Journal of Family Psychology, 32(4), 484495. https://doi.org/10.1037/fam0000372 66 67 OT PERCEPTIONS OF AUTONOMY SUPPORT Table 1 Participant Demographics Participant Number Degree Setting Years of Feeding Experience 1 Masters NICU 9 2 Masters Telehealth 10 3 Post Professional OTD Early Intervention 14 4 Masters Early Intervention/Private Practice/Community Based Practice 1.5 5 Masters Private Practice 39 6 Masters NICU/Acute Care Pediatrics 20 7 Masters Early Intervention 40 8 Bachelors NICU 12 9 Masters Early Intervention 6 10 Masters Outpatient 10 11 Masters Outpatient 5 12 Entry Level Doctorate Early 2 Intervention/Outpatient 13 Bachelors Private Practice 30 14 Masters Early Intervention 13 15 Masters Outpatient 30 16 Masters Private Practice and Early Intervention 39 OT PERCEPTIONS OF AUTONOMY SUPPORT 68 Table 2 Themes & Subthemes Theme Subtheme Autonomy & Control Considerations High Intentionality of Autonomy Support Example Quotes A lot of times, I have to look at their cues because they're not going to tell me necessarily. Sometimes they're lovely to be vocal about it, but really no matter what age, I've found you really have to look at their cues, their eyes, their eyebrows, facial expressions, and hands. They're really going to tell you what they do and do not want. So, I go off of what their comfort level is, see what they react to. (P-1) I think it's everything. We have to listen to what they're saying. They're little tiny beings that have few ways to let us know what they're feeling. And just because they're really little doesn't mean their emotions are really little. (P-9) I do teach parents how to look for when their child is giving them a green light or a red light in terms of their readiness to eat. . .Are they going to verbally or gesturally, or expressively show interest or protest? And to honor that voice early. (P-4) I would say, for a child, we need to understand that they are making choices sometimes for a reason. And we need to really understand why they're making those choices, you know, and respect sometimes the choices they're making, that it cannot be a battle. (P13) Subtheme Factors Influencing Intervention Approaches Example Quotes I think, sometimes, like when we just focus on things like, oh, sensory motor, what you're putting into your mouth, the texture of food, things like that. . .And you don't take into account how's the child breathing, how's the child digesting. (P-2) I always try and get a picture of what the family's culture is around eating and food and feeding. (P-2) OT PERCEPTIONS OF AUTONOMY SUPPORT 69 I think what influences me because I'm working with these babies, a lot of it has to do with the families and what the family's approach is like. (P9) My first and most highest priority is safety. And when I say safety, I don't just mean prevention of aspirating, I mean relational safety, felt absence of threat, and felt presence of connection for a child. (4) If kids just truly can't touch it, they don't want anything sticky or slimy or watery that's going to stay on their hands, I want to pick something that they can touch and let go of so that they feel safer, at least shove it out of the way; its no longer stuck on their hand. (P-12) Subtheme Actions When Interventions are Not Working Example Quotes Depending on what's happening in the situation, usually I encourage the family to take a break for mealtime, that it's getting to be stressful and not productive, and we can always come back to it, or we can take the snack to the floor or outside or a different location if we really need to consume what's eaten. But that's also a really good time to talk about hunger cues and when and how to encourage a child to eat versus letting kind of the child determine their appetite at that time. (P-12) I try different dynamics. I try and change it up. If I don't feel like it's getting somewhere, I'm very open to asking the family, saying it's not about what we've tried with it. However, there's a bigger need in a different area than my scope. (P-1) Theme Subtheme Autonomy & Control Considerations Conditional Intentionality of Autonomy Support Example Quotes Autonomy is going to look different based on the diagnosis that youre working with and the level of psychosocial support thats needed. (P-6) It is important. They need to know they have some choices. . .I use the idea of choice sometimes to drive them to pick something that might be on the newer OT PERCEPTIONS OF AUTONOMY SUPPORT 70 side, but also so that they know they're safe and they're not going to be forced to eat something uncomfortable. A lot of reassurance. (P-15) I mean, that is really, really important. And that's kind of always my goal. I never like to force-feed a kid; I never force them to do something they don't want to do. They definitely need to feel like they're in control. . .I usually try to give them control along the lines of This is what we're going to do, so you can have some control. You know, you can do it this way, or you can do it this way. You can do it before we do this or after. You know, control within what I want them to do (P-10) It's critical. Like, at least maybe co-control, like be a team about it. (P-5) I call it shared control, is how I term it with the parents because I kind of want to represent that both people are equal partners, and they have equal influence over each other's actions. (P-6) You know, just playing like, oh, I'm going to give you a kiss and something really fast so that they almost don't have time to process whether it was aversive or not. (P-16) I would like to say I never put something in a child's mouth without their permission, but that would be a little bit of a lie. There are some kids and some people who need a little push, and then they're like, oh yeah, that's not so bad. (P-5) Subtheme Factors Influencing Intervention Approaches Example Quotes I break down the systems. I'd say oral motor function, oral sensory defensiveness, swallow function, self-feeding is part of it. Also, looking at like mealtime routines, mealtime behaviors, the stressors on the family, really looking at what the barriers are. (P-15) I think the family dynamics are probably the biggest determining factor in my opinion, of success with feeding therapy if it's really sensory and behavior. (P-10) OT PERCEPTIONS OF AUTONOMY SUPPORT 71 Feeding is a heterogeneous population, so I have not found in my practice that one intervention approach is a one size fits all. And I really try to avoid that mentality, instead going back to the occupational therapy framework and looking at activity analysis and using the ICF. So I would say I'm a heavy ICF person where you're looking at, you know, the contextual factors as well as activity analysis and structure. (P-6) I may not even, like, add that in [food], and just for the first session or two that we're just kind of building connection, they're feeling safe, you know, just kind of being in my presence and, and trying new things that I might ask them to do. (P-11) Subtheme Actions When Interventions are Not Working Example Quotes I will change my approach. . .sometimes I realize that the demand is too much, and we have to back up and go back to something that's very comfortable and familiar so they can reestablish feeling safe. (P-15) Sometimes, I do refer out to other professionals. Sometimes I try to do a little more of a team thing. Sometimes I think more often what happens is the parent goes and seeks something out because it seems like my approach is not really working for them and their family. Or maybe I don't know what's going on. And, like, I would've thought that would've helped, and look, it didn't. So there's probably something else contributing to that that isn't in my scope of practice (P-5) Theme Subtheme Autonomy & Control Considerations Least Intentionality of Autonomy Support Example Quotes These questions are starting to overlap a little bit. . .I guess to me, some of these are starting to really fall in the same category. (P-7) "I mean, you don't obviously want them to have complete control. I like to call it more of an illusion of control. Do you want to do this, or do you want to do this?" (P-3) OT PERCEPTIONS OF AUTONOMY SUPPORT 72 You know what, I'm not often the one in control. I want to be in control, but there's sometimes a struggle. I'm a little bit in control. I sometimes can get away with it, but I often have to let them hold the spoon in their mouth. I find they have to be in control and will do it." (P-7) Well, I, I'm kind of respecting them. (P-7) So I think that's really based on some of the age. (P-7) I mean, a lot of it definitely depends on why they're refusing it. If it seems to be more of an I just don't want to sit down because you're telling me to, or if it's a true sensory overwhelm. If it is that like they're having a hard time just looking at the food, then you know, I'm going to respect that a lot more because I know pushing through sensory issues is not going to be the way. . .When it comes to just pure behavior, you need to sit when you eat." (P-3) Subtheme Factors Influencing Intervention Approaches Example Quotes I have some that are now diagnosed with cerebral palsy. I'm working on the head control, I'm working on the trunk control, I'm working on the positioning, I'm working on the presentation. I have a child with autism. One that is not yet diagnosed with autism. That I'm definitely taking more of a sensory approach, but I'm also working on a little bit of some of the behavioral approach. (P-7) The other thing that probably influences and makes a big difference, though, is just the families. (P-3) Sometimes I find that some of those basic family dynamics you almost have to get through first before you can even begin to do anything else (P-3). Subtheme Actions When Interventions are Not Working Example Quotes I've had to back off and change, and if they're melting down, it's not working, then I have to change. (P-7) Got to see what, what's missing? What, you know, are we, did I miss something? Oral motor, do I need OT PERCEPTIONS OF AUTONOMY SUPPORT 73 to check for a tongue tie? Do I need to try to get more information from the parent, and usually when that's the case, then you usually find out that there's something going on in the environment that you weren't aware of. (P-3) OT PERCEPTIONS OF AUTONOMY SUPPORT Figure 1 74 OT PERCEPTIONS OF AUTONOMY SUPPORT 75 Appendix A Social Media Post for Recruitment OTs & OTAs in Feeding Therapy - Research Participants Needed! Occupational Therapist's Perceptions During Feeding Interventions with Children Three and Under About the Research: Purpose: The purpose of this study is to understand the factors in which occupational therapists consider the selection and implementation of feeding interventions with children three and under. Increased understanding of occupational therapists knowledge and attitudes may improve outcomes and prevent traumatic experiences in young clients. Research participants will: Participate in a virtual, confidential interview via Zoom, for approximately 45-60 minutes. Participate in a follow up call within approximately 2-4 weeks following the interview, via phone or Zoom, to discuss and confirm the interpretation of themes gathered from the transcript of the interview, for approximately 30-60 minutes. Participant Eligibility: Occupational therapists or occupational therapy assistants within the United States. Minimum 6 months of recent experience with feeding interventions with children 3 and under. English must be your primary language. Contact Information: If you are interested in learning more about the study, please complete this short questionnaire here: https://uindy.co1.qualtrics.com/jfe/form/SV_cUUevrzAv0g2RzU Please reach out if you have any additional questions to Melissa Mattner mattnerm@uindy.edu. (This research project has been approved by the University of Indianapolis Institutional Review Board (IRB). Approval date 1/23/2023; Approval number 01805) 76 OT PERCEPTIONS OF AUTONOMY SUPPORT Appendix B Study Information Sheet Minimal Risk UIndy Study # 01805 Study Version: 1 Study Version Date: 1/23/2023 Informed Consent Form (ICF) Version: 1 ICF Version Date: 1/23/2023 Interprofessional Health & Aging Studies KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS This study aims to explore the perceptions of occupational therapy professionals who complete feeding interventions with children three and under. Your participation in this study will last one to two hours of your time, including a virtual interview and a follow-up contact to confirm your perspectives on the interpretation of the study results. You will be asked about your education, training, and experiences in feeding intervention planning and implementation. The interview will be conducted, depending on your convenience, virtually via Zoom. Interviews will be audio and video recorded, as back up. It will be stopped at your request or when the questioning and discussion is completed. You will be contacted approximately 2-4 weeks after the interview to clarify the main themes that were identified by the investigators from the transcript of the interview. There are no anticipated or identified risks for participation in this study. The investigators do not intend and cannot guarantee that you will directly benefit from participating in this study. Potential benefits to occupational therapists, including identification of topics for further recommended research may be gained from your participation in this research study. CONSENT TO PARTICIPATE IN RESEARCH STUDY Occupational Therapists Perceptions During Feeding Interventions with Children Three and Under Study Principal Investigator (PI): Lisa Borrero PhD FAGHE UIndy Email: borrerol@uindy.edu UIndy Telephone: (800) 232-8634 x5944 Student Investigator: Melissa Mattner MS, OTR/L UIndy Email: mattnerm@uindy.edu UIndy Telephone: (800) 232-8634 Lisa Borrero PhD, FAGHE & Melissa Mattner MS, OTR, L, from the Department of Interprofessional Health and Aging Studies at the University of Indianapolis (UIndy) are conducting a research study. OT PERCEPTIONS OF AUTONOMY SUPPORT 77 You were selected as a possible participant in this study because you are an occupational therapy professional that has recently completed feeding interventions in children three and under for a minimum of 6 months; this population makes up 25% or greater of your feeding caseload. Your participation in this research study is voluntary. Why is this study being done? The purpose of this study is to understand the factors in which occupational therapists consider selection and implementation of feeding interventions with children three and under. Increased understanding of occupational therapists knowledge and attitudes may improve outcomes and prevent traumatic experiences in young clients. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Participate in a virtual, confidential interview via Zoom, for approximately 45-60 minutes. Participate in a follow-up call within approximately 2-4 weeks following the interview via phone or Zoom, to discuss and confirm the interpretation of themes gathered from the transcript of the interview, for approximately 30-60 minutes. How long will I be in the research study? Participation will take a total of about 1-2 hours, including an interview and follow up on the interpretation and coding of the interview within 2-4 weeks of the interview. Are there any potential risks or discomforts that I can expect from this study? There are no anticipated risks or discomforts. Are there any potential benefits if I participate? You will not directly benefit from your participation in this research. The results of the research may garner recommendations for further research. Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation, or teaching materials. Will the data from my study be used in the future for other studies? Your data will not be used or distributed for future research studies even if there is no way for OT PERCEPTIONS OF AUTONOMY SUPPORT 78 your data to be linked with any information that could identify you. What are my rights if I take part in this study? You can choose whether or not you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and still remain in the study. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments, or concerns about the research, you can talk to one of the researchers. Please contact: Melissa Mattner, MS OTR/L Email: mattnerm@uindy.edu PH: 970-248-2306 The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant or you have concerns or suggestions, and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. How do I indicate my informed consent to participate in this study? You do not need to sign this, or any other document to indicate your consent. Completion and return of the screening questionnaire indicates that you are willing to participate. OT PERCEPTIONS OF AUTONOMY SUPPORT 79 Appendix C Interview Guide Hello (name). Thank you for agreeing to visit with me today. As you know, I am interested in visiting with you today about feeding interventions. I am performing a qualitative study as part of my dissertation with the University of Indianapolis. I am seeking to explore and better understand what influences feeding therapists, specifically, occupational therapists, to choose their approaches to feeding therapy, particularly with children ages three and under. Feeding therapy is a very complex topic. Through our discussion with you and other therapists, I hope to understand better how education and support tools can be created to ensure the best occupational therapy practice. With your permission, I will record our conversation and ask you questions about your personal experiences, beliefs, and attitudes about pediatric feeding treatment. The data used will be transcribed and de-identified to remove personal information. The transcribed interview will be stored in password-protected files. You have the right to refuse to answer any question you are not comfortable with and to end the interview and withdraw your consent for participation at any time. It is anticipated that this interview will last approximately 30-45 minutes. Do I have your permission to continue with the interview and the recording? (Once given consent, start the recording.) This is Melissa Mattner with, my guest, on a recorded conversation about feeding therapy to be used for a qualitative dissertation for the University of Indianapolis Doctor of Health Science program. We have previously discussed the details of the study and our goal for today, and they have given permission for the conversation to be used and recorded. Will you please confirm what I have said is true? You may also refuse to answer a question or withdraw at any OT PERCEPTIONS OF AUTONOMY SUPPORT 80 time. Do you agree to participate and be recorded? (Pause for interviewee statement). Do you have any questions at this time about the process described? Interview Questions: Experience To start off, Id like to know what it is like for you to be a pediatric occupational therapist. o How many years have you been an OT? o How many years have you considered yourself to be a feeding therapist? o Is feeding therapy a primary practice area for you or only part of your practice? Can you tell me about the typical pediatric feeding client that you treat? o What are the ages and diagnoses of the children that you work with? What diagnoses do you see more often? What ages have you seen most often? Tell me about the children you work with that have no official diagnosis. Training Tell me about the training youve had in this field. o What kind of training? (Sensory-related, behavior-related, swallowing, oral motor, responsive, etc.) o Can you expand on any experience that you may have had with a mentor? o Can you expand on any training you may have had in feeding during your occupational therapy program? OT PERCEPTIONS OF AUTONOMY SUPPORT 81 Treatment What influences the feeding approaches you choose for the children you work with? o What interventions/approaches do you prefer to use? Can you expand on why you may prefer to use one intervention/approach over any other? o What do you do when your chosen approach is not successful, or a child is not responding well to the treatment? What are some things that go through your mind during and after unsuccessful treatment sessions? Tell me about your approach to making goals for feeding therapy patients. o What sources of input do you use to create your goals? o Can you expand on how you use your clinical judgment to make goals? How do you consider whether a child will do well with the goals chosen for them by their parents? How do you establish rapport with a child before completing feeding interventions with them? o Can you tell me about the structure of a typical feeding session? How do you incorporate a childs input, views, preferences? o How important do you think it is to find ways to give the child some control of the session? o What do you do when a child refuses, or is uncomfortable or upset? o Do you feel youve ever had to convince a child to participate in feeding therapy activities when they seem uncomfortable interacting? OT PERCEPTIONS OF AUTONOMY SUPPORT What methods have you used to do so? (Rewards, Escape extinction, etc.) o How do you consider their autonomy when encouraging them to participate? Wrap Up Do you have anything else that youd like to share on the topic of feeding? What advice would you give occupational therapy students and therapists interested in completing feeding interventions? Do you have any questions about the interview or the use of this information moving forward? (Confirm with the interviewee that they have my contact information & are welcome to contact me with questions at any time) Thank you for taking the time to meet with me today. I appreciate it, and please do not hesitate to reach out if you have questions or anything to add. I will be reaching out to you following data analysis for member checking to verify that I have interpreted your interview appropriately. 82 ...
- Creator:
- Mattner, Melissa
- Type:
- Dissertation
20. ISSL2024 Proceedings The Role of Global Service-Learning in Transformational Leadership: Fostering Social Action & Vigilance
- Keyword matches:
- ... MAY 29 - JUNE 1, 2024 AT THE UNIVERSITY OF INDIANAPOLIS 9th International Symposium on Service-Learning The Role of Global Service-Learning in Transformational Leadership: Fostering Social Action & Vigilance SYMPOSIUM PROCEEDINGS 9th International Symposium on SERVICE-LEARNING May 29 - June 1, 2024 0 At the University of Indianapolis The Role of Global Service-Learning in Transformational Leadership: Fostering Social Action & Vigilance. With a focus on building reciprocal re lationships and exploring fresh ideas, we invite academics, stud ents, community partne rs, and professionals to join us for engaging dialogue and exchange of ideas. ~ ~N~~!!:?vbosch UNIVERSITYoF INDIANAPOLIS IYUNIVESITHI UN IVERS1TE IT Comm.unJty --En.1.aa:ed -"ll!ancc ),,lo! t-\-.1."V!..-OrTi ll "" OOfl-S C O l l lt. t ~ LAYSS Published by: University of Indianapolis 9th International Symposium on ServiceLearning 5. 28-6. 1. 2024 University of Indianapolis Co-Hosted by: Stellenbosch University, Stellenbosch, South Africa GIP Campus ESPRIT Industries (GIP CEI), Paris, France Campus Compact, USA Co-Sponsored by: The National University of the Union of Myanmar, Myanmar CLAYSS, Argentina Saint Marys of the Woods College, USA Community Engaged Alliance, Indianapolis, Indiana USA Copyright 2024 by University of Indianapolis and the International Symposium on Service-Learning (ISSL2024) Digital ISBN: 978-1-956390-42-1 Print ISBN: 978-1-956390-43-8 All rights reserved. No portion of this monograph may be reproduced in any form or by any means without permission of the Symposium Planning Committee, International Symposium on ServiceLearning 2024. Planning Symposium Chair: Marianna K. Foulkrod, University of Indianapolis Symposium Co-Chairs: Mawethu Nyakatya, Stellenbosch University Mohamad Fadl Harake, GIP CEI The chairs of the 9th International Symposium The Role of Global ServiceLearning in Transformational Leadership: Planning Committee contributed to the proceedings, editing, and proofreading. Cover Sources: Cover Design and Layout: Marketing Department, University of Indianapolis Logo Art: One14 Design Studio, University of Indianapolis Applied Design/Service-Learning Course Fostering Social Action & Vigilance. Edited by: Marianna K. Foulkrod Director, Center for Service-Learning and Community Engagement University of Indianapolis 1400 East Hanna Avenue Indianapolis, Indiana 46227 USA Contents W E L C O ME MESSAGES FROM : MARIANNA K. FOULKROD (SYMPOSIUM CHAIR ) MOHAMAD FADL HARAKE (SYMPOSIUM CO-CHAIR ) MAWETHU NYAKATYA (SYMPOSIUM CO-CHAIR ) PRESIDENTIAL MESSAGES FRO M : UINDY - STELLENBOSCH - GIP CE I MESSAGES FROM PARTNER S : CLAYSS - CAMPUS COMPACT - NUU M ACKNOWLEDGMENT S PEER REVIEW COMMITTE E AFFILIATED PARTNER AND SUPPORTER RECOGNITIO N : BACI - EXODUS - PAWS AND THIN K Contents ABOUT THE SYMPOSIUM SYMPOSIUM PURPOS E PUBLICATION S 10-YEAR STRATEGIC PLAN ) SYMPOSIUM THEME S PRESENTATION FORMAT S ABOUT THE UNIVERSITY O F INDIANAPOLIS (VENU E ) P A N E L I S T S A N D E M C EE OPENING CEREMONY: PANELIST S OPENING AND CLOSING CEREMONY EMCE E OPENING CEREMONY PROGRA M CLOSING CEREMONY PROGRA M Contents SYMPOSIUM PROGRAM SYMPOSIUM PROGRAM AT-A-GLANCE PRE-CONFERENCE PEN TO PAPER DETAILS DETAILED PRESENTATION PROGRAM ISSL 2024 ABSTRACTS Welcome Message by ISSL 2024 Co-Chairs Marianna K. Foulkrod University of Indianapolis Symposium Co-Chair M a w e t h u N y a k atya Ste l l e n b o s c h U n iversity S y m p o s i u m C o -Chair Mohamad Fadl Harake GIP CEI Symposium Co-Chair The 9th edition of the International Sympo s i u m o n Service-Learning (ISSL), a global scholastic man i f e s t a t i o n co-hosted by higher education institutions acr o s s t h r e e continents (Africa, Europe, and North Americ a ) , i s a testament to our shared commitment to service- l e a r n i n g . Each school, recognizing the global impact o f t h i s initiative, has joined forces to co-organize and c o - h o s t the ISSL in its 9th (USA), 10th (France), and 11t h ( S o u t h Africa) editions. Our decade-projected vision a c r o s s t h e three continents aims to broaden the scope of s e r v i c e learning as an educational methodology to i n t e g r a t e community needs into students' coursework an d h i g h e r education entities strategies. On another n o t e , t h e alliance of our three schools will focus on t h e m a n y transitions of higher education and the critical p a r t t h a t service-learning plays in the overall social transformation. That said, the three institutio n s h a v e pledged to focus on delivering essential service - l e a r n i n g experiences by both their staff and students to b e c o m e true agents of positive change for their com m u n i t i e s . Hence, the partnership between the United Stat e s , S o u t h Africa, and France will aim to draw attentio n t o t h e pivotal role that service-learning plays in h e l p i n g students become more involved and responsible c i t i z e n s and change leaders, faculty members becom e m o r e critical and collaborative, and the community be c o m i n g a true know ledge incubator for positive transfo r m a t i o n a l change. In other words, how each party ca n f o s t e r vigilance in the context of transformational c o m m u n a l change and sustainable actions. This collectiv e v i s i o n emerged as the theme of this years ISSL, The R o l e o f Global Service-Learning in Transformational Le a d e r s h i p : Fostering Social Action & Vigilance. We are priv i l e g e d t o p r e s e n t t h e symposium proceedings, a collective effort that refl e c t s t h e e x t e n s i v e a n d impressive work of our esteemed colleagues and ear l y c a r e e r r e s e a r c h e r s . T he diverse range of presentation styles and formats use d d u r i n g the s y m p o s i um facilitated meaningful conversations among scholars, p r a c t i t i o n e r s , community partners, international organizations, stude n t s , a n d o t h e r i n v o l v e d parties, underscoring the collaborative nature of this end e a v o r . ISSL 2024 10 T h e a u t h o r s w ork collected in these proceedings highlights the comp l e x i t i e s o f d e v e l o p m e n t , transition, and transformation within higher education a c r o s s t h e g l o b e . A l s o , many works have stressed the need to adopt a vigila n t s t a n c e re g a r d i n g s o c ial transformation and the adoption of change lead e r s h i p t o s p e a r h e a d e f f o rts for community or communal change. O n a n o t h e r n o te, many papers have explored improving critical service - l e a r n i n g ' s s o c i a l i n f l u e n c e. Many papers studied the new theoretical perspec t i v e s a n d a p p r o a c h e s i n higher education and how collaborative research and c u r r i c u l u m d e s i g n c a n e n hance service-learning's societal impact. Some of the p r e s e n t e d w o r k s s h o w c a s ed new ethical goal s that must be incorporated in an inno v a t i v e a n d tr a n s f o r m a t i v e pedagogy for social change. Hence, the result that we p r e s e n t t o th e r e a d e r s i s that we hope that we were able to develop a global servic e - l e a r n i n g c o m m u n i t y c a pable of catalyzing positive change initiatives further. W e w o u l d l i k e to express our heartfelt gratitude to our team, whose exce l l e n t w o r k e n s u r e d t h e success of the 9th edition of the ISSL. We also e x t e n d o u r a p p r e c i a t i o n t o our distinguished plenary speakers and Session Cha i r s , w h o s e in s i g h t s e n r i c h ed our discussions. We are deeply grateful to ISSLs pa r t n e r s a n d s p o n s o r s f o r t heir invaluable support, and to the participants for sharing t h e i r w o r k a n d m a k i n g t h i s experience a reality. Lastly, we acknowledge the dedica t i o n o f t h e e d i t o r i a l t e a m in getting these conference proceedings published. W e h o p e y o u f ind the 9th ISSL proceedings to be a valuable contributio n . S e e y o u a l l i n 2 0 2 6 i n F rance! Marianna K. Foulkrod University of Indianapolis Symposium Co-Chair ISSL 2024 Mawethu Nyakatya Stellenbosch University Symposium Co-Chair Mohamad Fadl Harake GIP Campus ESPRIT Industries Symposium Co-Chair 11 Dear 2024 International Symposium on Service-Learning Attendees: It is with great pleasure and enthusiasm that I extend a warm welcome to each and every one of you to the 2024 International Symposium on Service-Learning hosted at the University of Indianapolis! As we gather for this significant event, we embark upon a journey of exploration, collaboration, and enlightenment in the realm of service-learninga cornerstone of our educational philosophy at the University of Indianapolis. Service-learning embodies our commitment to not only academic excellence but also to the holistic development of our students as socially responsible citizens of the world. We believe in the power of service for impact as noted prominently in our newly revised University Mission. Our faculty lead and participate in local, regional, and international service-learning experiences that engage our students in a multitude of learning environments and contexts. The International Symposium on Service-Learning enables the development and implementation of context specific servicelearning teaching methodologies in higher education to support institutions around the world. Started as a collaboration between the University of Indianapolis and Stellenbosch University in 2005 with the very first International Symposium held in South Africa, this symposium has continued to bring thought leaders and practitioners to Indianapolis, Greece, China, Ireland, and Cyprus. In today's increasingly interconnected world, the significance of global engagement cannot be overstated. The challenges we face are complex and multifaceted, transcending borders and requiring collaborative efforts on a global scale. Service-learning serves as a catalyst for this collaboration, bridging cultural divides, fostering empathy, and nurturing a sense of shared responsibility towards humanity and our planet. As participants of this symposium, you are ambassadors of change, embodying the spirit of service and the pursuit of knowledge for the betterment of society. Your presence here today is a testament to your commitment to making a positive impact in your communities and beyond. I am confident that through your collective wisdom, experiences, and innovative ideas, we will not only deepen our understanding of servicelearning but also inspire meaningful action towards building a more just, equitable, and sustainable world. Once again, welcome to the University of Indianapolis. We hope you leave here inspired and more committed than ever before to drive positive change through your educational experiences! Warm regards, Dr. Tanuja Singh, President University of Indianapolis ISSL 2024 12 I would like to extend my best wishes to all participants at the 9th International Symposium on Service-Learning (ISSL). Its a privilege for Stellenbosch University to be one of your co-hosts, and Im excited to see this community come together to foster collaboration, innovation, and transformation. Service-learning is more than a methodits a commitment to connecting academia with the needs of society. The theme of this symposium, The Role of Global Service-Learning in Transformational Leadership: Fostering Social Action & Vigilance, reflects our shared dedication to building stronger communities and inspiring positive change. As we gather to share ideas and practices, I encourage you to take full advantage of the sessions, workshops, and networking opportunities. This is a unique chance to learn from one another, expand our perspectives, and explore new ways to make an impact. Stellenbosch University values the partnerships weve built through the ISSL, and were grateful to our cohosts, the University of Indianapolis and ESLI International, for their collaboration and vision. Together, we can make a lasting difference by promoting service-learning as a transformative force in education. I wish you all a fruitful and inspiring symposium. May the connections you make and the insights you gain here resonate far beyond these days, enriching your work and your communities. Thank you for being part of this journey. Best regards, Prof Wim de Villiers Rector and Vice-Chancellor Stellenbosch University ISSL 2024 13 Dear Symposium Attendees, It gives me great pleasure to speak to you today, even remotely, to welcome you most cordially at the official opening of the 2024 Symposium on Service-Learning at the University of Indianapolis. This event is the culmination of an enormous collective effort and many institutions and individuals contributed in one form or another towards: the organization of, this event. In recent years we have witnessed growing questions about the social impact of higher education. More specifically on its ability to raise awareness among its graduates about impactful social commitment. Embedding service-learning into our educational platform allows us to improve on both counts. We are only at the beginning of this truly innovative educational approach. Much remains to be tested and to do this, partnerships are certainly a preferred route. It is the philosophy and hopes of our symposium to open new paths, new bridges, provide new perspectives and new tools for the development of our students. We still have a long way to go, and only through a joint effort will we be able to reach our fundamental goal. Distinguished visitors, let me express, in the name of my organisation, GIP-CEI,, our most sincere wish that the discussions and agreements resulting from this Symposium will positively contribute to the consolidation of the aims of Service-Learning in higher education and thereby to the philosophy underlying it. With warm regards, P/O: Prof. Jean Michel Viola Prof. Thierry Sauvage General Manager, GIP-CEI, France ISSL 2024 14 Messages from Supporters Centro Latinoamericano de Aprendizaje y Servicio Solidario (Latin American Center for Solidarity Service-Learning) CLAYSS, which stands for Centro Latinoamericano de Aprendizaje y Servicio Solidario, or Latin American Center for Solidarity Service-Learning, promotes service-learning as an innovative pedagogy that uses a holistic approach to encourage the development of relevant competencies as a response to both the educational challenges of the 21st century and the needs of local communities globally. CLAYSS' mission is to contribute to fostering a fraternal and participatory culture worldwide through the pedagogical proposal of service-learning from a Latin American perspective. CLAYSS was created to support students, educators and community organisations in developing of solidarity service-learning projects. These offer opportunities for children and young adults to apply what they learn in service of their communities while learning throughout the process. Participating in these activities outside of the classroom allows them to simultaneously acquire new knowledge, explore new topics, and develop skills for life, work and civic participation. This innovative pedagogy, spread worldwide, improves both educational quality and inclusion, and local development. CLAYSS offers training, researches and publishes its findings and quality service-learning practices, supports educational institutions of every level around the world and weaves networks. For the last 27 years CLAYSS has been offering its International Service-learning Conference which gathers local and international specialists, practitioners, public officers, students and educators committed to the growth of service-learning around the world. During that same week we hold the meeting of the Iberoamerican Service-learning network, which centralises institutions from around the region who promote service-learning, as well as national service-learning networks. We are honored to be participating in the IX International Symposium on Service-Learning, thrilled to share our Latin American perspective as well as experience promoting service-learning around the world, willing to keep weaving and strengthening networks. Maria Nieves Tapia, Director ISSL 2024 15 Messages from Supporters Campus Compact The times we are living in are exciting, yet daunting. Each gathering of engaged scholarpractitioners seems to be growing as new faculty incorporate community-engaged teaching and learning into their courses every semester and as increasing numbers of community engagement professionals join the field at every level of the institution. But the list of challenges facing our world, communities, institutions, and students is also ever-growing. We are all navigating rapid change and uncertainty, whether it be attacks on our missions, values, and rights, continued constraints placed on resources, or deepening divides. These are the moments when our students, institutions, and communities need us the mostand when we most need each other. We are the people who lean into the tough issues and who understand the power and necessity of bringing people together to listen and talk across differenceand ultimately build solutions that lead to a more just and inclusive society. As Campus Compact reaches its 40th anniversary, we are excited for the future. Campus Compact is the largest and oldest organization solely dedicated to advancing the public purposes of higher education. Representing universities and colleges across the United States, Campus Compact members are place-based institutions focused on using their civic and community engagement capacity to positively impact the communities in which they reside. We firmly believe that higher education is uniquely positioned to make a difference in the most pressing challenges facing our communities and that our collective work as faculty, administrators, staff, and students committed to the public purposes of higher education is critical to bringing about the just and equitable future we all seek. ISSL 2024 16 Messages from Supporters National University of the Union of Myanmar With a vision of a well-educated society in a peaceful, democratic, and prosperous country in which all members have the opportunity to contribute to and benefit from civic and economic well-being locally and globally, the National University of the Union of Myanmar (NUUM) - Global Campus was established in July 2021 in response to the educational crisis in the Southeast Asia Nation [SPECIFY CRISIS] with its primary objectives of providing continuing learning opportunities for Myanmar students whose education had been disrupted by delivering high quality, equitable, and accessible academic programs and educational services. In doing so, we capitalized on the success and experience gained through the Center for Research, Policy, and Innovation (CRPI) over a decade of delivering highly successful local educational programs in Indianapolis and various training and scholarship programs implemented under the BACI's Myanmar Initiative. NUUM is not just an educational institution. It is a catalyst for change. Currently, it offers certificate programs to Myanmar students through online courses taught by fellows and instructors from Myanmar and around the globe. But its role continues. NUUM is actively contributing to reform efforts and building systems for future democratic institutions, serving as a hub for academic research, scholarship, and intellectual inquiry, and generating ideas for innovations and policy debate, all in supporting democracy in Myanmar. At NUUM, we deeply value the power of collaborative partnerships. We are excited about the opportunity to draw on local experiences and international expertise through individual and institutional partnerships. We are particularly pleased to collaborate with various global institutions through the International Symposium on Service-Learning (ISSL). We believe in the impactful effect that service-learning could bring to our shared global communities, and we are committed to supporting and participating in the realization of the vision of the ISSL and implementing of its ten-year strategic plan. ISSL 2024 17 Acknowledgments 2024 Symposium Planning Committee Members University of Indianapolis Chair Marianna K. Foulkrod, Center for Service-Learning & Community Engagement Julie Gahimer, Physical Therapy Lisa Borrero, Aging Studies Jennifer VanSickle, Sports Management Jeff Bryant, Social Work Toni Morris, Nursing GIP CEI Co-chair Mohamad Fadl Harake, Post-Conflict Public Management - Crisis / Urgent Logistics and Operations Jean Michel Viola, Strategic Management & Innovation Phillip Cartwright, Micro Economics & Performance, CABMR Campus Compact Laura Weaver, Special Projects Manager Nicole Springer, Senior Director of Professional Development and Scholarship, & Chief Equity Officer ISSL 2024 Katrina M. Reinhardt, Education Ghina Sadek, Center for Global Engagement Jyotika Saksena, History & Political Science Yvonne Wakeford, Office of Human Research Protections Stellenbosch University Co-chair Mawethu Nyakatya, Division for Social Impact Chevaan Peters, Division for Social Impact Lindsay-Michelle Meyer, Faculty Medicine & Health Sciences Additional Partners CLAYSS Community-Engaged Alliance The National University of the Union of Myanmar St. Mary-of-the-Woods College 18 Special Thanks to our Community Partners Paws & Think, Inc., a local nonprofit organization founded in 2001, is dedicated to improving lives through the transformative power of the human-dog connection. Our mission is to create a community where every person who can benefit from a dog has The opportunity, and every dog fulfills its potential. We achieve through two core programs: jjj our Animal-Assisted Interventions (AAI) and our YouthCanine Programs. AAI, commonly known as Pet Therapy, trains and mobilizes registered therapy teams to individuals of all ages and abilities. Our YouthCanine Programs teaches young people how to train shelter dogs through positive reinforcement behaviors. As a volunteer-centric organization, we collaborate with schools, libraries, hospitals, detention centers, youth agencies, humane societies, and more, emphasizing the profound impact of the human-animal bond on community health and wellness. Explore more about our work at www.pawsandthink.org. Exodus Refugee Immigration is dedicated to the protection of human rights by serving the resettlement needs of refugees and other displaced people fleeing persecution, injustice, and war by welcoming them to Indiana. Exodus was founded in 1981 to serve the legal needs of immigrants and Cuban refugees who arrived as a result of the Mariel Boatlift. In our 40-year history, Exodus has provided refuge to tens of thousands of individuals from 50+ countries. Exodus is an independent, nonsectarian, 501(c)(3) refugee resettlement agency governed by its own Board of Directors. Exoduss role is to provide the materials, services, support, and resources necessary to empower these new friends and neighbors. Our aim is for refugees to achieve selfsufficiency and create the secure, free life that every person deserves. For more information about the services that Exodus provides, please visit our website at exodusrefugee.org. BACI is a community-based organization, established to assist the growing refugee population from Burma in Indianapolis, in tackling the various issues among refugees basic needs, initially focusing on but not imited to, the refugees Education and Employment through:j Advocating Connecting Educating Serving. Vision: Education for all, a stronger community. BACI emphasizes the inclusiveness and openness across the lines of different ethnic groups from Burma in its organizational development, and respect for and cultural and linguistic sensitivity in our service delivery. To learn more, please visit www.baci-indy.org. ISSL 2024 19 About The Symposium The Ninth International Symposium on Service-Learning (ISSL), entitled The Role of Global Service-Learning in Transformational Leadership: Fostering Social Action & Vigilance, is an exciting opportunity for scholars and practitioners of service-learning to gather and learn from one another, continuing to build upon the opportunities generated by past symposia: The 1st ISSL, Service-Learning Models for the 21st Century: Intercommunity, Interdisciplinary, International was held at Stellenbosch University in Stellenbosch, South Africa, in 2005. The 2nd ISSL, Service-Learning in Higher Education: Paradigms and Challenges, was held in 2007 at the University of Indianapolis in Indianapolis, Indiana, USA. The 3rd ISSL, Service-Learning in Higher Education: Educators, Communities, and Students, was held in November 2009 at the University of Indianapolis campus in Athens, Greece. The 4th ISSL, Service-Learning in Higher Education: Connecting the Global to the Local was held in September 2011 in Ningbo, China. The 5th ISSL, Service-Learning across the Globe: from Local to Transnational was held in November 2013 in Stellenbosch, South Africa. The 6th ISSL, Service-Learning as a Global Movement: Transforming Communities & Higher Education was held in May 2015 in Indianapolis, Indiana, USA. The 7th ISSL, Service-Learning as a Response to Global Transitions in Higher Education: Opportunities for Transforming Higher Education and Advancing Social Impact was held in June 2017 in Galway, Ireland. The 8th ISSL (Part 1), Critical Service-Learning Across the Globe: Transforming Teaching into Social Action in June 2021, Virtual Symposium. ISSL (Part 2), Critical Service-Learning Across the Globe: Transforming Teaching into Social Action was held in June 2023 in Nicosia, Cyprus. ISSL 2024 20 Symposium Purpose The purpose of the 9th International Symposium on Service-learning is to promote global citizenship, scholarship, and resiliency in a time of uncertainty and rapid worldwide change. The symposium will continue to focus on the development of reciprocal and transactional relationships as well as the development of innovative and fresh service-learning initiatives in higher education globally. These focal points will be threaded throughout a variety of presentation types and formats to allow for meaningful dialogue and work exchange among academics, students, community partners, and other professionals. The 9th ISSL aims to: Highlight service-learning as a catalyst for societal, institutional (policy change), and student transformation. Encourage the integration of service-learning and multicultural education in academia globally. Promote service-learning as ethical leadership and educate about the challenges for academic institutions. Bring awareness to the challenges in engaging service-learning in higher education post-global crises and events, both practical and theoretical approaches. Promote the integration of service-learning through multicultural and/or multidisciplinary collaborative methodologies and engaged scholarship in higher education. Emerge global theoretical perspectives that link to the student transformation into critical and engaged citizens. Promote and support the transformation of education and resilience of service-learning approaches through global crises and events. ISSL 2024 21 International Symposium on Service-Learning Publications 1.Service-Learning: Intercommunity and interdisciplinary explorations. (Editors: Mac Bellner & John G. Pomery, University of Indianapolis Press). 2005 2. The Second International Symposium on Service-Learning Proceedings (Editor: Phylis Lan Lin, Asian Programs, University of Indianapolis). 2007 3.Service-Learn Paradigms for 21 st Century Intercommunity, Interdisciplinary & International (Editors: Kenneth Colburn & Rona Newmark, University of Indianapolis Press). 2007 4. The Third International Symposium on Service-Learning Proceedings (Editor: Phylis Lan Lin, Asian Programs, University of Indianapolis). 2009 5. Service-Learning in Higher Education: Paradigms & Challenges (Editors: Mary Moore & Phylis Lan Lin, University of Indianapolis Press). 2009 6.Service-Learning in Higher Education: National and International Connections (Editor: Phylis Lan Lin, University of Indianapolis Press). 2011 7. Service-Learning: Theory and practice in higher education (in Chinese; Editors: Phylis Lan Lin & Xu Weiming, Zhejiang University Press and University of Indianapolis Press). 2011 8. Service-Learning in Higher Education: Connecting the Global to the Local (Editor: Antoinette R. Smith-Tolken, Stellenbosch University Press). 2013 9.Service-Learning across the Globe: From Local to Transnational: Paper Series (Phylis Lan Lin & Mark R. Wiegand, University of Indianapolis Press). 2013 10. Service-Learning in Higher Education: Building Community Across the Globe (Editors: Phylis Lan Lin, Mark R. Wiegand, & Antoinette R. Smith-Tolken, University of Indianapolis Press). 2014 11. Service-Learning as a Response to Global Transitions in Higher Education: Opportunities for Transforming Higher Education and Advancing Social Impact Proceedings, NUI Galway, Ireland, 2017 12.Critical Service-Learning Across the Globe: Transforming Teaching into Social Action Proceedings, University of Nicosia, 2022 Journal Announcement and Work Submission Invitation by CLAYSS RIDAS is a scientific journal co-edited between the Faculty of Education of the University of Barcelona, CLAYSS (Latin American Center for Solidarity Service-Learning), and the Ibero American Service-Learning Network. It is aimed at researchers, academics, educators, specialists, and people interested in service-learning and intends to contribute to the creation of knowledge about service-learning in all socio-educational areas and educational levels. The articles it contains can be theoretical, conceptual, and historical reflections; research articles; good practices analysed; case studies; short experiences and testimonials; literature reviews and reviews. It is issued biannually and has a Peer Review Process. Articles can be presented in Spanish, English, and Catalonian. Full info can be found here: https://revistes.ub.edu/index.php/RIDAS/about ISSL 2024 22 10-year Strategic Plan The University of Indianapolis, ESLI International (Campus ESPRIT Industries), and Stellenbosch University have decided to join forces to co-organize and co-host the International Symposium on Service-Learning (ISSL) in its 9th (USA), 10th (France), and 11th (South Africa) editions. The aim of this international collaboration on three continents is to expand service-learning as a teaching approach to incorporate the needs of the community into students' learning to the needs of the community. Another aim of this partnership is to focus on the various transitions of higher education and the role that critical service-learning plays in social transformation as a whole. Indeed, the three institutions will be working on both their students and faculty's delivery of critical servicelearning experiences in order to become true agents of positive change for their communities. This American-European-African partnership aims to highlight the significant role that servicelearning plays in students becoming more engaged citizens, in faculty members becoming more critical and collaborative, and the community becoming a true knowledge incubator. This new dynamic will be discussed and threaded throughout the symposium via various of presentation types and formats to allow for a rich dialogue among academics, practitioners, community partners, international organizations, students, and other engaged parties. This new collaboration will allow for: The exploration of the complexities of development, transition, and transformation within higher education across the globe. The adoption of a vigilant stance when it comes to social transformation. The acquisition of the transformative change leadership skills necessary for the piloting of communal or community change initiatives. The enhancement of the social impact of critical service-learning in society. The review of current theoretical perspectives in higher education and how collaborative research and curriculum design can enhance Service-Learning's societal impact. The overview of new ethical goals and challenges impacting service-learning in higher education. The illumination of service-learning as an innovative and transformative pedagogy for social change. The strengthening of networking between the different engaged parties in social change initiatives across the globe. The development of a global service-learning community. ISSL 2024 23 Symposium Themes In our quest to contribute to a transnational service-learning pedagogy, presentations will cover one of the following: 1 Student and faculty engagement & impact of service-learning experiences 2 Conceptual frameworks, curricular design, and pedagogical techniques 3 Inter-, multi-, and trans-disciplinary initiatives and cross-border connections 4 Collaborations between higher education institutions and community partners & Transformative research Presentation Formats Storytelling: This is a medium through which best practice can be shared of servicelearning as a teaching and learning approach. These stories will be clustered in 25 minutes (including 5 minutes of Q & A) inputs by participants and a general discussion on new insights on practice. The presentation should consist of a context, outlining the practice and demonstrating the gain of using this practice to the audience. Research papers: This form of presentation is theoretically grounded in published theory or by introducing new theoretical insights. The presentation should include a rationale for the research and the design and outcomes from service-learning. The research should include what has been measured and (or) assessed. The research may also introduce a framework, model or theory that was developed through the research. The abstract should include the methodology and the outcomes or findings. For this format 30 minutes will be given to present including discussion time. Workshop: In a workshop, presenters showcase a particular research topic (or practice) through which best practices or new knowledge were developed. This form of presentation aims to build the audiences capacity on the diverse areas of servicelearning through ample discussion and interactive activities. It could also take the form of an institution presenting the progress they have made in practicing service-learning on an institutional level, highlighting how they enhance citizenship of students and staff. Each presenter should submit their abstract with reference to the central theme of the symposium. Workshops will be 60 minutes in length. ISSL 2024 24 About the University of Indianapolis The University of Indianapolis is a private residential institution founded in 1902. UIndy offers its diverse student body a comprehensive set of general, preprofessional, and professional programs grounded in the liberal arts. UIndy is home to almost 5,000 undergraduate and graduate students, and is recognized for personal attention, small and interactive classes, and flexible programming. As it develops its strategic plan, dubbed Vision 2030, the University is making investments in creative interdisciplinary ventures and opportunities to apply learning, strengthen the student-faculty connection, reflect the workplace realities students will encounter, and greatly enhance the educational process. Learn more at uindy.edu ISSL 2024 25 Panelists and Emcee Opening Reception Panel: The Power of Global Networks L u z Avruj C L AYSS Phillip Cartwright CABMR Gurinder Ka u r Immigrant Wel c o m e Center E l a i s a Vahnie B ACI Chevaan Peters Stellenbosch University Laura Weav e r Campus Com p a c t Opening and Closing Reception Emcee Tynnetta Muhammad University of Indianapolis ISSL 2024 26 Opening Ceremony Agenda Wednesday, May 29th, 2024 University of Indianapolis Student Center - Enders Hall 5:30 pm - 7:30 pm Emcee: Tynnetta Muhammad Welcome to ISSL Recognition of ISSL Logo Design Team & Emcee Introduction University of Indianapolis Marianna Foulkrod, ISSL2024 Co-Chair UIndy Presidential Remarks University of Indianapolis President, Dr. Tanuja Singh Presidential Message Stellenbosch University Presidential Message Jean-Michel Viola, GIP Campus ESPRIT Industries (GIP CEI) Campus Compact Remarks Nicole Springer, Senior Director of Professional Development and Scholarship & Chief Equity Officer, Campus Compact Provost Remarks Recognition of ISSL Co-Founder Dr. Phylis Lan Lin University of Indianapolis Provost, Dr. Chris Plouff ISSL Reflection from a faculty Dr. Candace Beitman, University of Indianapolis Occupational Therapy Associate Professor Emeritus & Long-term ISSL participant Panel on The Power of Global Networks Panelists: Gurinder Kaur, Immigrant Welcome Center; Elaisa Vahnie, NUUM & BACI; Phillip Cartwright, ESLI; Luz Avruj, CLAYSS: Centro Latinoamericano de Aprendizaje y Servicio Solidario; Cheevan Peters, Stellenbosch University; Laura Weaver, Campus Compact RIDAS Journal Announcement Preview of Upcoming Conference Program ISSL 2024 27 Closing Ceremony Agenda Friday May 31st, 2024 University of Indianapolis Student Center - Enders Hall 5:00 pm - 6:00 pm Emcee: Tynnetta Muhammad Closing Remarks University of Indianapolis, Marianna Foulkrod ISSL Co-Chair Project Presentation GIP Campus ESPRIT Industries (ESLI) Announcement of ISSL 2026 Jean-Michel Viola GIP Campus ESPRIT Industries (ESLI) Looking ahead to our ISSL global network The National University of the Union of Myanmar & the Burmese American Community Institute (BACI) ISSL 2024 Presenter Awards Emcee, Tynnetta Muhammad Reminder for RIDAS Journal Submissions Completion of Pledges and Giveaway of Candy Bars ISSL 2024 28 PRE-CONFERENCE & SYMPOSIUM PROGRAM AT-A-GLANCE Tuesday, May 28th Pre-conference Workshop "Pen to Paper," Trustees Dining Room A retreat focused on preparing scholars to publish their community-engaged work. Check in begins at 11:00 am in the Atrium of the Student Center. Wednesday, May 29th Pre-conference Workshop "Pen to Paper," Trustees Dining Room A retreat focused on preparing scholars to publish their community-engaged work. Check in begins at 9:00 am in the Atrium of the Student Center. Vendor & Affiliated Partners Fair, Schwitzer Student Center Shreve Atrium Symposium registration open at 12 pm in the Student Center Atrium. Opening Ceremony, Enders Engagement Center, Schwitzer Student Center Experience the Indianapolis Indians, Use Red Line Bus/Victory Field Enjoy an evening at the Indianapolis Victory Field located in Downtown Indianapolis! We will be visiting the field on Wednesday, May 29th, after the ISSL2024 opening festivities, to enjoy an evening of friendship and collegiality. Home to the Indianapolis Indians baseball team, the ballpark draws many visitors and is a popular attraction for baseball fans! Located in the White River State Park, Victory Field is found near the Indianapolis Zoo and Lucas Oil Stadium, with many people visiting all three while they are in the area. Thursday, May 30th Scholarly Presentations, Schwitzer Student Center Basement Rms 010, 011, 012, 013 Check in begins at 8 am in the Atrium of the Student Center. Lunch will be served from 12:30 pm - 1:30 pm at Ober Dining Hall. ISSL 2024 29 ISSL Mental Health Awareness Walk, Schwitzer Student Center Shreve Atrium Brigham Young University will host a Mental Health awareness walk with support from the University of Indianapolis. Walk participants will experience a demonstration of a structured Mental Health Awareness Walk. The 1-mile route will stop at several presentation stations that will present specific mental health disorders and their treatments. Group leaders will facilitate discussions between stations. The UIndy Student Counseling Center (SCC) will be one of the primary stops along the walk, where the director of the center will provide a tour and discuss mental health initiatives the center has developed for campus-wide mental health training and support, and will remain open for the Mental Health Awareness Walk between 4 - 5:30 p.m. A debriefing and a raffle drawing will conclude the experience. This mental illness stigma program will demonstrate several methods of engaging students in service-learning. How-to manuals will be available to participants. Cultural Dinner & Celebrations, Schwitzer Park Enjoy an evening of fun and music, grilling out some amazing hot dogs and burgers, and celebrating what makes America so unique...the melting pot of different cultures and cuisine! A few international desserts will also be available for us all to try, and we will spend the evening eating, dancing, and being together. Bamboo Dancing: The Cheraw Kan dance is a traditional bamboo dance and It is one of the most famous dances among the Chin traditional dances in Burma/Myanmar. Male performers clap bamboo staves rhythmically while female dancers move intricately between them. The Cheraw Kan features traditional music with instruments like gongs and drums, accompanied by agile dancers in colorful attire. They skillfully navigate bamboo sticks, creating intricate formation amidst a mesmerizing atmosphere. Women wear Vakiria (headdresses) adorned with feathers, beetle wings and other colorful objects, along with Kawrchei (traditional blouse) and Puanchei (sarong). Men wear Khumbeu (bamboo hats) and Ngotekherh (black and white checkered fabric that can be worn as a shirt or sarong). Indian Dancing: Originating from the vibrant Indian state of Gujarat, Dandiya Raas is a captivating socioreligious folk dance deeply intertwined with the festivities of Navaratri. Dandiya Raas adds an exhilarating twist by incorporating sticks held in both hands while dancing. The dance is traditionally performed in pairs, with each group consisting of an even number of participants. As the music sets the rhythm, participants form two lines facing each other, moving clockwise in a synchronized motion. The dance unfolds in an eight-beat time cycle known as Kaherva, where participants rhythmically strike their own sticks together, followed by coordinated movements with their partners. With each step forward, the exchange of stick hits creates a mesmerizing visual and auditory spectacle, symbolizing unity, harmony, and community spirit. As the dance progresses, participants seamlessly transition between partners, ensuring a continuous flow of movement and energy throughout the performance. This dynamic interplay of music, movement, and camaraderie makes Dandiya Raas a truly immersive cultural experience, embodying the joy and vitality of Gujarati heritage. In essence, Dandiya Raas is more than just a danceit is a celebration of tradition, togetherness, and the timeless spirit of Navaratri. Line Dancing: Line dancing is a form of dance where individuals perform choreographed steps in unison, arranged in lines or rows, typically without a partner. It originated from folk dance traditions where dancers would line up in rows and perform repetitive steps to music. However, the modern form of line dancing, as we know it today, emerged in the United States, particularly in the country and western dance scene during the late 20th century. Line dancing became particularly popular in the 1970s and 1980s, especially in country and western bars and clubs across America. Its simplicity and the fact that it doesn't require a partner made it accessible to many people. As it gained popularity, line dancing evolved to incorporate influences from various music genres, including country, pop, rock, and even Latin music. Bachata: Bachata is a style of dance that originated in the Dominican Republic. It is danced widely all over the world but not identically. The basics to the dance are three-step with a Cuban hip motion, followed by a tap including a hip movement on the 4th beat. The knees should be slightly bent so the performer can sway the hips easier. The movement of the hips is very important because its a part of the soul of the dance. ISSL 2024 30 Friday, May 31st Scholarly Presentations, Schwitzer Student Center Basement Rms 010, 011, 012, 013 Check in begins at 8 am in the Atrium of the Student Center. Lunch will be served from 12:30 pm - 1:15 pm at the Student Center cafeteria. Service-Learning with Exodus Refugee, Use Red Line Bus Exodus Refugee is proud to partner with UIndy for the ISSL2024 Service-Learning Experience in Exodus' on-site storage warehouse! During this time, service-learning participants will be assisting the Exodus office by sorting and organizing unprocessed donations and other housing inventory on shelves throughout the warehouse. These donations will include household items, toiletries, bedding items, furniture, and more! There will also be an opportunity to sort and organize unprocessed clothing donations in the client clothing room. Guests are advised to wear clothing that could get dusty. Service-Learning with Paws & Think, Schwitzer Student Center Shreve Atrium Participants will collaborate to create dog enrichment toys for local nonprofit Paws & Think. Paws & Think is dedicated to improving lives through the power of the human-dog connection. Their therapy dog programs bring comfort and joy to our college students and individuals in hospitals, schools, and other community partners. In contrast, their YouthCanine program pairs shelter dogs with vulnerable youth for mutual benefit. All toys created during this session will be donated for use in Paws & Think's Youth-Canine program, enriching the lives of both shelter dogs and participating youth. Don't miss this chance to make a difference while having fun and learning about the impact of service-learning in our community! Closing Ceremony, Enders Engagement Center, Schwitzer Student Center ISSL 2026 announcements, presenter award announcements, pledge to continue service. Saturday, June 1, 2024 ISSL2024 Excursion - Check-in begins at 9 am in the Student Center Atrium Buses will be located at the Bell Tower following check in Join us for a day of exploring Indiana! We will visit Brown County State Park, Indiana's largest park, with nearly 20 miles of tree-lined roads and many scenic vistas overlooking miles of uninterrupted forestland. We will stop by the quaint village of Nashville, Indiana, for a lunchon-your-own visit. Nashville is known for its unique craft, specialty, and antique shops, and it is best known as the center of the Brown County Art Colony. "We will also be visiting Hard Truth Distilling Company. At Hard Truth, they've traded skylines for tree lines, pavement for forest trails, and complicated for pure and simple. Hard Truth Distilling Co. is Indianas largest destination craft distillery featuring a full-service restaurant, a tours and tastings center, outdoor amphitheater and more. Guests ages 21 and older can tour the Hard Truth distillery, experience a guided tasting, or hop on an ATV with one of our guides and explore our 325 wooded acres while learning about the history of distilling. Visit them for mixology classes, single barrel selection experiences, and more!" ISSL 2024 31 Pre-Conference: Pen to Paper A retreat focused on preparing scholars to publish their community-engaged work. This event will take place from 12:00 PM on Tuesday, May 28, 2024, to 2:00 PM on Wednesday, May 29, 2024. An in-person writing retreat to learn the ins and outs of what makes writing about community engaged work different than writing about disciplinary work. Dr. Diane Doberneck and Laura Weaver, experts in the field of community engagement and public scholarship lead this preconference experience where participants will receive tips and tools to sharpen their writing skills and enhance productivity. A panel of editors from some of the top journals in the field of service-learning and community engagement will speak on ways to make a manuscript stand out from all the rest. Faculty of all ranks, administrators, professional staff, graduate students and community partners as individuals or writing teams are welcome. Facilitators Dr. Diane Doberneck Laura Weaver Diane M. Doberneck, Ph.D., is the director for Faculty and Professional Development, Office for Public Engagement and Scholarship, University Outreach and Engagement (UOE), Michigan State University. She provides leadership for UOEs faculty and staff professional development programs for graduate students, post-docs, academic staff, tenure-track faculty, administrators, and community partners. Laura Weaver, M.S. Ed., is an engaged scholar-practitioner dedicated to facilitating authentic community-campus relationships and partnering on community-driven engaged scholarship. She has nearly 20 years of experience supporting institutions as they work to actualize their culture for community engagement. ISSL 2024 32 ISSL 2024 Peer Reviewers Mohamad Fadl Harake France GIP Campus ESPRIT Industries Jean Michel Viola Virginie Nahas France France GIP Campus ESPRIT Industries EPSI Marianna Foulkrod Jennifer VanSickle Julie Gahimer United States United States United States University of Indianapolis University of Indianapolis University of Indianapolis Lisa Borrero Katrina Reinhardt Elizabeth Moore United States United States United States University of Indianapolis University of Indianapolis University of Indianapolis Lindsay-Michelle Jeannie Mitchell Meyer United States South Africa Saint Mary-of-the-Woods Mawethu Nyakatya South Africa Stellenbosch University Stellenbosch University Tricia Pierce Ushotanefe Useh United States South Africa Saint Mary-of-the- North-West University College Denise Ferrell United States Marian University Woods College ISSL 2024 33 9th International Symposium on Service-Learning University of Indianapolis, May 29th - June 1st, 2024 Thursday, May 30th, 2024 Workshops (SC012) 60 minutes per presentation Research (SC011) 30 minutes per presentation Session Time Storytelling (SC010) 30 minutes per presentation 9:00 11:00 am D. Pracht, K.H. Fletcher, C. Lawlor, & M. Coyle Overcoming challenges through successful partnerships for an international service-learning study abroad program. S. Denney & K. Reinhardt Exploring Service-Learning as a Tool for Expanding Pre-Service Teachers Professional Role Identities. E. Kung, K. Kaiser, & C. van der Vyver Rising from the ashes the story of a facultys journey to a culture of Service-Learning. P.A.Cartwright The Impact of Service-Learning on Public Policy Making. J. VanSickle, K. Watkins, A. Garabrant, T. Morris, & S. Wareham Service-learning Across Disciplines: One Event, Multiple Opportunities. A. Naidoo Enacting community service-learning as an integrated social justice pedagogy: Lessons from a 25-year retrospection. L. Gilchrist Service-Learning and Inclusion: Building Capacity and Partnership through Universal Design for Learning Principles. S. Ross, W. Scogin, & B. Aho An International Service-learning Trips Impact on Graduate Students Interprofessional Collaboration: A Mixed-methods study. C. Ruby, M. Drnach, A. Pilsner, B. Sloane, B. C. Chvez, & G. K. Gngora Cultivating Change: A 20-Year Journey in Global Rehabilitation Partnerships. Workshops (SC013) 60 minutes per presentation M. Pietersen, R. Hector-Kannemeyer, & P. Khosa Utilizing a Moodle platform to advance engaged citizenship and enable national virtual service-learning initiatives as a curricular requirement for social work students at Stellenbosch University. D. Coker-Kolo & L. Reed Integrating service-learning with social justice: A critical opportunity for candidates in an educational leadership program. BREAK 11:30 am 12:30 pm S. Asim An Easy Tool to Transform Teacher Preparation: Integrating Global STEM Career Role Models through Leveraging Picture Books. U. Useh From job-seeking to jobcreation initiative: Changing the ecosystem and improving graduate attributes for African graduates through service-learning. S. Ramer & K. LaComba Global Leadership in Troubled Times: A student-led international sister city project. E. Gahimer Upon Return: Cultivating Global Citizenship & Social Action in U.S. Global Health Students: A Case Study in Crdoba, Argentina T.Morris An Innovative Faculty Role: A Catalyst To Incorporate ServiceLearning And Engaged Scholarship Into Higher Education. T. Jones, P. Jones, M. Voice, & G. Gee Beyond Words: Service-Learning and Hip-Hop as a Language of Social Change. LUNCH (Ober Dining Hall) 1:30 3:30 pm I. C. Beulaygue & K. S. MurchShafer Service-Learning Impacts on Career Exploration and Wellbeing in the Exploratory Studies Program T.Pierce How to promote a global change from a service-learning course on your campus. ISSL 2024 M. Foulkrod & P. Lan Lin Global Leadership Adaptability Through Servant Leadership and Cultural Humility: A Conceptual Framework L. Borrero Indirect Service-Learning: Aims, Advantages, and Best Practices C. Peters Bridging Knowledge and Action: Insights from Stellenbosch University's Social Impact Knowledge Platform L. Avruj, A. Peregalli, & C. Ferrara Service-learning networks: conceptions, skills and conditions of a glocal transformative movement. P.Cartwright Ascencias Center for Applied Business and Management Research M. D. Freeman E. Orr Self-Directed Learning to Promote Healthy Lifestyles for Adults with Chronic Illness. Changing Knowledge, Awareness, and Stigma Through the Service Learning Activity of a Mental Health Awareness Walk. J. Bester & M. Kloppers Going full circle in SLEAK project & Stronger together. T. Nqowana Fostering Social Justice Through Service-Learning: A Closer Look at the Vulindlela Parent Engagement Program's Initiatives. 34 BREAK 4:00 - 5:30 pm MENTAL HEALTH AWARENESS WALK (Schwitzer Student Center Shreve Atrium) CULTURAL DINNER (Schwitzer Park) 9th International Symposium on Service-Learning University of Indianapolis, May 29th - June 1st, 2024 Friday, May 31st, 2024 Session Time 9:00 - 11:00 am Storytelling (SC010) 30 minutes per presentation Research (SC011) 30 minutes per presentation Workshops(SC012) 60 minutes per presentation A. Schlessman, J. Foucrier, S. Trotter, & C. A. J. M. Viola M. Glowacki-Dudka & R. Lordeni - Berg-Carramusa The Implementation of Service-Learning into an Accelerated Hybrid Multi-Site Physical Therapy Program. Service-Learning as a unique way to develop soft skills. Service-Learning for Communities through Transformative Leadership and Culturally Expansive Learning. S. Moore, J.R. Jamison & T. Morris M. Foulkrod & C. Giardina Leadership Transformation in times of change and cultural adversity. Service-Learning for Student Transformation. J. Schlessman A High School Service-Learning Course: Transforming Students into Engaged Citizens. K. H. Fletcher, D. Pracht, & M. Coyle An Irish tale: How four unlikely characters came together to create a successful international service-learning study abroad program. C. Pearison Theory Integration in Education Transformation and Resilient Service-Learning Amid Global Crises. L. Kojich & J. Gahimer Enhancing the 21st Century Skills: An EService-Learning Toolkit of Creative Pedagogies. S. Shall New constructs for service, learning, and practice: Understanding the transformative power of building abroad on communities and students. BREAK 11:30 am 12:30 pm R. Wolverton Becoming change makers through service-learning and human-centered design: Students & community standing in the gap together. E. Konwest, K. Silvester, & S. Asim Implementing the Global Community Engaged Learning Course Development Institute at Indiana University-Bloomington. T.Jones Amplifying Voices: Service-Learning and the Imperative to Capture the Experiences of Black Women. R. Rostom & C. Paterson Building Energy Conservation and Cost Savings Into A Campus Renovation. M. Sass Connecting AI with Service-Learning. LUNCH (Ober Dining Hall) 1 - 5:30 pm ISSL 2024 SERVICE- LEARNING EXPERIENCE (Exodus Refugee; Paws & Think) 35 9th International Symposium on Service-Learning Abstracts ISSL 2024 36 Ov e r c o m i n g c h allenges through successful ser v i c e - l e a r n i n g study abroad program. D. P r a c h t , K . H . F l etcher, C. Lawlor, & M. Coyle partnerships for an in t e r n a t i o n a l This interactive workshop will be structured to share what one institution (University of Florida), one global partner (Ionad Naomh Pdraig), and one program provider (Learn International) are doing to integrate high-impact experiences that lead to career integrated global learning to promote global citizenship and cross-cultural exchanges. The structured portion of this workshop will include interactive activities modeling our best-practices for high-impact learning and outcomes. We will demonstrate preflection, reflection, mindfulness, and gratitude experiential learning exercises. Collectively, we will share these experiences through overcoming challenges of a global pandemic together, along with its impact on our global partner, The Ionad. Through these challenges of incorporating meaningful international service-learning (ISL) experiences, resiliency, adaptability, and flexibility were essential as we pivoted with programming and placements. We will share examples of how we integrated community, culture, academic learning, and experiential learning throughout this program to transform our educational and ISL experiences for our students and our global partner. Through extensive reflection and evaluation of the past four programs, the three entities (UF, Learn International, and The Ionad) improved the educational and programming experiences tailoring the approach to include several key elements in the predeparture sessions. The number of predeparture sessions have increased the resiliency in our most recent cohort (Summer 2022). Another key element gained through observation, student input, and evaluation, was to include an interview to match student expectations with ISL program goals, to increase the number of predeparture sessions to four, which now includes a preflection exercise (Cully-Garbers & Roberts, 2019), and include teambuilding sessions. In our initial predeparture session, we work to establish a sense of camaraderie through a charcuterie board teambuilding activity. In our second, predeparture session our students are oriented, trained and screened through the National Vetting Bureau with An Garda Sochna prior to arriving at their placement. They also, begin to select their accountability partners for the program to ensure safety and accountability, while creating a sense of belonging. During our third predeparture session, we discuss health and safety protocols, along with self-care best practices, and mindfulness and gratitude exercises. In our final predeparture session, we maintain a sense of camaraderie through a potluck dinner while providing an informal opportunity to answer any last-minute questions the students may have regarding the program. During this final predeparture, we also have them write a letter to their future selves where we return their letter on the final week of our program. This fellowship and camaraderie building is continued with a welcome dinner at the onset of our program and a celebration dinner to finalize the end of the ISL program. Another key component gained through evaluation, was to create an E-learning Hub for all prospective students as centralized electronic location for information regarding this program. This includes the following: it begins to create an online learning community, it facilitates organizing interview times, it provides information regarding all our NGOs and our program partner, all predeparture information, course syllabi, course calendar for academic-related materials and assignments, itinerary of the program, and a centralized communication hub. While on program, we continue to utilize this E-learning Hub for best-practices to include both written weekly reflections and in-person group reflection sessions, an electronic portfolio, and cultural journals connected to excursions. Two other critical elements on program include communications featuring an international group-chat (WhatsApp) and a routinely updated itinerary that students have easy access to (E-learning site). The final component gained through evaluation of this program and the collective partnership between the three entities was to expand its citizenship of students, faculty, and staff to include a graduate student on all future programs. This graduate student will serve as a pivotal member of the interviews, the decision-making team, and will serve as a core member of planning and implementing team on all four predeparture sessions, along with co-leading the ISL Program with the Director. ISSL 2024 37 The three partners continue to collaborate through conducting evaluation, research and presenting globally. As a result of this partnership with Learn International, they been approved as an official program provider of sponsored Faculty-Led study abroad programs for The University of Floridas International Center. Based on the collaborative efforts of three partners, it has been determined that the time spent in-country has positively impacted both leaders and children/youth at the Ionad Naomh Pdraig, one of our NGO Partners, where we have each learned from the skillsets of one another. In addition, the children/youth at the Ionad learn about the diversity of cultures while the American students are exposed to their rich heritage, culture, and the old Irish Celtic language. The local Irish community benefits socially and economically from this valuable program, and the American students learn about the importance of community development and the impact a social enterprise has on a disadvantaged, marginalized rural community. Dr. Pracht is an Associate Professor Community Based Organizational Systems for the University of Florida and has been a faculty member in the Department of Family, Youth and Community Sciences (FYCS) since 2007. His research expertise is risk management, service-learning, experiential learning, youth leadership development, volunteer management in nonprofit organizations, and transformational leadership. He teaches undergraduate and graduate courses, conducts research, and provides service through IFAS Extension serving all 67 counties in the state of Florida. Kate H. Fletcher is a Senior Lecturer for the University of Florida and has been a faculty member in the FYCS since 2008. Her research is service-learning, experiential learning, youth leadership development, and mentorship. She teaches undergraduate courses, conducts research, and provides service through academic advising and mentoring of undergraduate and graduate students. She is pursuing a doctorate degree in Leadership through the Department of Agricultural Education and Communication at the University of Florida. Chris Lawlor is the co-founder and Chief Executive Officer at Learn International. Mary Coyle has been building local community capital since 1996 in County Donegal, Ireland. Her founding purpose is rooted in promoting positive social change and community development. She has established, promoted, operated, and developed an internationally known Community Centre. She continues to fundraise and manage the Centre. The Centre is dedicated to the direct provision of community support, development, enterprise and education services for children, young people, parents, and families in the community. ISSL 2024 38 Rising from the ashes the story of a facultys journey to a culture of Service-Learning. E. Kung, K. Kaiser, & C. van der Vyver The story we bring to you is the story of a Faculty of Educations journey to embedding Service-Learning into pre-service teacher curriculums as a catalyst for societal, institutional, and student transformation. We are but at the beginning of the journey but hope that the growth over the last five years is indicative of the road ahead. To provide context to our situation, we need to share a short history, paint a picture of the faculty today and share our dreams. The North-West University (NWU) came into being in 2004, as part of a restructuring of tertiary education in South Africa. A forced merger of three vastly different institutions, the University of the North (a black, rural university situated in what was previously Bophutatswana), the Potchefstroom University for Christian Education (a traditional, white, Afrikaans university, consisting of a main campus in Potchefstroom and a satellite campus in Vanderbijlpark) and the Sebokeng campus of the Vista University (a multi campus university for black students spread across South Africa). As one can imagine, this merger did not come about without many issues and baggage. Jumping to 2016, the management of the NWU embark on a complete restructuring of the university to counter division between the three campuses, Mahikeng, Potchefstroom and Vanderbijlpark. Along with the restructuring also came full alignment of programmes across campuses. One of the aims of the restructuring was to ensure equal managerial representation across the institution. Thus, a faculty would have an executive dean, supported by three deputy deans, one per campus. Each deputy dean took responsibility for a portfolio, Teaching and Learning, Research and Innovation and Community Engagement. By creating a focused position for community engagement, the NWU ensured to address the worldwide cry for universities to move from ivory towers of knowledge to collaborators with the members of the societies they serve. Our story emits from an exploratory participatory action research study making use of the narrative method forming part of a larger project focused on storytelling as teaching strategy. The aim of the exploratory study is to establish how Service-Learning can contribute to societal, institutional and student transformation within a faculty from an interprevist paradigm. The focus of our story will be the lived experiences of various role players in faculty, i.e., management, ServiceLearning project owners, students, staff, and community members participating the in Service-Learning projects, sharing their journey on the road to slowly change minds and transform initial teacher training within the Faculty of Education of the North-West University. Our purpose is to share with the audience a journey of growth. Our story will share how Community Engagement as the stepchild in tertiary education is slowly rising from the ashes with the aim to encourage some of our audience to embark on a similar and/or renew the passion for change in other audience members. At the same time, we wish to learn from our audience and their experiences through conversation. Dr Elize Kng is currently the Deputy Dean, Community Engagement and Stakeholder Relations in the Faculty of Education of the North-West University. She obtained a BA, PGCE, B.Ed. Hons, M. Ed at the then P.U. for C.H.E and her Ph.D. at the North-West University. While her research has focused on human rights, but of late her interest is in the role of ServiceLearning and Work Integrated Learning in preservice teacher education. Prof Kotie Kaiser is the director of the School for Languages in the Faculty of Education of the North-West University. Her areas of expertise are ESL teaching and learning, LAC, and Multilingual Pedagogies. Dr Corn van der Vyver is a lecturer in the subject group Afrikaans for language education in the Faculty of Education She obtained the following qualifications: BA(Ed) from the University of the Free State (1990); and the consecutively from the North-West University, Honors in Language Practice (2007), MA in Afrikaans and Netherlands (2014) and PhD (2018). ISSL 2024 39 Service-learning Across Disciplines: One Event, Multiple Opportunities. J. VanSickle, K. Watkins, A. Garabrant, T. Morris & S. Wareham In the traditional service-learning model one faculty member partners with a community organization to enact a service-learning project related to a specific course that fulfills a specific community need (Bringle, Philips, & Hudson, 2004) thus connecting the service to specific course/program content (Eyler,1999). While it is widely known that servicelearning benefits students across a variety of disciplines, providing opportunities for personal, professional, and cultural growth (Jarrett, Dunnm, Tomchek, Reynolds, & Mercer, n.d.), rarely do faculty from different disciplines intentionally work together with one community partner (Marx, Glaser, Moran, & Tucker, 2021) on a project that meets everyones needs. This presentation will tell the story of how faculty from 7 different disciplines (music therapy, nursing, occupational therapy, physical therapy, education, public health, and sport management) collaborated to implement a unique servicelearning project for Special Olympics Indiana athletes. Presenters will share the processes used for creating the project and the benefits derived by students, faculty and the community partner, Special Olympics Indiana. Attendees will provided with a model for creating a similar project. Jennifer L. VanSickle, Ed.D., is currently Professor of Sport Management and Department Chair for Kinesiology, Health, and Sport Sciences at the University of Indianapolis. Her research interests include community engagement, volunteer and event management, and experiential teaching and learning. Jennifer earned her doctorate from the University of Kentucky. Kristina Watkins, OTD, MOT, OTR is an Assistant Professor and Academic Fieldwork Coordinator for the School of Occupational Therapy at the University of Indianapolis. Her clinical experience is in pediatrics with a special interest in infant and child feeding and eating. Her academic interests include experiential education, interprofessional education, and professional development. She is also passionate about enhancing support and education related to justice, equity, diversity, inclusion, and belonging. Alissia Garabrant, OTD, MS, OTR is an Assistant Professor and Academic Fieldwork Coordinator for the School of Occupational Therapy at the University of Indianapolis. Her clinical experience is working with people across the lifespan and in a variety of settings. Her academic and scholarship interests include experiential education, interprofessional collaboration, and loneliness in homebound older adults. Toni Morris, DNP, RN, CNE is an Associate Professor in Nursing at the University of Indianapolis. She is a nurse with over 25 years of experience and interest in operating room nursing, informatics, community-public health, service-learning, interprofessional education, disaster simulation, and nursing education. Dr. Morris earned her Bachelor of Nursing from Indiana University, her Master of Nursing Education from the University of Indianapolis, and her Doctorate of Nursing Practice from Indiana State University. Sarah Wareham, PhD is an Assistant Professor of Education, teaching in the areas of special education, inclusion, and Universal Design for Learning. Dr. Wareham joined the University of Indianapolis School of Education faculty in 2019. Previously, she worked for 15 years as a special education teacher in a large, urban school district in Indianapolis. Dr. Wareham earned her doctorate in Educational Leadership from Indiana State University studying the impact of teacher attitudes on professional collaboration and student participation. She presents at international, national, state, and local conferences, speaking on the topics of Universal Design for Learning and Inclusion. ISSL 2024 40 Service-learning and inclusion: Building capacity and partnership through universal design for learning principles. L. Gilchrist Inclusive higher education (IHE) programs designed to serve the needs of college students with intellectual disability continue to be on the rise (Grigal & Papay, 2018). In even more recent years, the call for inclusivity on college campus have been evident. In tandem, inclusive higher education programs are being called to design academic components within inclusive, not segregated settings. In other words, inclusive higher education (IHEs) are being challenged to teach essential independent living skills in inclusive environments. Over the past two and a half years, this inclusive model has been strengthened through the partnership with a Vanderbilt University, Human and Organizational Development (HOD) service-learning course and the Next Steps at Vanderbilt program. Together, the HOD undergraduate course and the Next Steps program leadership developed a multiyear service-learning partnership aimed as joining students and faculty from both contexts to thoughtfully address inclusivity in program design and delivery. The mission of the undergraduate course is to explore the complexities of health service delivery to diverse populations. Social-ecological models are applied to provide a deeper understanding of the impacts of health policy, social justice, structural inequities, and the systems of diverse communities so that students may be more effective in serving the needs of all people. Launched in 2010, Next Steps at Vanderbilt is a 4-year inclusive higher education program committed to providing students with intellectual disability an inclusive, transformational postsecondary education in academics, social and career development, and independent living, while honoring equality, compassion, and excellence in all endeavors. This partnership provides the opportunity for undergraduate students to serve in two capacities, as tutors assisting students enrolled through Next Steps with these independent studies, and scholars working to differentiate independent study syllabi. students will be working in conjunction with Next Steps students, faculty, and staff as well as external community-based resources in researching, developing, and delivering Experiential Seminar course syllabi used for the personal and professional development for students enrolled in the Next Steps program. The focus of the tutoring and syllabi design efforts will address areas as social and career development, health and well-being, community resources and engagement, and independent living. Through this initiative, HOD students will better understand the value and application of Universal Design for Learning principles in inclusive program and service design and delivery. All participants learn valuable skills in collaboration, teamwork, and are experiencing, first-hand, the power and importance of inclusion. The decision to utilize service-learning pedagogy to guide the collaboration between Next Steps and the HOD undergraduate course was intentional and aimed to engages students, faculty, and program leaders in all aspects of the learning process. As an instructional method, service-learning has been found to enrich learning and strengthen communities (Fiske, 2001). Other research has emphasized the relationship between service-learning and critical thinking skills and deep learning (Hahn & Hatcher, 2015; Conway et al., 2009). Further, much has been written about the benefits of service-learning for students including greater self-awareness; development of interpersonal and leadership skills; preparedness for future professional responsibility (Huda et al., 2018); and potential to improve students sense of self-concept and self-efficacy (Reeb et al., 2010). Considering these critical areas of stakeholder growth and development, service-learning proved to be the shared mechanism through which program goals, course objectives, and student learning were realized. ISSL 2024 41 The nature of the service-learning collaboration lends itself to the power of building capacity to better achieve the measurable outcomes listed above. The end of the Fall 2023 semester marks the completion of five semesters implementing this academic structure and in partnership with a service-learning course. Through this service-learning partnership, over 40 students enrolled through Next Steps have demonstrated an increased level of knowledge, skills, and awareness of community resources pertaining to their topic of choice. Joining with the HOD undergraduate class, Next Steps was able to illicit the support of over 140 HOD students. Serving as tutors and syllabus developers, these HOD students tackled syllabus topics as entrepreneurship, building technology skills, civic engagement, managing mental health, building cultural diversity, and developing leadership skills. In a direct effort to build community and encourage reciprocity of learning between Next Steps and the HOD course, the service-learning initiative was developed to continuously integrate Next Steps students, undergraduate student, faculty, and program leaders in the design-feedback-evaluation process. We are looking forward to the continued growth of this service-learning initiative and reflecting on its journey with those at the International Symposium on Service-Learning. Leigh Z. Gilchrist is an Associate Professor and serves as the Director of Undergraduate Studies in Human and Organizational Development (HOD) at Vanderbilt University. Her research examines the impact of service-learning and community engagement on student development, community partnerships, and teaching practices within the context of Higher Education and K-12. She incorporates service-learning and community engagement into her teaching and service and views the campus and broader communities as vital components to her professional identity. ISSL 2024 42 Global Leadership in Troubled Times: A student-led international sister city project. S. Ramer & K. LaComba While inquiry into international service-learning endeavors under normal circumstances is plentiful (Furco & Billig, 2020), little is known about what if anything educational institutions and their constituents (faculty, staff, and students) can do to offer meaningful assistance in times of crises, especially as violent and damaging as armed conflict. The philosophical purpose of this storytelling session is to demonstrate that extraordinary circumstances need not be a deterrent to involving students in meaningful service-learning opportunities, and a creative approach to stakeholder support can produce lasting and self-sustaining results. Practically, this storytelling session has a purpose of demonstrating a replicable mechanism through which students can engage in a multicultural collaborative service-learning project that addresses the needs of local communities during a time of a global crisis. Russias full-scale invasion of Ukraine in February of 2024 ended the world as we know it and posed unprecedented challenges to international organizations, refugee nonprofits, world governments, and academic institutions. In response, the United States Agency for International Development (USAID) has sharply increased its investment in Ukraines victory through projects in local governance and accountability, fiscal system reform, cybersecurity, and economic resilience. One of its largest projects is implemented by DAI Global and focuses on assisting Ukraine with its decentralization reform (Udovychenko et al., 2017), including a process of pairing up Ukrainian communities with US communities for mentorship and knowledge exchange around local government transparency, fiscal responsibility, and community engagement. Several such sister city partnerships have been established, including two in Indiana: Wabash with Korosten and Monticello with Luibar. Once established, these partnerships require careful guidance on collaboration policies and strategies of communications and outreach to local communities (Gil, 2020). Such tasks are often a challenge to the local communitys capacity, especially for those affected by an active invasion and the day-to-day response to emergencies. This is where collaborations with local institutions of higher education can be the key in both addressing local government needs and providing students with real-life service-learning opportunities and ways to get involved with their community for the long term. One of such opportunities in Indiana emerged through the PhD in Global Leadership Program at Saint Mary-of-the-Woods College, where students in GL 886 International Policy and Communications are driving the creation of a collaboration plan and community outreach strategy for a sister city partnership between Terre Haute, Indiana in the US and Zviahel, Zhytomyr Oblast in Ukraine. The students are preparing the communities to engage in the sister city partnership by conducting in-depth research on geographic, demographic, and economic characteristics of each community; they are working with the local governments to understand priorities and strategic growth plans; and they are working with the local stakeholders to understand the opportunities for community outreach and engagement. Because of the challenging and rapidly changing environment, the group benefits from employing a variety of data collection methods: source material research (maps, census data, historic records), qualitative data collection based on interviews with project leadership and city administration officials, and expert assessments from academic and professional sources. Through the service-learning project, students identified several findings consistent with current research: 1) effective sister city, while an international level partnership, heavily relies on local activism (Creme et al., 2001); 2) the more similarities the communities possess, the more likely the sister city is to be a success (Baycan-Levent et al., 2010); 3) creative solutions in the face of limited resources are necessary to maintain a long-term relationships (Cross, 2010). This demonstrates the empirical importance of the study as it demonstrates that the main tenets of sister city relationship success are still applicable in times of armed conflict and can be used as successful guides for an international service-learning project. Which means that these pillars of success can apply in other upheavals, whether natural or manmade. ISSL 2024 43 In this manner, the findings of this project fill theoretical and practical gaps in the service-learning realm by providing guidance on the strategies that remain successful in troubled times. In a world that was rocked by the COVID-19 pandemic (Reif-Stice & Smith Frigerio, 2021) and is now ripe with multiple simultaneously occurring armed conflicts, this knowledge is valuable to those who still want to provide students with service-learning opportunities to bring about positive changes in most challenging environments. During the conference storytelling session, facilitators will outline the initiation of the sister city project, steps involved in working with relevant stakeholders, and the process by which students drive the creation of a collaboration policy and communications strategy. This will be a highly practical session with applicable learnings for managers (faculty, university and nonprofit staff managing service-learning program) through demonstrations and hands-on activities. Participants will understand how such service-learning projects can become catalysts for societal change, how collaborating with multiple international stakeholders creates an opportunity for long-term impact, and how conducting this type of project can make a substantial difference in communities affected by global crises. Participants will receive take-home materials and templates that will allow them to apply the methods in their own institutions and replicate this type of servicelearning project for other communities worldwide. Born and raised in Ukraine, Svitlana obtained her MS and PhD in the US, focusing on acculturation and diasporic travel. She is currently a Senior Communications Manager, Ukraine Projects with DAI Global and Adjunct Faculty in PhD in Global Leadership at Saint Mary-of-the-Woods College. Kimberly LaComba, Ph.D. is the Director of the Ph.D. in Global Leadership program and an Assistant Professor of Global Leadership at SMWC. With more than 20 years of experience in higher education, she has served in a variety of faculty and administrative roles. Dr. LaComba has taught both graduate and undergraduate students in business and leadership courses. ISSL 2024 44 Service-Learning Impacts on Career Exploration and Wellbeing in the Exploratory Studies Program I. C. Beulaygue & K. S. Murch-Shafer This project aims to answer the following research question: To what extent and in what ways does Service-Learning benefit the exploration of majors and careers while improving student well-being in the Exploratory Studies Program at the University of Nebraska at Omaha (UNO)? Rationale: This research describes the novel and unique Service-Learning activities of the Exploratory Studies Program at UNO. This multicultural and interdisciplinary wrap around support network helps first-year undecided students to explore majors and careers, improves their sense of belonging in the UNO community, and guides them to declare an academic path. Our faculty, students, and community partners (UNOs Service-Learning Academy, AIM Brain Exchange, Together Inc.) have conducted Service-Learning projects connected to the interdisciplinary exploration of majors and career pathways in STEM fields, environmental and sustainability, gerontology, and educationwhile connecting pedagogy to real world social issues such as climate change, food insecurity, AI and the future of work, etc A wide body of research has demonstrated that helping others through service and human interaction can improve our own happiness levels, foster community engagement, and build meaningful connections. In addition, research shows that people who help others have reduced mortality and experience less stress (Poulin et al. 2013). Service-Learning enhances the growth of the community and the common good. Finally, it fosters the development of civic responsibility, while generating measurable impact in our campus communities (Eyler 2002). Methodology: Community partners help design Service-Learning projects to assure that interactions help organizations fulfill their missions. Students visit community partners twice in the semester and help complete service projects, while also learning about all the careers needed to make partner organizations run effectively. The current research uses qualitative thematic analysis of post-Service-Learning student reflection writings to uncover various dimensions of two outcomes for first-year students at UNO: 1. Major Exploration and 2. Career Affinities. Student Well-Being Preliminary Findings: Preliminary data suggests multiple dimensions of enhanced student well- being (increased agency, increased sense of belonging, having an uplifting feeling when helping the community, which resulted in a very impactful experience. Additionally, research found students had increased affinities for career identities as a result of the experience. Expected Outcomes: This research will highlight new theoretical insights aligning well-being to finding ones major/career purpose. In addition, we expect this project to enhance community building and well-being across a variety of stakeholders, while discovering global career opportunities. We anticipate that our results will be scalable and applicable at other institutions and in other (academic and non-academic settings) and will discuss related policy implications. The current project is value-aligned with the mission of the 2024 International Symposium on Service-Learning in that it aims to create reciprocal and transactional relationships between students and community partners, while looking at global social issues and career opportunities. ISSL 2024 45 Dr. Isabelle Beulaygue is half-French and half-Colombian. She is currently an Instructor of Exploratory Studies and Sociology at the University of Omaha, Nebraska. She earned her doctorate in Sociology from the University of Miami and completed a postdoctoral fellowship at the Center for Promise at Boston University. There, she explored the social, educational, wellness, and economic conditions necessary for children and youth to thrive. Her research focuses on adolescent development and substance use and its impacts on education and well-being during adulthood. Dr. Karen Murch Shafer: My research interests primarily center on the study of Apis mellifera (the European honeybee) and native bees. Current projects investigate identifying genetic honeybee strains that are best able to fight off ecological threats, such as infestations of the Varroa destructor mite and wax moths. Im also interested in providing undergraduate students with small research projects that get them excited about asking scientific questions, and designing and executing approaches to answer those questions. Recent projects include identifying methods for small scale fungal propagation, and the development of new techniques to investigate tooth decay. Best pedagogical practices for teaching science are also an interest. ISSL 2024 46 An Easy Tool to Transform Teacher Preparation: Integrating Global STEM Career Role Models through Leveraging Picture Books. S. Asim The elementary school years play a pivotal role in shaping students' perspectives on science, technology, engineering, and mathematics (STEM) learning. In this context, every elementary teacher emerges as a powerful global educator and a catalyst for change in the educational system. This presentation underscores the critical role of elementary educators in a global context, acknowledging their influence not only within the confines of the classroom but also in shaping attitudes and awareness on a global scale. Recognizing the need for a comprehensive and transformative approach to STEM education, this curated book list advocates for the integration of global education. By leveraging the inherent influence of elementary educators, we aim to propel STEM education to new heights, emphasizing its global relevance and impact. The pedagogical approach proposes a strategy for globalizing STEM efforts by anchoring lessons in picture books that showcase STEM careers and role models from diverse cultures around the world. Drawing inspiration from successful examples such as Tu Youyou's groundbreaking malaria treatment discovery rooted in Chinese herbal medicine and Istou Ceesay's grassroots movement to recycle plastic bags in Gambia, the literature serves as a powerful tool for connecting students to real-world contexts and fostering career awareness. During the poster session, participants will actively engage in a book walk, exploring a curated list of literature that exemplifies catalyzing service-learning through learning about diverse cultures. Through this multidisciplinary approach, the aim is to stimulate dialogue, raise awareness, and inspire educators to become agents of positive change in the face of global challenges. (I am open to making this a workshop session if it's worth of participants time and the audience attending) Dr. Sumreen Asim is a COFFEE enthusiast. She is an associate professor science and technology and teaches courses to both undergraduate and graduate students at Indiana University Southeast. Over the last two decades she has focused her work to share, love and grow with fellow educators. ISSL 2024 47 How to promote a global change from a service-learning course on your campus. T. Pierce The purpose of this storytelling session is to inspire, share and provide evidence of ways a servicelearning course provided reciprocal relationships and improved the overall health and well being on campus. The exercise science program offers a service-learning course that provides students career experience with faculty and staff. Students practice interactions with staff or faculty as a student personal trainer. Each staff or faculty must commit to twice per week, 30 minutes of physical activity. Students prepare a HIIT training program which offers aerobic and strength benefits in 30 minutes. HIIT training is defined as brief bursts of moderate to vigorous activity with short periods of rest or a less intense activity. Methods: Students designed a semester program, lasting 12 to 14 weeks. Participants volunteered for the program, signed an informed consent, and were screened for limitations. Volunteers committed every Tuesday and Thursday from 12:15 pm to 12:45 pm. Workouts began with a light intensity circuit consisting of 12 exercises for 30 seconds with a 15 second rest. As the group gained strength, stamina and confidence, their workouts became moderate and at the final weeks, workouts are vigorous. The final weeks consisted of 8-10 exercises, 45 second and 15 second rest. Warm-ups and cool downs were completed if time allowed flexibility was added. Training principles followed were individuality, overload, progression, adaptation, and recovery. Results & Discussion: The group reported decreased overall blood glucose levels, improved balance and coordination, as well as more energy overall. Patients saw an increase in range of motion and decrease in waist circumference. The group completed more complicated exercises with increased intensity and time compared to when they first began their exercise program. Figure 1.1 shows the various heart rate zones or intensity of the participant in the HIIT training. Blue represents moderate, yellow being moderate vigorous, and orange being vigorous. The progression of the workouts can be clearly identified, increase in overall heart rate, increase in minutes in the moderate vigorous level and 3 minutes of vigorous activity. This shows the overall overload and progression that HIIT training offers. Participants reached 80 - 90% of their maximum heart rate and doubled the number of calories burned. Conclusion: Students and participants were able to build reciprocal relationships based on the conversation and relationship building. Relationships are a way to strengthen overall campus culture and encourage staff and faculty to engage with students. Students are able to have a professional relationship with the staff and faculty. Students are able to continue building and networking with the staff and faculty as their career develops. The course provides career readiness, communication skills, cueing techniques, motivational opportunities and behavioral strategies. Students are working with people outside of their known age groups, activity levels and profession. This course addresses the worldwide epidemic of sedentary lifestyles and incorporating activity into your day to day life, as a student and faculty. Lack of physical activity is a global health problem, the covid pandemic causes reduced time spent on physical activity and increased sedentary behavior. Future Work In the future, we are hoping to include nutrition accountability and healthy eating education. Participants would understand the impact of an exercise program and a balanced diet can lead to a healthier lifestyle. There are many areas to make improvements, such as, before and after photos, pre and post resting blood pressure measurements, pre and post waist circumference reporting and body composition changes. Dr. Tricia Pierce is a Registered Clinical Exercise Physiologist through the American College of Sports Medicine. Dr. Pierce worked clinically with cardiac and cancer patients. Currently Dr. Pierce is the Assistant Professor of Exercise Science at St. Mary-of-the-Woods College in Terre Haute, Indiana. ISSL 2024 48 Bridging Knowledge and Action: Insights from Stellenbosch University's Social Impact Knowledge Platform C. Peters The 9th International Symposium on Service-Learning convenes under the theme "Global ServiceLearning and Transformational Leadership: Cultivating Social Action and Vigilance," reflecting on the imperative of collective action in addressing global challenges. This paper offers reflections on the role of Stellenbosch University's (SU) Social Impact Knowledge Platform within the framework of the Quadruple Helix model, and the context of the Global South, and the necessity of robust monitoring and evaluation mechanisms to gauge impact. SUs Social Impact Knowledge Platform serves as a hub for academic engagement, community partnerships, and societal transformation, embodying principles of service-learning and transformative leadership whilst serving as a conduit for knowledge exchange and fostering collaborations that extend beyond the academic realm and contributing to the University's broader societal impact. Grounded in the Quadruple Helix framework, which emphasizes collaboration among academia, government, industry, and civil society, SU's platform exemplifies a holistic approach to addressing complex socio-economic and environmental challenges through fostering multistakeholder dialogue and co-creation of knowledge, SU's initiatives transcend traditional boundaries, catalysing innovative solutions and empowering local communities. In the context of Stellenbosch University, social impact is defined as the positive, measurable change resulting from knowledge-driven actions that address pressing societal challenges. It encompasses a commitment to advancing the well-being of local and global communities through informed, ethical, and transformative initiatives. This paper posits that the transformative potential of service-learning initiatives can only be fully harnessed through systematic monitoring and evaluation, serving as a crucial feedback loop to inform future endeavours. Through the Social Impact Knowledge Platform, service-learning initiatives can be enriched with interdisciplinary perspectives and real-world insights. However, a critical gap persistsinsufficient monitoring and evaluation infrastructure undermines the true potential of service-learning. The abstract further highlights this disparity, urging a collective reflection on how to amplify monitoring and evaluation practices. I argue that comprehensive assessment strategies are paramount to bridge the divide between transformative aspirations and measurable societal impact. However, the dynamics between the Global South and Global North present unique considerations in the context of servicelearning initiatives. While the Global South often serves as a locus for experiential learning and community engagement, power differentials and historical legacies of colonialism necessitate a nuanced approach to partnership-building and knowledge exchange. SU's social impact knowledge platform embraces principles of reciprocity, mutual respect, and cultural sensitivity, acknowledging the importance of co-learning and solidarity in fostering sustainable development. Practical examples within the South African Local Government sector will be shared, highlighting how it is applicable and or adaptable for the Higher Education sector within the South African context. This paper positions the Social Impact Knowledge Platform as more than just a repository of information but a tool fostering knowledge exchange between academia, practitioners, policymakers, and community stakeholders and revealing the platform as instrumental in shaping service-learning initiatives that lead to tangible societal impact. Chevaan has over a decade of experience in community engagement within the Higher Education sector of South Africa and remains actively involved through his current role as Manager of Knowledge Information Systems at Stellenbosch University, Division for Social Impact and Transformation Office. He has a Bachelor of Arts in Community Development and furthering his studies while he is accountable for the strategic and operational management of SUs Social Impact Knowledge Platform and provides essential support for the institutionalization of social impact at SU. He fulfills a critical role in advancing the university's mission to create positive social change. The platform he meticulously manages serves as a hub for knowledge-sharing and collaboration, bringing together faculty, students, and external partners to address complex social challenges. ISSL 2024 49 Se r v i c e - L e a r n i n g for Student Transformation. S. M o o r e , J . R . J a mison & T. Morris In o r d er t o f o s t er student transformation and promote global citizenship, f a c u l t y f e l t tha t p ro v i d i n g a service-learning trip to Cyprus was an ideal opportuni t y . T h i s t r i p wa s d e s i g n e d f o r students to immerse themselves in another culture and g a i n i n s i g h t to i s s ue s f a c i n g others around the world. This trip provided a way for s t u d e n t s t o wo r k w i t h t h e Center for Social Innovation to support community m e m b e r s , de v e l o p i n g a r e ciprocal and transactional relationship. This trip (2024) w a s a f o l l o w up t r i p t o t h e 2 023 Cyprus Spring Term trip. We have continued the part n e r s h i p w i t h Ce n t e r f o r S o c i a l Innovation and are taking part in the Young Cities initiati v e . Th e p u r p o s e of the teaching strategy: To create an innovative, i n t e r a c t i v e , ed u c a t i o n a l o p p ortunity for foundational concepts in global citizenship. T h i s s e r v i c e lea r n i n g e x p e r i e nce was designed to enhance cultural understanding, d e v e l o p a n ap p r e c i a t i o n o f other populations, and to provide an opportunity to creat e a n d f o s t e r tra n s a c t i o n a l a nd reciprocal rela tionships. Student engagement with t h e l o c a l co m m u n i t y g i v e s insight to challenges others may face, and how inn o v a t i o n a n d pa r t n e r s h i p s c a n mitigate challenges; ultimately bringing communities tog e t h e r . Me t h o d / p r o c e d u res : Faculty and Trip Leaders held call out meetings t o r e c r u i t stu d e n t s f r o m a variety of degree plans. After the recruitment period en d e d , r e g u l a r me e t i n g s w e r e held. The meetings were designed to educate students o n w h a t t o ex p e c t w h e n v i s iting a different country. Students studied topics such a s t r a d i t i o n a l foo d s , r e l i g i o n , education, views on healthcare, and climate. The gro u p m e t v i a Go o g l e M e e t w i t h community partners (Center for Social Innovation) to d i s c u s s w h a t pro j e c t w e w i l l be completing, and to develop a relationship prior to visit i n g C y p r u s . Th e s e m e e t i n g s not only were informative, but essential as group dyna m i c s a r e a sig n i f i c a n t f a c t or when traveling abroad. These meetings and dev e l o p i n g a n un d e r s t a n d i n g o f group dynamics was essential to meet objective 3: To l e a r n a b o u t gro u p d y n a m i c s , how to collaborate with others in a group, and inc r e a s e s e l f aw a r e ne s s o f o nes role in a group. Major outcomes: The students all ex p r e s s e d a n ap p r e c i a t i o n f o r this service-learni ng experience. Many discussed how d i f f e r e n t t h e cu l t u r e w a s , w h ile also identifying similarities. The engagement with C y p r i o t s w a s ins t r u m e n t a l i n this trips objectives; To learn about another culture whi l e e x p l o r i n g on e s o w n a t t i t udes, beliefs, and biases regarding cultural diversity and t o g a i n a n un d e r s t a n d i n g of international applications and implications for Servic e - L e a r n i n g . Ma j o r o u t c o m e s with the Young Cities initiative have yet to be determined . Co n c l u s i o n s a n d implications: As future global leaders, it is crucial that s t u d e n t s b e off e r e d t h e o p p ortunity to travel abroad. This experience allows them t o d e v e l o p co m m u n i c a t i o n skills, see other viewpoints, gain a better understanding o f w h a t i s go i n g o n i n t h e world around them, understand that providing a service to o t h e r s n o t on l y h e l p s t h e community but is foundational in developing transa c t i o n a l a n d rec i p r o c a l r e l a t i onships for the futu re. ISSL 2024 50 Dr . S h a n n o n M o ore is an Associate Professor in undergraduate nursing a t U n i v e r s i t y of I n d i a n a p o l i s . She works as a registered nurse at both IU Health Riley H o s p i t a l a n d IU H e a l t h B l o o m i ngton in the Neonatal Intensive Care Units. Dr. Moore ha s a p a s s i o n for s e r v i c e - l e a r ning and has led several medical mission trips to Ecuador, a s w e l l a s a se r v i c e - l e a r n i n g trip to Cyprus. She believes that student engagement wit h t h e w o r l d aro u n d t h e m i s t he best teaching strategy. J. R . J a m i s o n i s an award-winning author and storyteller who hosts the In d i a n a P u b l i c Rad i o a n d N P R podcast The Facing Project (based on the organization o f t h e s a m e na m e t h a t h e c o -founded, and where he serves as president). The Facing P r o j e c t h a s hel p e d o v e r 7 , 0 00 people in 20 U.S. states and 11 countries tell their stori e s o n t o u g h top i c s s u c h a s homelessness, depression, gun violence, and more wit h a g o a l o f cre a t i n g a m o r e understanding and empathetic world. J.R.s nonfiction a n d f i c t i o n wr i t i n g h a s a p p e ared in The Huffing ton Post, Pangyrus, Beyond Words, Wr i t e r s D i g e s t an d v ar i o u s o t h er print and web publications, and his work has been c o v e r e d b y ou t l e t s s u c h a s The Guardian, Harlem World Magazine, PBS, Runners Wo r l d , a n d T h e Sta t e s i d e r , a m o ng others. J.R.s memoir, Hillbilly Queer, was a Libro.fm b e s t s e l l e r i n LG B T Q n o n f i c t i o n (audiobook, narrated by the author) and received star r e d r e v i e w s fro m L ib r a r y J o urnal and Foreword Reviews Magazine, and was chosen as o n e o f T h e Be s t A u d i o b o o k s of 2023 by Library Journal. In addition, the paperback e d i t i o n w a s the s i l v e r w i n n e r of the 2022 Nautilus Book Award for Best Memoir and a f i n a l i s t f o r the 2 0 2 2 I n d i a n a Authors Award. He can be found online at jrjamison.com . To n i M o r r i s D N P, RN, CNE is an Associate Professor in Nursing at the U n i v e r s i t y o f Ind i a n ap o l i s . S h e is a nurse with over 25 years of experience and interest i n o p e r a t i n g roo m nursing, informatics, community-public health, servi c e - l e a r n i n g , int e r p r o f e s s i o n a l education, disaster simulation, and nursing education . D r . M o r r i s ea r n e d h e r B a chelor of Nursing from Indiana University, her Master o f N u r s i n g Ed u c a t i o n f r o m the University of Indianapolis, and her Doctorate of Nurs i n g P r a c t i c e fro m I n d i a n a S t a te University. ISSL 2024 51 The Implementation of Service-Learning into an Accelerated Hybrid Multi-Site Physical Therapy Program. A. Schlessman, J. Foucrier, S. Trotter, & C. A. Berg-Carramusa Context: Tufts Universitys Doctor of Physical Therapy (DPT) multi-site (Boston, Phoenix, Seattle, and Atlanta) program values humanism and social responsibility and is intentional with their mission in positively impacting societal health and improving the human experience with a commitment to excellence, inclusion, discovery, and meaningful service. Its dynamic and innovative curricular design is explicit with integrating servicelearning (SL) longitudinally for a geographically diverse group of students that reaches across the entire United States through collaboration within a novel accelerated hybrid education model. This education model poses unique challenges for the academic program, community partners, and students with SL logistics and implementation that demands eliminating the metaphorical box while pioneering and exploring alternative and practical approaches to meet the needs of students, the program, the profession, and society at large. Our purpose with this storytelling session is to provide an intimate account of our SL journey at Tufts DPT and to share our curricular design and educational strategies that have been effective in promoting positive professional formation in our students while impacting communities served and the physical therapy profession in a meaningful way. We aim to ignite scholarly dialogue and future research in sharing our work, lived experiences, and lessons learned with the implementation of SL into an accelerated hybrid DPT curriculum. We will showcase how our SL curriculum is a catalyst of student transformation in becoming a change agent and ethical leader within local and regional communities, healthcare sectors, and the profession through planning, collaboration, instruction, action, and reflection. We will discuss our SL curricular design and processes in how we empower our students to be agile, adaptive, and resilient by comprehensively facilitating learning across the cognitive, psychomotor, and affective domains so they can effectively navigate global challenges and barriers within evolving communities and situations. Additionally, we will impart our lessons learned in coordinating and adapting SL into a novel accelerated hybrid DPT curriculum.2 We will share SL engagement perspectives through qualitative data from our students, faculty, and community partners. Lastly, we will talk about logistical challenges and limitations encountered within our contemporary educational model. We seek to facilitate an open dialogue with session attendees on engaging innovative and fresh SL initiatives into higher education and hybrid learning, how SL can catalyze positive professional formation and foster development of ethical leadership, and how to transcend posed challenges of SL for an accelerated hybrid curriculum in unison with other organizational and societal barriers. Objectives: Attendees will: 1. Understand the uniqueness of an innovative SL curricular design and the opportunities and challenges of SL implementation within a novel accelerated hybrid educational model. 2. Compare and contrast approaches to engaging SL across different educational models within higher education in fostering professional formation and ethical leadership development in students. 3. Reframe curricular design and teaching and learning strategies to mitigate challenges and barriers to SL implementation in a novel accelerated hybrid educational model. ISSL 2024 52 Amy has been a pediatric physical therapist since 2002 in Ohio. She has taught in higher education since 2005 with expertise in online and hybrid formats. She is a former faculty liaison in a Center for Teaching Excellence. Her research focuses on pediatric health promotion and the scholarship of teaching and learning. She has given over 60 presentations at national and state conferences, and over 100 invited speaker presentations. She serves APTA Pediatrics in leadership roles. Dr. Jeffrey Foucrier is an Assistant Professor for the Doctor of Physical Therapy Program at Tufts University School of Medicine (Phoenix). Dr. Foucrier is a Board certified as an Orthopedic Clinical Specialist. He practices in an interprofessional alternative family medicine clinic in Tumwater, WA. He also serves as a clinical member on the Washington State Board of Physical Therapy. His research interests are in online education methodology, curricular development, and clinical education. Dr. Trotter has a robust community service agenda in the area of delivery of rehabilitation services to resource-limited countries. She has led interprofessional service trips for Potter's House Association International. Her scholarship agenda has been tied to her service work, with presentations at various national and international conferences. She is currently evaluating the effectiveness of pre-departure training for an Interprofessional Service-Learning experience emphasizing simulation to help train for global health experiences. Dr. Berg-Carramusa's academic experiences embody clinical education, professional formation, & leadership. She has taught across several areas of practice from Neuro & Cardiopulmonary to Geriatrics & Population Health within the context of acute care, inpatient rehabilitation, home health, and outpatient. She held several administrative/leadership roles and worked internationally in Italy. Her scholarly focus is professional formation, the affective domain of learning/clinical practice, values, and financial management. ISSL 2024 53 A High School Service-Learning Course: Transforming Students into Engaged Citizens. J. Schlessman A recent study of almost 1,000 middle and high school teachers and almost 1,000 parents of middle and high school students found very limited amounts of service-learning (SL) occurring in middle school and high school (Atwell et al 2021). Most teachers reported their school did not have formalized SL programs at their school (only 16 percent had community service activities directly connected to a course) (Atwell et al 2021). In the study, both parents and teachers reported perceived benefits of SL opportunities, believing SL prepares students to become good citizens, give back to their community, and get along with and understand people different from them (Atwell et al 2021). Around 60% of teachers and parents also believe that SL would benefit students for work and life after high school (Atwell et al 2021). St. Xavier High School in Cincinnati, Ohio, offers an innovative, SL course for juniors in high school. The course, titled Mortality and Social Justice with Service, is a course students can choose to take. The course is offered directly before or after lunch time, allowing extended time for students to go off-campus and engage with a variety of community partners for service-learning during school hours throughout the school year. The most basic questions to be explored in this class are What does it mean to be human, and what will be our response? Students engage in a systematic approach to moral problem-solving and conscience formation which is ultimately rooted in these questions. Students are asked to reflect on what type of person they want to be (and why) and then encouraged to define their own position on various moral and social justice issues which confront the human community. Students also learn to recognize various stages of moral growth and development. Another focus of the course is exquisite mutuality. This means not separating individuals into social classes, shaming the poor, and upholding the belief that the lives of some individuals are more important than others. Exquisite mutuality also teaches doing service throughout ones life, for the greater good of humanity, not just as an obligation. I will share SL perspectives of students, faculty, and community partners. I will discuss logistical challenges and limitations encountered in the course. Objectives: Attendees will: 1. Understand the uniqueness of an innovative SL course for high school students. 2. Identify the facilitators and barriers of a SL course for high school students. 3. Identify the benefits of a SL course for high school students. I am Jacob Schlessman. I am a junior at St. Xavier High School where I swim, and run cross country and track, and get involved in the my schools community by taking advantage of leadership opportunities, such as editing my school newspaper and and participating in science Olympiad and weekend service. I decided to take morality and social justice with service because upperclassmen had told me what an interesting and fulfilling class it was. I find service-learning to be an extremely valuable opportunity that I would happily recommend to any high school, middle school, or college student. ISSL 2024 54 An Irish tale: How four unlikely characters came together to create a successful international service-learning study abroad program. D. Pracht, K. H. Fletcher, C. Lawlor, & M. Coyle t all began with a vision and a desire of one faculty member wanting to create an international youth development service-learning (ISL) study abroad program because of not studying abroad as an undergraduate student. The only issue, she needed a country, a partner, a program provider, and in-country NGO partners for her future students to volunteer directly with youth in another country. An opportunity through service-learning with a local organization, led to a conversation with a study abroad advisor, which lead to a sit-down meeting to share potential program providers and suggestions on countries that provide youth-based ISL opportunities. After this initial meeting, a country (Ireland) and location (Galway) were identified, then the faculty member immediately ran to her department chairs office to seek permission and guidance. The Chair suggested a partner with expertise in both service-learning and study abroad, and so the faculty member walked down the hallway and knocked on the door of this suggested faculty member to partner with. She asked this potential future partner, want to go to Ireland with me on a study abroad? and he said Sure. And so, the partnership began. Now, with City, Country, and Partner identified, the next step was to connect with a program provider. But, this initial program provider was anything but what this fledging program and people needed to be successful. After 4-weeks in country on program, without a secured NGO partner, a massive kerfuffle ensued, instigating a ripple effect through the program, students, and faculty partners to find a new partner that truly understood both Ireland and ISL intimately. Therefore, we parted ways with the original program provider and took the advice of the Assistant Director of the International Center to contact a brand-new program provider. In comes the mighty CEO of one Irish-based program provider to save the day. He vision-casts not just one city, but a rural, remote Irish village with an Irish Fairy Godmother who can make all your dreams come true. Our best-practices include a shared vision, daring to dream, accumulated experience, openness to change, a concern for the community, a love of culture and people, and desire to transform lives. This story-telling session will include two faculty members, two program providers, and one community partner. This will be a collaborative storytelling session in which a rich and detailed story will be expanded upon from the above description. ISSL 2024 55 Dr. Pracht is an Associate Professor Community Based Organizational Systems for the University of Florida and has been a faculty member in the Department of Family, Youth and Community Sciences (FYCS) since 2007. His research expertise is risk management, servicelearning, experiential learning, youth leadership development, volunteer management in nonprofit organizations, and transformational leadership. He teaches undergraduate and graduate courses, conducts research, and provides service through IFAS Extension serving all 67 counties in the state of Florida. Kate H. Fletcher is a Senior Lecturer for the University of Florida and has been a faculty member in the FYCS since 2008. Her research is service-learning, experiential learning, youth leadership development, and mentorship. She teaches undergraduate courses, conducts research, and provides service through academic advising and mentoring of undergraduate and graduate students. She is pursuing a doctorate degree in Leadership through the Department of Agricultural Education and Communication at the University of Florida. Chris Lawlor is the co-founder and Chief Executive Officer at Learn International. Mary Coyle has been building local community capital since 1996 in County Donegal, Ireland. Her founding purpose is rooted in promoting positive social change and community development. She has established, promoted, operated, and developed an internationally known Community Centre. She continues to fundraise and manage the Centre. The Centre is dedicated to the direct provision of community support, development, enterprise and education services for children, young people, parents, and families in the community. ISSL 2024 56 Becoming change makers through service-learning and human-centered design: Students & community standing in the gap together. R. Wolverton This presentation will focus on empowering students and leaders to transform their community by taking on the work of social justice. Its the story of the partnership of University of Indianapolis One14 Design Studio, a faculty-led student-staffed design agency and non-profit partner, ProAct Indy. The goal of ProAct is to empower youth to stand in the gap for vulnerable populations to turn the world outward. ProAct is committed to improving the mental health and well-being of vulnerable youth in Indianapolis and beyond. They believe that people, not programs have the power to create meaningful change through characterbuilding, mentoring and leadership training through a curriculum focused on social equity and community service. When One14 invited ProAct Indy to take on a human-centered socially-just design project it was a collaboration aligned to both of their missions. Human-centered design involves not just designing for but designing solutions to social justice issues together. One14 Design aims to help graphic design students learn how to utilize strategy and research with design skills to become creators of transformation and not just makers of things. This starts by helping students fill a toolbox with something beyond physical tools research methods and strategies for not just solving design challenges but seeking out the needs and offering solutions for real people. By implementing service-learning it allows us to break away from the classroom to work with communities on real life challenges, even social issues that might be considered wicked problems because they often have deep rooted social and cultural dimensions that are deeply interconnected with other things making them resistant to quick fixes. You will hear both the perspective of the leaders in the ProAct community and faculty in One14 Design. Experience the shared perspectives, innovative process, impactful tools, and the transformative outcomes of our joint efforts in service-learning. Discover how we fostered trust, sustained engagement, and leveraged human-centered design to address challenges related to racial disparity, restorative justice, community service, and appreciation. Rhonda Wolverton seeks to be a creator of transformation. By leveraging designs ability to inform, persuade and advocate her work empowers individuals, connects people and engages communities and often includes service-learning. For the last 8 years an Assistant then Associate Professor at University of Indianapolis. There she served as the Creative Director for One-14 Design a student-staffed design agency. Wolverton is currently a Assistant Professor of Graphic Design at Texas Christian University. ISSL 2024 57 Amplifying Voices: Service-Learning and the Imperative to Capture the Experiences of Black Women. T. Jones "Power is the ability not just to tell the story of another person but to make it the definitive story of that person. The Palestinian poet Mourid Barghouti writes that if you want to dispossess a people, the simplest way to do it is to tell their story and to start with "secondly." Chimamanda Adichie In Adichie's TED talk, she shares the danger of the single story. This abstract examines the intersection of service-learning and the imperative to capture the distinct experiences of Black women within the educational sector. This research explores how service-learning can be utilized as a powerful tool to engage and document Black women's unique perspectives and contributions by recognizing the importance of diverse narratives in shaping comprehensive educational approaches by delving into the historical and sociocultural contexts that have shaped the experiences of Black women, emphasizing the need for inclusive educational practices, multifarious educational pedagogy, expanded curricula, and diversified "Best Practice." It explores how service-learning initiatives can serve as platforms for Black women to share their stories, perspectives, and insights, fostering a deeper understanding of their roles in historically accurate teaching and learning, fugitive pedagogy, curricula/community development, and social change. Drawing on theoretical frameworks and practical examples, this abstract showcases how tailored service-learning programs can capture and amplify the voices of the many Black educators who utilize alternative measures to ensure historical accuracy, data-driven teaching and learning, metacognitive thinking, problem-solving, and instituting a new set of best practices for kinesthetic tactical learners. Through storytelling, this work explores and seeks to answer how service-learning can be utilized as a powerful tool to engage and document the unique perspectives and the educational prowess of Black contributors, especially Black women. The work will address the challenges associated with the endeavor, such as the potential for double consciousness, especially when interacting outside of the learning environment, tokenization, and the importance of establishing ethical frameworks for storytelling within service-learning initiatives. By prioritizing narrating the experiences of Black women in service-learning, this research contributes to a more nuanced understanding of community engagement and social impact, emphasizing the role of educators, community partners, and students in co-creating spaces that authentically capture and celebrate the rich contributions of Black women to the service-learning narrative. Ultimately, integrating Black women's experiences into servicelearning initiatives enhances the educational experience and promotes social justice and equity within the broader community. Tasha Jones is a rare and wonderful artist who strikes a balance in a world so often lopsided. Jones is a student of life and a teacher of lessons. On stage, she tells the story of her life and, in doing so, tells the story of all women. She offers a perspective, poignancy, and insight in her writing that allows men to see themselves through her work and women to see themselves in it ISSL 2024 58 Going full circle in SLEAK project & Stronger together. J. Bester & M. Kloppers The SLEAK (Skills, Learning and Educational Activities for Kids) project was established in 2008 as a joint partnership between a community and the Division of Occupational Therapy Stellenbosch University. The vision of the SLEAK program is to create a sustainable, non-profit, leisure-time activity project for the youth aged 10-13 to curb drug and gangster-related activities and to foster healthy work-related skills in these youths to make them responsible and productive members of their community. The project is situated in Bishop Lavis that forms part of the Cape Flats a previously disadvantaged community with a high unemployment rate and limited resources. In 2019, the Dean of the Faculty of Medicine and Health Sciences pointed out that the largest advancement in health for those living in resource-constrained settings is going to be made outside of the healthcare realm. Therefore, to address the most pressing healthcare challenges, and specifically in the context of equity and equal opportunity, initiatives should acknowledge the social determinants of health in which these activities are embedded. This led the Division of Occupational Therapy to seek intrainstitutional partners to share knowledge, collaboration, and an innovative mindset, to re-imagine and strengthen the already established SLEAK project, in a way that the collaborative effort could increase the impact. At the end of 2019 SLEAK 2.0 was established by forming collaborative partnerships with two other faculties (Theologys Unit for Moral Leadership and Maties sports Centre for Sport Leadership) to enrich and expand the activities SLEAK could offer the project participants. The new partnerships enabled SLEAK 2.0 to expand its focus from learner centered to the learner within their context strengthening the input offered to the SLEAK parents and learners. The input offered by the three collaborators is as follows: The Division of Occupational Therapy conducts weekly training of community volunteers to present age-appropriate constructive leisure-time activities to learners to facilitate the development of transferable skills. These activities are presented twice a week as part of the after-school activities. Home visits are conducted four times a year to each of the learners' parents in an attempt to build relationships and foster shared values with the parents. The Faculty of Theology joins Occupational Therapy students on home-visits to SLEAK learner parents and contributes to the creation of a stable home environment by facilitating value development and character building within the family so that the learners can prosper. The Centre for Sport Leadership (Maties sport) provides physical sport activities and skill development as part of the weekly after-school activities. ISSL 2024 59 All partners follow a quarterly theme with their activities, ensuring a shared focus in the project. Collaboration is further maintained and strengthened by partners attending an annual planning meeting at the start of every year. At the end of every quarter a reflective meeting is held where partners have the opportunity to give feedback on their experience of the collaboration as well as changes to project activities that need to be made. Furthermore, daily and/or weekly communication occurs via WhatsApp and email for implementation of the day-to-day running of project. An annual project evaluation report is done by Occupational Therapy students incorporating feedback from all partners and project participants. This evaluation report is used to plan the project for the next year and apply for funding as needed. The gains from this collaboration are on multiple levels. The students involved have opportunities for peer-to-peer learning in a wider arena than their own professional field (interdisciplinary awareness across faculties). They gain exposure to other cultures and have the opportunity to develop leadership skills for the greater good of the project participants. The SLEAK learners have access to sport resources and skill development that otherwise was not available to them in their community. SLEAK parents receive support on a spiritual level to help them build a family value system. The SLEAK project itself now has access to a wider network of resources to enable a wider reach and impact. Ms. Maatje Kloppers: Lecturer in Occupational Therapy. My research interests include Interprofessional Education, technology in teaching and rehabilitation outcomes in community-based settings. Ms. Juanita Bester: Senior Lecturer in Occupational Therapy. My research interests are focused on the field of education with a specific interest in interprofessional education, service-learning and fieldwork education. ISSL 2024 60 Enacting community service-learning as an integrated social justice pedagogy: Lessons from a 25-year retrospection. A. Naidoo In this presentation I propose to reflect on a career as a black community psychologist/academic with a deep commitment to engaged service-learning scholarship in a predominantly white university setting in the South African context. I will firstly present my own journey to enact an approach to psychology as a discipline and practice that engages with the social justice imperative of a country still struggling to emerge from its apartheid past. I will then describe, using examples and illustrations from two major projects that Ive initiated, the theoretical and practical considerations that guided the conceptualisation, development, implementation and adaptation of these projects in different community settings. This will include endeavours to integrate teaching, praxis and research at graduate level, with the needs of racially diverse students and the needs of the community partners. I will also reflect on how COVID-19 conditions impacted on project implementation and provided opportunity for multidisciplinary collaborative and innovative methodologies. Finally, I will share my own lessons gleaned from 25 years experience straddling the roles of community psychologist, activist, academic (teaching, training and research) and transitions for the future. Anthony Naidoo is an Emeritus Professor in Community Psychology at Stellenbosch University, South Africa. He holds a PhD in Counselling Psychology from Ball State University. He has a track record of 25 years as an academic-activist committed to a community based participatory action research pedagogy with a social justice value, emanating from his experience as a Black South African growing up in the apartheid era. ISSL 2024 61 Th e I m p a c t o f S ervice-Learning on Public Policy Making. M. F . H a r a k e & P . Cartwright Lin k i n g s e r v i c e - learning to social transformation, the purpose of this p a p e r i s t o stu d y t h e r o l e o f academia in drawing public policy. A French study was c o n d u c t e d i n ord e r t o e x p l o r e the role of higher education institutions when it com e s t o b o t h im p l i c a t i n g t h e i r students in the associative world through curriculu m c h a n g e s , pro j e c t i n i t i a t i v es, state funded actions, etc. and participation in policy m a k i n g . T h e stu d y r e v i e w t he role of universities and business schools in the d r a f t i n g a n d im p l e m e n t a t i o n of French laws that recognize and promote students en g a g e m e n t i n so c i a l d e v e l o p ment both locally and abroad and how it is concretiz e d i n t h e i r ed u c a t i o n i n v a rious forms such as course credit awarding, exemption f r o m c e r t a i n co u r s e s o r i n t e r nships relating to t he student's course and pre-requisite f o r v a r i o u s de g r e e s , s c h o l a rships, etc. Interviews conducted with academic offic i a l s , p u b l i c se r v a n t s , l e g i s l a tors, and students between 2022 and 2023 identify a ver y p a r t i c u l a r Fre n c h s e r v i c e - l earning model. Results indicate the emergence of hybrid s y s t e m t h a t rec o g n i z e v a l u e d skills and abilities acquired through voluntary activ i t i e s w i t h i n op e r a t io n a l p r o j ects by students that have been both identified and put in t o p l a c e b y ac a d e m i c i n s t i tutions and framed by both national and regio n a l p u b l i c ad m i n i s t r a t i o n s . Prof. Dr. M. F. HARAKE is a management Professor based in France. He is currently the Director of International Academic Affairs of GIP CEI (a French Higher Education and Research Institution) and the scientific director of the MBA DELIVERWEB at ALTERNIS Business School (Bordeaux France). On another note, Dr. M.F. HARAKE is a research fellow at the CEREGE Research Laboratory (University of Poitiers France), and a visiting research fellow at CABMR Research Center (Paris France). His research interests include Post-Conflict Public Management, Crisis and Urgent Operations Management, Humanitarian Logistics, and Project Management in Unstable Environments. Dr. Phillip A. Cartwright is an American citizen raised in the Chicago area living in France for over thirty years. A Ph.D. in economics from the University of Illinois, Urbana-Champaign, he has forty years of academic and business experience and he has published extensively in leading journals. He has been posted at the University of Georgia, Imperial College School of Business, London Business School and INSEAD. Today, he is Full Professor and Academic Dean, International DBA, Ascencia Business School, Paris and Director, Ascencia Center for Applied Business and Management Research; and Visiting Researcher, Royal College of Music, Centre for Performance Science, London. Phils teaching and research interests are in the areas of research methodology (quantitative), corporate finance, performance science, and the performing arts. He is Founder, HorizonVU Sound and Movement. He studies music theory and composition at the Berklee College of Music and he is a member of the American Economic Association, American Psychological Association, American Musicological Society, the Dance Studies Association, and the Society for Dance Research. ISSL 2024 62 Exploring Service-Learning as a Tool for Expanding Pre-Service Teachers Professional Role Identities. S. Denney & K. Reinhardt Significant increases in the population of immigrant students in U.S. schools over the last decade has challenged K-12 educators to move beyond traditional support systems typically focused on English language proficiency. To design lessons, deliver instruction, and enact pedagogies that are culturally sustaining, future teachers need to know about students funds of knowledge the personal, cultural, and community assets students bring with them from their homes into the classroom. The enactment of culturally relevant pedagogy requires teachers to first engage in critical self-reflection and gain knowledge of their own culture and the cultures of others. In this qualitative study, theories of culturally sustaining pedagogy (CSP), funds of knowledge, and the Dynamic Systems Model of Role Identity (DSMRI), are employed to examine the role identities of pre-service teachers before and after a service-learning project that allowed them to interact with K-12 English Language learners (ELLs) and gain firsthand insight into the K-12 students funds of knowledge. As a part of this qualitative case study, undergraduate students enrolled in education courses with multicultural lenses will engage in initial reflection on their perceptions of their professional role identities as teachers in relation to CSP. The service-learning project consists of a minimum of 5 contact hours with ELLs. The teacher educators worked collaboratively with community agencies and K-12 classroom teachers to develop the service-learning project activities. Pre-service teachers were tasked with getting to know students cultural backgrounds and interests, as well as supporting students with homework, reading strategies, and social emotional programming coordinated by the hosting teachers. At the completion of their service-learning experience, pre-service teachers will be surveyed a second time, and again asked to reflect upon their purpose of CSP, beliefs about CSP, self-perceptions, and perceived action possibilities related to CSP. Preliminary findings from the study suggest that pre-service teachers (undergraduate students) are able to grow in their knowledge and skills designing instruction and classroom environments for culturally and linguistically diverse students, and thus shift their professional role identities to come into greater alignment with the tenets of CSP. We anticipate the results of this study will demonstrate how teacher preparation programs can creatively partner with classroom teachers and community partners to bring concepts from multicultural education to life through service-learning. The current climate surrounding teacher preparation is pushing programs to prepare teachers quickly and efficiently, making it difficult to add additional experiences, courses, and credit hours for students to explore concepts such as CSP in-depth. With thoughtful co-planning and structuring of the service-learning experiences, teacher preparation programs can more fully allow students to embrace professional identities as multicultural educators. Sarah Denney is an assistant professor in the School of Education at the University of Indianapolis. She teaches courses in multicultural education, social studies education, and educational assessment. She has 9 years of K-12 experience as both a classroom teacher and administrator. She earned her Ph.D. in Curriculum and Instruction from the University of South Florida, in Tampa, FL. Katrina Reinhardt is an assistant professor in the School of Education at the University of Indianapolis. For 10+ years she has served UIndy students by teaching introductory, literacy, and EL courses, arranging fieldwork, coaching teachers, and coordinating the secondary education program. She is currently enrolled as an EdD candidate at Indiana University for Literacy, Culture and Language Education where she is researching how teachers are prepared to teach ELs in the general education classroom. ISSL 2024 63 From job-seeking to job-creation initiative: Changing the ecosystem and improving graduate attributes for African graduates through service-learning. U. Useh Background: The burden of youth unemployment in Africa is documented and recorded in various political statements and government bulletins across the continent. African graduates are illequipped with the right skills to transfer or apply their learning to the real life or in the work environment. It is hoped that effective service-learning initiatives will positively impact on this narrative. Rationale: This initiative shall assist in re-evaluating and reviewing South Africas higher education ecosystem in order to train graduates who will not only be job-seekers but also be job-creators through service-learning re-engineering. Problem being addressed: Traditionally, a higher education or training is believed to be the pathway towards securing employment by youths. However, this is no longer the case in our society as African graduates have been deemed unemployable by employers. They are said to lack the skills to apply their training to the real-world issues that are to be addressed in the workplaces and services to achieve the mandate of the African Union. The official unemployment rate released by StatSA in the second quarter of 2022 showed that the total number of unemployed youths aged 15-34 increased by 2% (92000) to 4.8 million from the first quarter of the year. Youths in South Africa continue to be disproportionately affected by unemployment with the majority often classified into three categories uneducated, unemployed, and unemployable. It therefore behooves on universities and other higher education institutions to be more innovative in the design of their curricular from admission to graduation to train graduates who are equipped to apply their learning outside the classroom. Expected outcomes: To train graduates who will be job-creators would involve a modification in pedagogy technique and approach to include an inter-professional and multi-sectoral in which students from several disciplines would work together towards developing social impact drivenprojects for national development. The pre-requisite skills enhancement should include transferable, entrepreneurial, ICT, and presentation and communication skills. Transforming African our graduates from job-seekers to job-creators must be transversal, involving the joint work of several disciplines and dialogue between different areas of the same discipline. Integration has a long and rich history that is reflected in higher education and professional practice. It is our view that students from different disciplines and groups and cultures and/or across faculties in a university should be able to work together to build themselves into job-creating graduates. Conclusion: Service-learning should be seen as a framework for developing curriculum to enhance job-creation attributes amongst graduates. Dr. Ushotanefe Useh is the Deputy Dean, Faculty of Health Sciences (for Community Engagement and Stake Holder Relations). A multidisciplinary professional in Health (Physical Therapy), Education, Law, Humanities, and Management and a C2 rated research with the National Research Foundation (NRF). He has been committed to excellence in teaching and learning, research, and community engagement. He is particularly committed to a broader outlook on university strategy that involves keying into global initiatives for sustainable development such as the United Nations Sustainable Development Goals (UNSDGs). ISSL 2024 64 An International Service-learning Trips Impact on Graduate Students Interprofessional Collaboration: A Mixed-methods study. S. Ross, W. Scogin, & B. Aho International service-learning exposes students to cultural, societal, political, and physical experiences. This exposure is especially beneficial for healthcare professional students as they prepare for practice in a world that is globally interconnected. An additional aspect of healthcare practice is interprofessionalism. Interprofessional practice occurs when two or more providers are jointly involved in patient, which has evidence to support improved patient outcomes. Most all health professional education programs have required components of interprofessional education. The frequency of interprofessional international service-learning opportunity for healthcare professional students has been growing; however, there is still a lack of strong evidence as to the effectiveness of these trips. The purpose of this study was to look at the impact of an interprofessional international service-learning trip on the interprofessional collaborative skills of graduate healthcare professional students, and how it impacts them as it relates to working in cross-cultural services or with underserved populations. Methods: This was a mixed-methods study composed of a quantitative survey study and phenomenological study of healthcare professional graduate students' experience on a service-learning trip to Ecuador. The study consisted of students (n=37) from physical therapy (n=11), physician assistant (n=11), and speech-language pathology (n=15). Data collection took place during two separate servicelearning trips over two consecutive years. The Interprofessional Collaborative Competencies Attainments (ICCAS) was administered to the students immediately prior to the trip (pre-IPE) and during the final trip debrief (post-IPE). The ICCAS is validated instrument which assesses perceived IPEC core competency skill attainment. The ICCAS-Q20 has 20 items that are scored from 1-7, with 1 being strongly disagree and 7 strongly agree. ICCAS constructs include communication, collaboration, roles and responsibilities, patient-centered care, and conflict management-team functioning. The data from the surveys were analyzed for descriptive information, as well as pair sample test to determine any pre-post difference. Qualitatively, the final debriefing of each trip was recorded and transcribed. This debriefing session was summative in nature, looking across the whole experience. The debriefing questions and session were semi-structured in nature. All students participated in the debriefing session. The transcripts were qualitatively analyzed for themes underlying the students experience, both from an interprofessional and a cross-cultural service standpoint. Results: Preliminary findings show a statistically significant (p<0.05) difference on all 20 ICCAS items post-IPE compared to pre-IPE. Cohens d effect size ranged from 0.80 to 1.82, indicating that each item on the ICCAS demonstrated a large effect. Additionally, preliminary qualitative findings show themes and subthemes including student growth and change in personal world views, practice within their own discipline, and working as an interprofessional team. Expected Outcomes: A service-learning trip to Ecuador enhanced the communication, collaboration, roles and responsibilities, patient-centered care, and conflict management skills of PT, PA, and SLP students. Additionally, students were impacted personally, professionally, and interprofessionally. Sarah Ross, PT, DPT, PhD is an Associate Professor of Physical Therapy within the School of Health Professions at Samford University in Birmingham, Alabama. She is in her seventh year of academic service. Dr. Ross focuses on incorporating experiential learning into the curriculum and is highly involved in the programs simulation events. Her research area is focused on the use of simulation in PT education and the impact of international service-learning on students interprofessional attitudes and competence. Will Scogin, PT, DPT, ScD, is an Assistant Professor of Physical Therapy at Samford University in Birmingham, AL. He has 7 years of experience working with chronic pain patients in various outpatient orthopedic settings across the country. He also assists weekly with chronic pain clients through Samfords pro-bono partnership with Cahaba Medical Center. He is a Board-Certified Orthopaedic Clinical Specialist by the American Board of Physical Therapy Specialists, as well as a Certified Orthopedic Manual Therapist by the International Academy of Orthopedic Medicine US. Mrs. Beth Aho served adult patients for thirty years as a speech-language pathologist in the inpatient rehabilitation, home health, private practice, and skilled nursing settings. Her clinical experience includes treatment of patients with aphasia, dysarthria, apraxia, upper airway dysfunction, dysphagia and cognitive impairment resulting from various medical conditions. Beth is trained to administer and interpret modified barium swallow studies and has a passion for patient/caregiver counseling and education. ISSL 2024 65 Global Leadership Adaptability Through Servant Leadership and Cultural Humility: A Conceptual Framework M. Foulkrod & P. Lan Lin Adaptability is critical for future global leaders and a mechanism through which leaders can be best prepared to navigate constantly changing environments and shifting circumstances. Objectives: The authors aim to explore the relationships between global leadership mindset and adaptability by applying servant leadership and cultural humility perspectives. Leadership theories and approaches to leadership and adaptability will be discussed relative to leadership traits, skills, and knowledge and their potential relation to the degree of leadership adaptability. Servant leadership refers to the leader's aim to serve others first, and it differs from the commonly traditional leadership, where the leader's primary focus is to help their company or organization thrive. Cultural humility is a mindset and process that enables a global leaders ability to adapt to a culturally diverse environment. A global leader with cultural humility develops cultural awareness and tends to interact and adapt effectively with people of different cultures. We propose that by combining servant leadership and cultural humility through service-learning practices, mindsets will enhance the development of global leadership adaptability. Being adaptable as a leader allows for innovation and growth while navigating cultural disparities. Global leaders must be resilient, relevant, vigilant, ready to address crises, and strive for stability and progress for humanitys survival while transforming and inspiring effective change. Leadership transformation influences and inspires team and organizational transformation in times of uncertainty or change. The authors suggest a conceptual framework with servant leadership and cultural humility perspectives to create a global leadership mindset to enhance leadership adaptability to meet leadership challenges today. Marianna Kalli Foulkrod, MAAS, is the Director of the Center for Service-Learning and Community Engagement (CSLCE), adjunct faculty at the Shaheen College of Arts & Sciences at the University of Indianapolis and St. Marys of the Woods College, where she also pursues her Ph.D. in Global Leadership. Marianna has a strong passion for higher education and service-learning particularly, and she is committed to supporting her institutions motto, Education for Service, through a variety of faculty, community, and student programming between the university and the community locally, nationally, and globally. Marianna is a strong advocate for community engagement, civically and academically, and she is committed to providing quality education through service to higher education students. Much of her work is showcased in the latest videos, UIndy: Changing Lives through Service, which tell the universitys story of how students, faculty, and staff are engaged in their local, national, and international communities. Phylis Lan Lin, PhD., Professor Emerita, University of Indianapolis, serves as the senior advisor to the Asia Organization Development (AODN). She received the UIndy Meritorious Award for 45 years of dedicated teaching, administration, and service, and the Phylis Lan Lin School of Social Work and Counseling is named in her honor. Dr. Lin received a Ph.D. in sociology from the University of Missouri in 1972. She is a prolific writer and editor in Chinese and English, including numerous research papers, monographs, and books, including Organizational Behavior, Stress Management: Enhancing Quality of Life, Marriage and the Family, Crisis Intervention: Theory and Practice, Service-Learning in Higher Education, Medical Sociology, etc. She organized and chaired the International Symposium on China, the International Symposium on Service-Learning, and the International Symposium on Families: East and West. She established the University of Indianapolis Press. The Master Au-Ho-Nien Museum, founded in 2004 at UIndy, is one of her enduring cultural legacies. ISSL 2024 66 Se l f - D ir e c t e d Learning to Promo te Healthy Lifestyles for Adults w i t h C h r o n i c Illn e s s . M. D . F r e e m a n he p r e s s i n g i s s ue at hand is people's lack of knowledge and access t o e s s e n t i a l res o u r c e s t o f oster healthy behaviors and effectively manage chroni c d i s e a s e s . Ch r o n i c d i s e a s e s, including heart disease, diabetes, obesity, arthritis, lun g d i s e a s e s , an d o t h e r s , s t a n d as the leading causes of mortality and morbidity worldw i d e ( G r e e n e et a l . , 2 0 2 1 ) . C o nsequently, there is an urgent need to address the inform a t i o n a l v o i d an d r e s o u r c e d i sparities that limit the well-being of patients distresse d b y t h e s e co n d i t i o n s . T h o mpson et al. (2020) claim that while other determinant s o f h e a l t h (ge n e t ic s , e n v i r onment, and medica l care) influence health outcomes, by f a r t h e m o s t im p o r t a n t f a c t o r contributing to health outcomes is individual lifestyle and b e h a v i o r s . Sp e c i f i c a l l y , t h e core of the problem lies in the absence of training or e d u c a t i o n a l pro g r a m s t a i l o r ed to empower patients with chronic diseases. Throug h t h e s e l f dir e c t e d l e a r n i n g process, those who struggle with chronic disease wil l s e t g o a l s , de t e r mi n e h o w t heir progress is as sessed, and define activities and the t i m e l i n e f o r the i r l e a r n i n g ( Robinson & Persky, 2020). A comprehensive review of t h e e x i s t i n g lite r a t u r e u n d e r scores the necessity to equip individuals with the kno w l e d g e a n d ski l l s r e q u i r e d to adopt and sustain healthy lifestyle habits, such a s e x e r c i s e , nu t r i t i o n , a n d more. The targeted population, in this context, compris e s p a t i e n t s gra p p l i n g w i t h c hronic conditions, whose overall quality of life and healt h o u t c o m e s ca n b e s i g n i f i c a ntly enhanced through informed, evidence-based interven t i o n s . Th e c o r e p r o b l em identified is th e gap in training, in other words, th e n e e d f o r tra i n i n g o r e d u cational programs that help inform patients with chro n i c d i s e a s e co n d i t i o n s o n i mproving their lifestyle. Although the literature is broad, th e s t u d y w i l l foc u s o n t h e e x perts in nutrition, health science, and primary care me d i c i n e . T h i s pro v i d e s a m u l tidisciplinary collaborative approach to community-bas e d s e r v i c e lea r n i n g . Co m m u n i t y e d u cators can become involved with a coalition of provider s t h a t w o r k tog e t h e r t o b u i ld a program of education about healthy lifestyle habi t s i n c l u d i n g ex e r c i s e , n u t r i t i on, yoga, and meditation. Patients then become partners w i t h n o t o n l y the i r p r i m a r y c a re physician but also this coalition. There are barriers to t h i s t y p e o f tra i n i n g i n t h a t there is a lack of personnel trained in a primary care se t t i n g w h i c h ma k e s s e l f - m a nagement courses unavailable. Additionally, many w i t h c h r o n i c co n d i t i o n s a r e deep into the medical model and do not see the bene f i t s o f s e l f ma n a g e m e n t e d ucation programs (Bodenheimer et al., 2002). In my resea r c h p a p e r , I pla n t o s h a r e w h at I have found in the literature regarding this problem a n d t h e w a y s tha t t hr o u g h c o l laboration service-learning can be the catalyst for socie t a l c h a n g e s in h e a l t h y l i f e s t yle habits. Marcia D. Freeman, M.A. is a third-year doctoral student in the Ed D. Program at BSU. Serving in the ministry for 23 years and working 33 years in secular careers in finance and medical fields. Published in the summer of 2022, and 2022, also featured on a Fox 59 Wheres Sherman episode in September of 2022. Getting a doctorate in my 60s serves to challenge and encourage service and lifelong learning. ISSL 2024 67 Service-learning networks: conceptions, skills and conditions of a glocal transformative movement. L. Avruj, A. Peregalli, & C. Ferrara The 21st century challenges us to work in networks (Castells, 2015); to integrate the glocal as a characteristic of individual and organizational identity (Tapia & Peregalli, 2020). If at some point in history social and educational processes were conceived as entities isolated from the whole that sustains them, today they cannot be understood without the other. We are part of multiple networks and we are networked; valuing diversity and learning together and from each other. Service-Learning Networks (SLNs) are communities of actors that collaborate, structurally and subjectively, guided by the objective of contributing to build a fraternal world (Peregalli, Avruj, Ferrara, 2023). They coordinate their actions to promote Service-Learning (SL) pedagogy and strategically influence society and public policies. SLNs are dynamic, complex entities, in tension, with different levels of formalization, formality and impact (Avruj, Mayer, 2022). They are inserted in a local, regional and global ecosystem and face the challenge of managing different processes, times and histories to enhance their objectives and impact. Their action and agency is stimulated and promoted, both individually and collectively, to expand SL in the terms they consider appropriate for their region and country, to give sustainability to the actions and advance towards profound transformations. This article describes, at a double and complementary level, how to lead and manage SLNs (structural level) and what perceptions relevant actors have about the state of affairs and challenges of networking at a global level (subjective level). This is based on CLAYSS knowledge of experience (Balduino, 1993) - analysis of documentary and programmatic records of actions carried out between 2002-2022 - as well as the results of the first and second Global SL Mapping (ZIGLA-CLAYSS, 2019 and 2022). Using quantitative and qualitative techniques, the Mappings surveyed over 1300 stakeholders. At the structural level the results show that the good development of SL requires sharing certain concepts, deploying certain skills and generating conditions. The results express that the motivations to integrate SLNs are: strengthening of good practices and resources; alliances to advocate toward public policy; assistance for institutionalization processes. In terms of the needs to be met to expand SL through networking, the following stand out: human resources, funding and collaboration. The following are perceived as opportunities to develop SL: new partnerships; commitment to postpandemic social issues. And as challenges: differentiating SL from other approaches/practices; institutionalization; contextual particularities (insecurity, inequity). SLNs support webs of actors who work collaboratively and in diversity to achieve common goals. They are action strategies (structural level), but even more so, an identity trait of the actors; a way of being, doing and being in the world (subjective level); a community that learns collaboratively. At the subjective level, we explore motivations to be part of SLNs; what is needed to expand SL, opportunities and challenges to develop it. The analysis of the perception of key actors regarding SL in the current context reveals differences among regions: in Ibero-America there has been an incipient development of pedagogy in the last 20 years, an issue that favors the discussion on the relevance of SL and its inclusion in the field. The Ibero-American Service-Learning Network (REDIBAS) has been a crucial space for exchange to promote this type of work for over two decades. Other regions have shown similar results: in Europe, both national and regional SL networks such as the European Association for Service-Learning in Higher Education (EASLHE) and the Pan-European Network of SL in Schools and Organizations (SLESON) were mentioned as key actors to make the pedagogy more visible and to obtain support from local and international public bodies, same with the Service-Learning Asia Network (SLAN). ISSL 2024 68 The visibility that SL and similar approaches have gained in the last 30 years (e.g., Community Engagement; Community-Based Learning) is perceived as a trend conducive to inter-actor collaboration. Despite the contextual differences, the interviewees express that the need to teach and research with a purpose of social transformation has increased, also reflected in documents of international organizations (UNESCO, 2022) and of the Catholic Church (e.g., Global Compact on Education) that explicitly refer to SL. Among other materials and experiences, these conceptions, skills and conditions for managing and leading SL are illustrated and substantiated from the experience of the Program Promotion of SL in Central and Eastern Europe 2016-2022. The development of inter-actor relationships played a key role in the Program, it involved coordinating knowledge, time and experiences in order to facilitate and promote reciprocity, an encounter between equals (Avruj and Ferrara, 2022). "Connecting and networking have strategic value when there is a shared purpose. People and institutions that intentionally work together to expand knowledge, practices and SL projects create powerful movements. In times of change, networks sustain them, and in turn, they strengthen them with common projects and action. Concretion and communication enhance growth and help gain political support, sustainability, funding, among others." Democracy is a construction, a process; it is not something given but an in process that depends on all the social actors that somehow intervene. The action of SLNs is strategic, working with others in dynamic contexts within the framework of democratic and democratizing constructions. It therefore becomes evident, as Rovere points out, that networks bring about the logic of "organized heterogeneities" (2006); different from that of the "systemic logic" (homogenizing apparatus). The management and leadership of SLNs implies acting on both levels: structural and subjective; so that the institutional framework and institutional cultures are complementary elements that get coordinated to achieve the proposed objectives. From the moment a SLN is formed, its members enter into a web of solidarity ties, which is not simple: as Batlle expresses: "this need for alliances generates a broad consensus (...) who would disagree? The problem is that there is not enough training for it in the educational and social sectors (...) to promote service-learning in a specific territory, in addition to the novelty of giving impulse to an educational methodology, it is necessary to deal with the effort of moving it collaboratively, something quite unusual" (2018). This session intends to share some learnings on creating, sustaining and strengthening SLNs around the world with the aim to promote more of these and encourage more exchange on this topic which is key in the expansion and systematization of SL around the world. Luz Avruj holds a B.A. in Institutional Organization and Management (UNSAM), Specialist in Social Network Analysis and Management (Universidad Bolivariana de Chile) and University Diploma in Education (Universidad del Museo Social Argentino). Her two passions have always been Education and Social Development and she has worked in both fields for more than 20 years: in schools and universities as a teacher and teacher trainer and with social organizations offering technical assistance, facilitation, training and developing didactic materials. She has also worked with companies in negotiation and conflict management. She was CLAYSS Training Coordinator for several years and was in charge of the Service-Learning Promotion Program in Central and Eastern Europe. She is currently the Coordinator of Institutional Relations and Networks, an area from which she promotes the formation, strengthening and interrelation of networks related to the subject all over the world. ISSL 2024 69 Fostering Social Justice Through Service-Learning: A Closer Look at the Vulindlela Parent Engagement Program's Initiatives. T. Nqowana South Africa's education system continues to grapple with deep-rooted disparities that mirror the country's historical legacy of inequality. Despite progress made since the end of apartheid in 1994, significant gaps remain in access to quality education, resources, and opportunities. These disparities disproportionately affect marginalized communities, perpetuating cycles of poverty and limiting social mobility. Furthermore, socioeconomic factors exacerbate this divide. Makhanda stands as an embodiment of the profound inequality pervasive in South Africa, particularly evident within its educational framework and socioeconomic landscape. Addressing this injustice and anchoring Rhodes University within the Makhanda community necessitates collaborative efforts from the university and the community to transform the local education system. Without such transformation, both the future of Rhodes University and the overall well-being of Makhanda are at risk. In this regard, alternative approaches to reshaping South Africa's education trajectory, such as the community engagement initiatives undertaken by Rhodes University's Community Engagement Division (RUCE), assume critical importance. This paper focuses on research conducted from January 2022 February 2024, and looking at the impact and effectiveness of service-learning courses within the Vulindlela Parent Engagement Program, which is one of RUCEs programs, with the goal of advancing social justice in Makhanda. The theoretical framework guiding this study is rooted in the principles of social justice, which entail a commitment to fairness and equity in the distribution of power, resources, and societal obligations among all individuals. In the context of this research, social justice is characterized by equal access to educational resources, financial advice and other essential elements underpinned by principles of inclusion, cooperation, collaboration, equal opportunities, and equal access. Community-Based Participatory Research (CBPR) was employed as the multicultural /multidisciplinary research approach to guide the study, emphasizing collaborative planning and implementation between the facilitators, parents and learners of the Vulindlela Parent Engagement Program (community partners) and the different departments of Rhodes University. Within this framework, the teaching of the service-learning courses and the engaged research study were jointly planned and executed, and a focus was particularly given to two services-learning courses within the Vulindlela program. One of the service-learning programs is a collaboration between the Vulindlela Parent Engagement Program and the School of Journalism and Media Studies (SJMS) at Rhodes University. As part of this course, third-year journalism students compile relevant educational materials onto SD memory cards and distribute them to Grade 12 learners in the Vulindlela program and across Makhanda. Additionally, these students conduct interviews with learners, write reflective articles, and create social media blog posts to document their experiences and provide a comprehensive assessment of their learning. This partnership between the Vulindlela program and SJMS exemplifies the program's commitment to addressing educational disparities and fostering collaborative partnerships, both of which are central to the pursuit of social justice. Another service-learning course the study focused on within the Vulindlela program, is known as the Financial Life Skills Course, and is developed in collaboration with the Rhodes University Management Department and GBS Mutual Bank. This course empowers parents with financial literacy skills that they can share at home with their families, promoting economic empowerment within the community of Makhanda. The curriculum encompasses both theoretical content provided by GBS Mutual Bank and practical components facilitated by the Management Department at Rhodes University. By equipping parents with practical knowledge of financial management, this course contributes to social justice by promoting fairness and equity in accessing financial resources and opportunities. ISSL 2024 70 Reflections, interviews, student articles, and course evaluations served as key methods of data collection within this CBPR approach, facilitating a comprehensive understanding of the impact and effectiveness of the service-learning initiatives. The sample of this qualitative study comprised of 38 parents, 38 learners and 27 students. Students engaged in critical self-reflection, documenting their experiences and insights through personal reflections and articles. Interviews were conducted with parents, learners, and other stakeholders to gather their perspectives on the program's outcomes and effectiveness. Course evaluations provided valuable feedback from both students and parents, informing continuous improvement and refinement of the service-learning courses. The tangible outcomes of these efforts, including improved access to career pathways due to improved learner performance, certificates awarded to parents, and the teasing out of the hidden curriculum from reflections from both parents and students, serve as evidence of the success of these initiatives. This study contributes to the existing literature by illustrating the effectiveness of service-learning in addressing educational disparities and empowering parents and learners and students, offering valuable insights for educators, policymakers, and stakeholders seeking to enhance educational outcomes and promote community development. Thandiswa Nqowana is a service-learning Lecturer and coordinator of the Vulindlela Parent Engagement Program at Rhodes University in Makhanda, South Africa. She holds this position in the Community Engagement Division, and is currently registered at Rhodes University for her doctoral studies in the Biotechnology Innovation Centre (RUBIC) at Rhodes. Her research focuses on the development of products and processes with direct societal impact. This includes collaboration with communities on the topics of water quality testing and treatment in remote areas. Through her work, she studies how direct science engagement with communities regarding research and technology, holds multiple benefits for communities, science students, and ultimately for the successful development and deployment of beneficial water products. ISSL 2024 71 Upon Return: Cultivating Global Citizenship & Social Action in U.S. Global Health Students: A Case Study in Crdoba, Argentina E. Gahimer This proposed research presentation comes out of the fields of international higher education, education abroad, and global health education and has meaningful intersections with global servicelearning and ethical community engagement. The presented study derives from dissertation research looking at U.S. students participating in a global health education program to Crdoba, Argentina in June 2023 with the organization Child Family Health International (CFHI). The studys research questions were 1) What are the experiences of U.S. college students who participate in a sociallyconscious, ethics-informed global health education abroad program to Argentina? and 2) How do U.S. college students understand power differentials in Global North-Global South community engagement in a global health education abroad program to Argentina? Using a post-colonial theoretical framework, the study was carried out as a qualitative case study examining a cohort of 12 global health students studying in Crdoba, Argentina in June 2023. Data collection took place at pre-departure, on-site, and re-entry phases and included on-site field observations, focus groups, and 1:1 interviews. The knowledge gap being addressed, and therefore the rationale for the study, was learning more about how U.S. students engage with issues of power differentials, and their accompanying ethical implications, in their education abroad programs to the Global South. The sessions purpose will be to present the findings of this study as it relates to student experiences and understanding of power differentials, specifically highlighting the findings related to the nature of the relationship between the students and the Argentine host community, the embodied assetbased orientation towards Argentina, as well as the duality of roles assumed by students as both neoliberal consumers and global citizens. Extended discussion about how U.S. students demonstrated a spirit of social action for their future careers as health professionals in the U.S. will be highlighted. The session will underscore the themes of service-learning serving as a catalyst for societal, institutional (policy change), and student transformation (1), also, service-learning as a means to address ethical leadership (3), and, lastly, emerging theoretical perspectives that link to student transformation into critical and engaged citizens (6). In terms of expected outcomes for service-learning, this research spotlights the possibilities that exist for U.S. students upon return from global health education programs. It spotlights the life-long impact global community engagement can have for cultivating socially-conscious, transformational leaders as social actors in the U.S. context. It does so while also centering ethical best practices related to host communities abroad, notably when global health education providers embody a socially-conscious & ethics-informed ethos in their approach to global community engagement. Erin Gahimer is a doctoral student at the University of Illinois Urbana-Champaign studying Global Studies in Education through the College of Education. Erin recently defended her dissertation research and will be graduating in May 2024. Erin will continue working in the field of International Education, building on her previous 8 years of professional experience working at the Office of Education Abroad at the University of Dayton in Dayton, Ohio. ISSL 2024 72 Building Energy Conservation and Cost Savings Into A Campus Renovation. R. Rostom & C. Paterson The purpose of this presentation is to demonstrate a service-learning project within a Heat Transfer course in the Bailey College of Engineering and Technology, including the student and community partner outcomes. Senior undergraduate students collaborated with Duke Energy Company to conduct an energy audit of two buildings at Indiana State University slated for renovation. The twobuilding technology complex has 50,481 sq. ft. of space including the Technology Annex, built in 1980, and the Myers Technology Building, built in 1997. As part of the senior engineering heat transfer course, students performed an energy audit of the building complex to determine how energy is consumed. This assessment identified potential energy conservation strategies, associated energy cost savings, and projected incentives. The students were tasked with measuring room spaces and identifying leakages from pipes and infiltrations from windows using thermal imaging. They also collected information on general equipment in the building and room temperatures using data loggers. Once the data was collected, the Duke Energy Companys contractor toured the space to verify the accuracy of the data and finalize the energy audit. The estimated base cost to renovate heating, ventilation, air conditioning (HVAC), and lighting systems to meet the current code requirement is $165,126. Going beyond code and achieving energy efficiency design would cost the university an additional $15,379. This will result in an estimated annual energy cost savings for lighting and HVAC systems of $34,235. This service-learning project is but one example of the larger commitment our institution has to our broader community. Building renovation is no small environmental or financial endeavor. By directly involving students and their developing expertise with multiple levels of private industry, they created a more environmentally sustainable building plan. Communicating their recommendations and later seeing them realized in a campus structure signifies connection and permanence with the campus, industry, and community. Dr. Rostom teaches engineering and engineering technology classes. Her research focuses on combining mechanical and civil engineering disciplines by performing energy usage simulations of mechanical HVAC systems, electrical lighting systems with civil engineering for better greener buildings. She is involved in research on engineering education by studying the effect of various education techniques applied in classrooms on student success and how it can improve the rate of success for future engineers. Cat Stemmans Paterson has served on faculty since 1998 and has been affiliated with the Center for Community Engagement since 2008. She serves as Editor of the Journal of Community Engagement and Higher Education. Dr. Paterson is a Professor in the Department of Applied Medicine and Rehabilitation. ISSL 2024 73 Leadership Transformation in times of change and cultural adversity. M. Foulkrod & C. Giardina This storytelling presentation will focus on discussing the ways that higher education institutions play a critical role in the delivery of innovative local and international collaborations that integrate servicelearning through multicultural collaborative methodologies resulting in impact on current social and global concerns. Events such as pandemics, digital revolution, economic flux, healthcare advancement, global warming, and natural disasters with catastrophic consequences are reasons for a major global system reform. Higher education must consider a more innovative approach to prepare young adults to be critical and engaged global citizens. Global leaders must address the need for stability and progress for humanitys survival while transforming and inspiring to effective change. Servant leadership is a philosophy in which the leader aims to serve (Greenleaf, 1970). This differs from the commonly traditional leadership, where the leader's primary focus is to help their company or organization thrive. Servant leadership researchers often associate this type of leadership with shared leadership approaches and love, which signifies empowerment and humility but often conflicts with certain cultural groups and societies globally and is not as welcomed (Kwasi, 2019). Transformational leadership is a theory that highlights the working relationship of a leader with their teams or followers beyond their immediate self-interest to identify necessary change, create a vision to guide the change through influence and inspiration and execute the change in tandem with committed group members. This change in self-interests elevates the followers' maturity levels, ideals, and concerns for achievement. Transformational leadership is an integral part of the full-range leadership model (Bass, 1999) and has a micro and a macro influence on leaders and followers (Yahaya et al., 2011). These leadership styles are key to adapting to a leadership style that is all inclusive of cultural intricacies and perspectives and play a role in the degree of leadership adaptability that young leaders develop while in college. Adaptability is critical for future global leaders and a mechanism through which leaders can be best prepared to navigate constantly changing environments and shifting circumstances. Being adaptable as a leader also allows for innovation and growth and the ability to continually navigate cultural differences and imbalances. One of the ways that leaders learn about leadership and leadership adaptability is by observing others around them and adapting themselves as role models in order to inspire their teams and organizations to embrace change and adapt to challenges (Dweck & Leggett, 1988). Higher education can set at example and support the notion of Organizational adaptability, which involves responding at a quick pace to allow the organization to thrive (Birkinshaw & Gibson, 2004). Leaders who observe others and adapt their leadership are ones that value the perceptions of their teams and allow for those to influence them as such, allowing spaces for feedback and reinforcement while reshaping particular leadership behaviors. Global leadership experiences are linked to adapting an individuals behavior contrary to social norms reshaping the culture nationally and internationally (Vitolla et al., 2021). Possibly, while taking into consideration the cultural norms of their own society, leadership institutions should also consider common verbiage or a code of ethics that would reshape internal processes and regulations to improve processes and behaviors towards social well-being. It is imperative that institutions globally continue to identify ethical values as it helps them prioritize their decisions and enhance their ethical sustainability and the findings of this study will support the need to better prepare leaders to the need for continued growth and constant adaptability. Leadership strategy in change is about accommodating and adjusting skillsets to meet current needs and to be consistent with current trends. Strategy and sharing that through effective communication with others who follow is the key to solid leadership's effectiveness. ISSL 2024 74 This presentation suggests a servant transformational approach to global leadership as a solution to leadership challenges faced in global fast pacing settings, where change is inevitable and often unexpected. Leadership transformation influences and inspires team and organizational transformation in times of uncertainty or change. This presentation will provide insights to understand better the internal factors (such as personality traits) and external factors (such as perceptions and approaches of others) that influence leadership adaptability and response to such needs. Marianna Kalli Foulkrod, MAAS is the Director of the Center for Service-Learning and Community Engagement (CSLCE) and adjunct faculty at the Shaheen College of Arts & Sciences at University of Indianapolis, in Indiana, USA. Since her migration from Cyprus to the United States, Marianna has had a fascinating and diverse career, starting as the Assistant Director for a non-for-profit advocacy organization that works for and with people with disabilities. She quickly realized her passion for higher education and moved back to that environment working to support her institutions motto Education for Service through a variety of faculty, community and student programming between the university and the community locally nationally and globally. She currently co-chairs the upcoming International Symposiums on Service-Learning (ISSL) that will be hosted in Nicosia, Cyprus in June of 2022. Marianna oversees UIndys Service-Learning Council, a faculty and staff advisory council who supports the development, delivery, and assessment of service-learning initiatives at the institution. Marianna is a strong advocate for community engagement, civically and academically, and she is committed to providing higher education students with quality education through service. Much of her work is showcased in latest videos UIndy: Changing Lives through Service, which tell the universitys story of how students, faculty, and staff are engaged in their local, national, and international communities. Mariannas most recent endeavors included publications, UIndy receiving the Community Engagement Classification through Carnegie Foundation for the Advancement of Teaching (2020), as well as recognitions from the Presidents Higher Education Community Service Honor Roll. Marianna has most recently been recognized by Indiana Campus Compact with the Community Service Director Award (2016) as well as by UIndy with the Beyond UIndy Award (2019). Dr. Claudia Giardina grew up in Saudi Arabia and Germany and earned a doctorate from Vanderbilt University in Comparative Literature and German Studies. Since then, she has taught a wide range of courses in Language, Literature, Translation Studies, and, most recently, Service-Learning. As Resident Director for U.S. exchange programs at the University of Regensburg, Germany, Claudia had an opportunity to work with Syrian refugees and their families. This experience was so fulfilling both professionally as well as personally that it led her to pursue similar work at IUPUIs Office of International Affairs as a Program Associate for Global Learning and International Partnerships before joining the University of Indianapolis in 2021. Here, she has been happily teaching German, first-year seminars, and service-learning courses emphasizing applied language in the community and the world. As a comparatist, Claudia has always been interested in the inter spaces between the different disciplines, as it is through communication between individuals from different fields, we can be the most creative and inspired, and create meaning for our lives and those of others. ISSL 2024 75 Service-Learning as a unique way to develop soft skills. J. M. Viola & M. F. Harake Rohan Rajiv, Director of Product Management at LinkedIn, states that soft skills have become even more important given the rise of remote and autonomous work, and are growing in importance across industries, levels, and work environments, representing as much as 78% of jobs posted globally over the last three months. Continuous education is also considering upskilling workers to address the social and emotional skills that are in high demand. Empathy and interpersonal skills are specifically targeted. Soft skills generally refer to categories like leadership, communication and problem-solving. On the other hand, hard skills are the technical capabilities that can be quantified and measured. Typically, workers can acquire this knowledge through formal coursework, on-the- job training, and real-world experiences. We conduct an inquiry through a GIP-CEI students projects in an NGO dedicated to green supply chain, using sailing boat to transport fair-trade coffee. The idea was to evaluate through a questionnaire students soft skills across three dimensions that are very hard to develop in the classroom: Ability for decision-making based on judgement. Relational skills. Coordination skills, ie multitasking. Primary results show a solid improvement in terms of relational and coordination skills but only a symbolic increase in decision-making based on judgement. Beyond our tests, the experiment shows opportunities to develop a dedicated pedagogical framework to develop soft skills and tacit knowledge withing the context of service-learning. It offers opportunities to create a unique context, a good-enough environment to stimulate learning. The good-enough environment was theorized by Winnicott (1975) in his book Playing and Reality. Inspired by his on work on the mother-child relationship, the good-enough environment provides a space of freedom. A freedom that is not absolute but situated, framed, providing protection to allow creativity (Simon, 2002) We propose a framework to design and monitor knowledge acquisition in the context of service-learning, providing guidelines to optimize learning, focusing on the context, on the identification and use of boundary objects." Jean-Michel Viola has over 15 years of professional experience, at JP Morgan (Paris office), as a professor of strategic and innovation management at HEC Montreal and CEU Business School in Budapest, and as a consultant. He has founded two knowledge providing boutique firms, Strafitech Inc. in Montreal and Knowstrat SRL in Bucharest. Both French and Canadian citizen, he is was an associate professor with ESC Rennes School of Business where he is the director for Graduate Executive Programs and now an Associate Professor & Director Accreditations at ESLI / ESTI/ GIP CEI! Prof. Dr. M. F. HARAKE is a management Professor based in France. He is currently the Director of International Academic Affairs of GIP CEI (a French Higher Education and Research Institution) and the scientific director of the MBA DELIVERWEB at ALTERNIS Business School (Bordeaux France). On another note, Dr. M.F. HARAKE is a research fellow at the CEREGE Research Laboratory (University of Poitiers France), and a visiting research fellow at CABMR Research Center (Paris France). His research interests include Post-Conflict Public Management, Crisis and Urgent Operations Management, Humanitarian Logistics, and Project Management in Unstable Environments. ISSL 2024 76 New constructs for service, learning, and practice: Understanding the transformative power of building abroad on communities and students. S. Shall Architecture was, and is, a patronage-based practice. This reality profoundly imprints itself upon both the architect and educator, compelling them to prioritize linear, hierarchical, and largely impositional processes designed for a carefully-curated clientele. These processes typically result in the creation of prestigious works, designed to offer status for those fortunate enough to have the resources to enlist the services of these professionals (Crawford, 1991). Although not without utility, these exclusionary patterns become quite problematic when one attempts to use them in service-learning activities or community-centered design efforts - ambitions which obviously must be founded upon the tenants of authentic dialogue and social equity (Jacobson, 2010). To be effective in this arena, the architect and educator must critically examine the prejudice embedded within their current approaches and formulate new, more inclusive, patterns of engagement (Friere, 2010). Only then will they become able to avoid imposing their design ideals upon constituencies historically disadvantaged by them and inadvertently generating the malevolent urbanism such approaches naturally create (Theime & Kovaks, 2015). In the session proposed by this abstract, attendees will explore this assertion through the analyses of three design actions constructed within informal communities over the last few years as a part of an ongoing building-abroad, service-learning experience in Africa. Built by small, inter-disciplinary teams of students and professionals in only a few days using scavenged means and budgets of less than $1500, these modest works will offer attendees several unique vantages into a more inclusive and dialogical approach to service and learning, as each project was realized using a distinct form of community-based engagement (Image 01). From remote learning to design-build, globalized crowdsourcing to hyper-local peer-to-peer production, hands-on bricolage-based constructions to acts of digital fabrication, each of the analyzed works will present distinct insight into new forms of service-learning and community-based design. The proposed session will examine each of these approaches, as well as the resulting schools, homes and makerspaces, using an innovative assessment tool so as to better understand their efficacy in two ways: as an act of service-learning and as an act of community-based design. This assessment, and the meaningful dialogue it encourages, will allow session attendees to understand the assets and limitation of each approach and work as catalysts for both societal change and student transformation, inciting a radical reimagination of the relationship between service, learning, and practice. Scott Gerald Shall, RA, is an Associate Professor of Architecture at Lawrence Technological University (LTU), founding principal of houm (ourhoum.com) and the founding director of the International Design Clinic, a registered non-profit that realizes socially-responsive creative action with communities in need around the world. Shalls work has been disseminated widely, including contributions to publications by the Routledge and AIA Press and inclusion within exhibitions at the Venice Architecture Biennale and MoMA. ISSL 2024 77 An Innovative Faculty Role: A Catalyst To Incorporate Service-Learning And Engaged Scholarship Into Higher Education. T. Morris This session will discuss the progress the University of Indianapolis has made over the past decade in practicing service-learning on an institutional level. Practical and theoretical approaches are used to foster social action, enhance the citizenship of students and staff, and integrate service-learning through multicultural and/or multidisciplinary collaborations. The Distinguished Professor of ServiceLearning (DPSL) at the University of Indianapolis is a unique role that has catalyzed meaningful dialogue and work exchange among academics, students, community partners, and other professionals. This role serves as an institutional support system for an appointed faculty member to explore diverse areas of service-learning and help promote civic engagement, scholarship, and resiliency in a post-pandemic, rapidly changing world. The role provides support for faculty to focus on the development of reciprocal and transactional relationships as well as developing innovative service-learning initiatives in higher education at the local and global levels. Learner objectives: 1. Learn about the importance of institutional support systems that help advance service-learning 2. Gain an understanding of the role and responsibilities associated with the Distinguished Professor of Service-Learning at the University of Indianapolis 3. Explore lessons and opportunities to branch out beyond your discipline and develop a platform to advance service-learning initiatives Toni Morris, DNP, RN, CNE is an Associate Professor in Nursing at the University of Indianapolis. She is a nurse with over 25 years of experience and interest in operating room nursing, informatics, community-public health, service-learning, interprofessional education, disaster simulation, and nursing education. Dr. Morris earned her Bachelor of Nursing from Indiana University, her Master of Nursing Education from the University of Indianapolis, and her Doctorate of Nursing Practice from Indiana State University. ISSL 2024 78 Implementing the Global Community Engaged Learning Course Development Institute at Indiana University-Bloomington. E. Konwest, K. Silvester, & S. Asim Architecture was, and is, a patronage-based practice. This reality profoundly imprints itself upon both the architect and educator, compelling them to prioritize linear, hierarchical, and largely impositional processes designed for a carefully-curated clientele. These processes typically result in the creation of prestigious works, designed to offer status for those fortunate enough to have the resources to enlist the services of these professionals (Crawford, 1991). Although not without utility, these exclusionary patterns become quite problematic when one attempts to use them in service-learning activities or community-centered design efforts - ambitions which obviously must be founded upon the tenants of authentic dialogue and social equity (Jacobson, 2010). To be effective in this arena, the architect and educator must critically examine the prejudice embedded within their current approaches and formulate new, more inclusive, patterns of engagement (Friere, 2010). Only then will they become able to avoid imposing their design ideals upon constituencies historically disadvantaged by them and inadvertently generating the malevolent urbanism such approaches naturally create (Theime & Kovaks, 2015). In the session proposed by this abstract, attendees will explore this assertion through the analyses of three design actions constructed within informal communities over the last few years as a part of an ongoing building-abroad, service-learning experience in Africa. Built by small, inter-disciplinary teams of students and professionals in only a few days using scavenged means and budgets of less than $1500, these modest works will offer attendees several unique vantages into a more inclusive and dialogical approach to service and learning, as each project was realized using a distinct form of community-based engagement (Image 01). From remote learning to design-build, globalized crowdsourcing to hyper-local peer-to-peer production, hands-on bricolage-based constructions to acts of digital fabrication, each of the analyzed works will present distinct insight into new forms of service-learning and community-based design. The proposed session will examine each of these approaches, as well as the resulting schools, homes and makerspaces, using an innovative assessment tool so as to better understand their efficacy in two ways: as an act of service-learning and as an act of community-based design. This assessment, and the meaningful dialogue it encourages, will allow session attendees to understand the assets and limitation of each approach and work as catalysts for both societal change and student transformation, inciting a radical reimagination of the relationship between service, learning, and practice. Eli Konwest serves as the Director of the Center for the Study of Global Change at Indiana University Bloomington. Katie Silvester is an associate professor of English and coordinator of multilingual writing at Indiana University Bloomington. Her recent work includes Living English, Moving Literacies: Women's Stories of Learning between the US and Nepal, forthcoming in December 2023. Dr. Sumreen Asim is a COFFEE enthusiast. She is an associate professor science and technology and teaches courses to both undergraduate and graduate students at Indiana University Southeast. Over the last two decades she has focused her work to share, love and grow with fellow educators. ISSL 2024 79 Theory Integration in Education Transformation and Resilient Service-Learning Amid Global Crises. C. Pearison In the evolving landscape of education amidst global crises and transformative events, the integration of robust theoretical frameworks holds paramount importance. This presentation is poised to dissect the pivotal nexus between theoretical paradigms, educational restructuring, and the enduring resilience of service-learning initiatives. It aims to meticulously unpack the strategic infusion of diverse theoretical lenses into pedagogical practices, curriculum design, and the formulation of adaptable educational policies. Our discourse will delve deeply into the multifaceted dimensions of employing theoretical frameworks as catalysts for educational transformation during tumultuous times. Drawing upon empirical evidence, case studies, and best practices, I aim to illustrate the transformative potency of theory application in navigating and thriving amidst global crises. Moreover, this session will navigate the intricate landscape of service-learning programs as resilient mechanisms nurturing adaptability, empathy, and social responsibility amidst adversity. Through interactive engagement and collaborative discussions, we will explore the symbiotic relationship between theoretical frameworks and service-learning methodologies, emphasizing their collective role in fostering resilience and robust community engagement. Embracing an interdisciplinary approach, the presentation aims to serve as a platform for educators, researchers, and practitioners to share innovative strategies, interdisciplinary approaches, and evidence-based practices. These practices underscore the integration of theories in educational reformation and the fortitude of service-learning endeavors. By transcending disciplinary boundaries, this session endeavors to foster a deeper understanding of the nuanced intersections between theories, educational resilience, and service-learning innovation. Ultimately, this presentation aspires to catalyze transformative discourse, advocating for the integration of theories as fundamental pillars in the evolution of education amidst tumultuous global landscapes. By embracing theory-driven pedagogies and nurturing resilient service-learning frameworks, I aim to equip educators and stakeholders with actionable insights to navigate and thrive in times of crisis, fostering a more adaptable, empathetic, and resilient educational ecosystem. Christy Pearison is a serial entrepreneur who has a continual love for learning, teaching, and giving back to her community and those around her. As a graduate of Saint Mary-of-the-Woods college she earned her undergrad degree in Human Services with a Minor in Business Administration, she continued on to earn her masters degree in Leadership and Development, as well as her Womens Global Leadership Certificate in 2020, both at Saint Mary the Woods. She is a current Ph.D. candidate in Global Leadership, teaches adult academics for Wagler education, she is the Assistant Director of the West Central Indiana Small Business Development Center at Indiana State University, and is an Adjunct Professor for the Scott College of Business. Christy and her husband own two businesses and a nonprofit organization in their small-town of Sullivan, Indiana, where they focus on community development, networking support and advocacy services. She sits on the Saint Mary of the Woods College Alumni Board, Pace Community Board, Addiction Recovery Sub-Committee board for United Way, Sullivan County Chamber of Commerce Board, Sullivan County Tornado Recovery Board, and is the Chair of the Sullivan County CEO Board. She is a wife, mother, granny, and was awarded the 2021 Leader of the Year award for Sullivan County. Christys passion goes far beyond her everyday life activities and really lies in the realm of giving back to other inspiring students and entrepreneurs. At the end of the day, she feels most successful when she has helped someone else see their own potential. ISSL 2024 80 Cu l t i v a t i n g C h a nge: A 20-Year Journey in Global Rehabilitation Partners h i p s . C. R u b y , M . D r n a ch, A. Pilsner, B. Sloane, B. C. Chvez, & G. K. Gngora Th e W o r l d H e a l t h Organization (WHO) estimates that more than 1 billion p e o p l e ( 1 5 % ) in t h e w o r l d t oday experience disability. 1 In both developed and d e v e l o p i n g co u n t r ie s , i n d i v i duals with disabilities face higher rates of poverty, lower e d u c a t i o n a l ac h i e v e m e n t s , f ewer economic opportunities, and higher rates of poverty t h a n p e o p l e wit h o u t d i s a b i l i ties. Studies in many developing countries conclude t h a t a h i g h pe r c e n t a g e o f i ndividuals with disa bilities requiring rehabilitation do not r e c e i v e t h e nec e s s a r y c a r e . 1 Unmet rehabilitation needs can lead to deteriora t i n g h e a l t h , inc r e a s e d d e p e ndency on others for assistance, and decreased quality of l i f e . S e v e r a l ba r r i e r s t o p r o v i ding rehabilitation have been identified, including cost, o r g a n i z a t i o n , lac k o f f o r m a l training, and curricular issues. WHO recommends inter d i s c i p l i n a r y co l l a b o r a t i o n and the implem entation of community-based re h a b i l i t a t i o n int e r v e n t i o n s a s a means to overcome these obstacles. This panel prese n t a t i o n w i l l de s c r i b e h o w a model of international service-learning, that u t i l i z e s a n int e r d i s c i p l i n a r y team of professionals with students from Doctor of Physi c a l T h e r a p y Pro g r a m s f r o m multiple universities from the USA and the state of Yucat n i n M e x i c o , ref l e c t t h e W HOs recommendations of collaboration and comm u n i t y - b a s e d reh a b i l i t a t i o n , a nd discuss the model utilized to meet curricular and ac c r e d i t a t i o n ob j e c t i v e s . T h e focus will highlight the development of this partnersh i p a n d t h e sig n i f i c a n t c h a nges observed over the past 20 years, which include i n c r e a s e d all o c a t i o n o f r e sources, upgraded facilities, technology and equipment, a s t r o n g e r em p h a s i s o n e ducation, and a changed cultural perspective on indiv i d u a l s w i t h dis a b i l i t i e s . T h e panel will also present on the continuation of this collabo r a t i o n a m i d the C O V I D - 1 9 p andemic, highlighting the infrastructure upgrade that th e p a n d e m i c fac i l i t a t e d . C l i n i cians from the USA and Mexico will share their exper i e n c e s a n d pe r s p e c t i v e s , d etailing the impact and reach of service-learning on re h a b i l i t a t i o n pra c t i c e i n a d e veloping country. At t h e c o n c l u s i o n of this presentation, participants will be able to: 1. R e c o g n i z e t h e importance for rehabilitation for individuals with disabiliti e s . 2. I d e n t i f y o b s t a cles for rehabilitation in developing countries. 3. C r e at e s t r a t e gies to overcome those obstacles. 4. C r e at e s t r a t e gies to actively engage community partners. 5. R e c o g n i z e h o w feedback from community partners shapes future oppo r t u n i t i e s . 6 . De s c r i b e h o w i n ternational service- learning can affect change in healthca r e p r a c t i c e . Dr . C r a i g R u b y i s the Program Director for the developing Doctor of Physi c a l T h e r a p y Pro g r a m a t S e t o n Hill University in Greensburg, Pennsylvania. Dr. Ruby has d e v e l o p e d , im p l e m e n t e d a n d participated in local, regional and international serv i c e - l e a r n i n g ex p e r i e n c e s f o r physical therapy students over the past 18 years. He ha s p r e s e n t e d on s e r v i c e - l e a r n ing at national and international conferences and publis h e d j o u r n a l art i c l e s a n d b o o ks chapters on service-learning topics. ISSL 2024 81 Dr . M a r k D r n a c h is a Professor of Physical Therapy at the University o f F i n d l a y i n Oh i o . H e i s k n o wn for his work in the area of pediatrics and is the prima r y a u t h o r o f the t e x t b o o k T h e Clinical Practice of Pediatric Physical Therapy: From t h e N I C U t o Ind e p e n d e n t L i v i ng. He has published over a dozen articles on pediatric an d d i s a b i l i t y iss u e s a n d h a s published several book chapters on the topics of h e a l t h c a r e ec o n o m i c s , a c c ounting and finance, and service-learning in various tex t b o o k s a n d jou r n a l s . D r . D r n ach is active in service-learning, organizing and coordina t i n g t r i p s t o the Y u c a t a n i n Mexico, Chimbote, Peru, and Santiago in the Dominican Rep u b l i c . H e i s als o a c t i v e i n a NGO that supports the educational programs in Mexico an d G h a n a . Ali s o n P i l s n e r , MPH, BSN, RN, CPH, IBCLC is on faculty at the College of Nu r s i n g a t t h e Un i v e r s i t y o f C olorado Anschutz Medical Campus. She has dedicated he r c a r e e r t o ma t e r n a l a n d c hild health research and practice with a focus on health d i s p a r i t i e s an d h e a l t h e q u i t y. She has been instrumental in the development of healt h e d u c a t i o n an d p o l i c y i n i t i a tives to support public health efforts at the national lev e l . O v e r t h e pa s t 1 5 y e a r s , P ilsner has also participated in and helped to organize g l o b a l h e a l t h mi s s i o n s t o M e x i co, Central, and South America. Dr . B e t h a n y S l o ane, PT, DPT, PCS is an Associate Professor at Oregon H e a l t h a n d Sc i e n c e U n i v e r s ity in the Institute on Development & Disability. She i s a P h D ca n d i d a t e a t O regon State University conducting research to promo t e p o w e r e d mo b i l i t y i n t e r v e ntions for young children with developmental disabilities. D r . S l o a n e s inv o l v e m e n t i n i nternational service-learning began as a graduate student i n 2 0 0 9 t o Ch i m b o t e , P e r u and grew into continued participation and coordination to t r i p s t o t h e Yuc a t a n i n M e x i co over the past 10 years. L.R . B e a t r i z C a nch Chvez is graduated in rehabilitation from the F a c u l t y o f Me d i c i n e o f t h e Autonomous University of Yucatn. With nine years of ex p e r i e n c e a t Co n s t r u y e n d o S onrisas, she has been dedicated to the early interventio n a r e a , a n d she i s c u r r e n t l y leading the rehabilitation department. Beatriz is a certifi e d t h e r a p i s t in N e u r o d e v e l o p mental Treatment by EBTA, Orofacial Myofunctional The r a p y R e g o To r r , a n d N e u r omuscular Taping. Also holds diplomas in Pediatric Physio t h e r a p y a n d Ne u r o de v e l o p m ent. L.R . G a b r i e l a K i m Gngora is graduated in rehabilitation from the Faculty o f M e d i c i n e of t h e A u t o n o m ous University of Y ucatn. She has been working at the a s s o c i a t i o n co n s t r u y e n d o s onrisas for two year s in the area of early intervention. She o b t a i n e d a Dip l o m a i n P e d i atric Physiotherapy and Neurodevelopment by the Marist a U n i v e r s i t y of M r i d a . S h e s tudied English as a Second Language at Howard Commu n i t y C o l l e g e as p a r t o f c o n t i n uing education. ISSL 2024 82 Utilizing a Moodle platform to advance engaged citizenship and enable national virtual servicelearning initiatives as a curricular requirement for social work students at Stellenbosch University. M. Pietersen, R. Hector-Kannemeyer, & P. Khosa What is the role of education and its purpose? What is the value if it cannot respond to the common good? How should the university, contribute to our knowledge of the world? There is growing recognition across the world of the urgency of tackling a range of difficult, complex, and interrelated issues that impact human well-being. These issues include food, energy, and water security; the spread of infectious diseases; developments in technology and medicine; climate change; and of course, education. We need to look at the contribution that academia can make to understanding and addressing these global challenges. However, faculty will need to become more fully engaged in directly responding to real-world problems, especially in partnership with communities outside of campus. As the pace and complexity of our global society increase exponentially, there is an urgent need to realign the design and infrastructure of education with the needs of the people our educational systems are intended to serve. There are two major trends in the world that pose a fundamental challenge to and many opportunities for our education system. One is that the world is shifting from an industrial economy to a knowledge economy. The other is that the rising generation raised on the Internet is very differently motivated to learn. These two forces, argues Dr Tony Wagner, co-director of Harvards Change Leadership Group, compel us to reconceptualise education. He identifies what he calls a global achievement gap, which is the gap between what our institutions are teaching and what is regarded as critical skills of the future. The Stellenbosch University Vision 2040 core theme of a transformative student experience is cognisant of the global skills gap when preparing students for a global market. Universities have a social responsibility to also use our talents to the benefit of those in society who are not as privileged as ourselves. To develop well-rounded thought leaders who have broadened their horizons and feed what they have learned and experienced back into society. We need to take a close look at the world right now and highlight the fact that there is a greater vulnerability and inequality, which is pulling people further apart. Maybe we need to do more than reflect on social transformation and emancipation as the ways of knowing and reflect on where education has not gone far enough. As a creator of sustainable hope in Africa, Stellenbosch University aspires to create the kinds of conditions that will enable each student to acquire the attributes in order to graduate with the following capabilities outlined below: 1. an enquiring mind 2. an engaged citizen 3. a dynamic professional 4. a well-rounded individual. The Advancing Engaged program was created to enable students to participate in community engagement and civic involvement activities while also fostering social responsibility, sharpening leadership abilities and graduate attributes for the workplace, and equipping them to tackle complex social issues. The work of enabling student/ community relationships was birthed through Matie Community Service in 1964. The program facilitates learning opportunities within the various sectors of society be it the Government, the NGO sector, business, schools, etc where the introduction of the seven critical skills is applied in the experiential component of the training course which also facilitates learning opportunities for students to critically engage in diverse contexts on a national level in order to enable the development of the graduate attributes identified by Stellenbosch University (Strydom, Jacobs & Kirsten, 2012: 4). ISSL 2024 83 As a pioneer of Community Engagement at Stellenbosch University, the Engaged Citizenship Hub has evolved over five decades. The Engaged Citizenship Hub brings together all the stakeholders involved in social impact at Stellenbosch University to ensure that student initiatives are informed and guided by professional development principles. Further, it is a hub for all student-driven social impact initiatives. It provides support and enhancement to student volunteer and service-learning initiatives to ensure that they are sustainable and adhere to best practice principles. The hub provides a variety of offerings. The Advancing Engaged Citizenship short- course has evolved from a forty-two participants course in the co-curriculum to a curricular offering for three hundred students as part of the service-learning component of their social work degree. It is envisaged that this offering will continue to contribute to an environment where student learning is enriched, and research relevance is enhanced. It supports the institutional commitment of reciprocity, redress, development, and transformation. Renee completed a Masters Degree in Social Development, majoring in Conflict, Transformation, and Peace studies, and holds both an Honours Degree in Psychology and an Honours Degree in Geography at the University of the Western Cape. Renee has been actively involved in the field of Social Development for the past twenty-five years. She has presented a number of lectures on topics including healing and transformation, restorative justice, restitution, student-driven social impact, social identity and youth development in a South African context. Renee currently holds the position of Deputy- Director for the Division of Social Impact. A key priority of her work focuses on ensuring that young people are equipped and supported to make strategic choices and to choose a pathway that holds value in a rapidly changing world. Michelle Pietersen grew up under Apartheid South Africa, where her family also suffered racial discrimination. She currently plays a vital role at a historically white university, as the Senior Programme Manager at the Division of Social Impact and Transformation. Michelle is responsible for the portfolio: Engaged Citizenship at Stellenbosch University - in line with the Stellenbosch Universitys vision to reciprocity, redress, development, and transformation. With 16 years of experience as a community practitioner, she is responsible for leadership training for all Social Impact leaders within the university residence environment, encompassing two large campuses: the medical faculty and the main campus. She also oversees the compulsory Transformative Social Work online course, which introduces first-year Social Work students to develop responses to real-life challenges and encourages active citizenship. Dr. Priscalia Khosa is a Lecturer in the Department of Social Work at Stellenbosch University. ISSL 2024 84 Integrating service-learning with social justice: A critical opportunity for candidates in an educational leadership program. D. Coker-Kolo & L. Reed Integrating multiculturalism within service-learning allows students to deconstruct the issues of diversity, equity, inclusion, and social justice (DEIJ) within the realities of the larger communities of which they are a part. Social justice and multiculturalism are inextricably connected. Social justice entails an understanding of structural inequities and issues of oppression (which multiculturalism also addresses) and requires that individuals take action to eradicate them. Service-Learning is an intentional teaching strategy that allows learners to transfer theory into practice in an authentic environment while concurrently meeting genuine needs in their local community. Rather than operating from a charitable, doing for perspective in which institutions are in a position of privilege in relationship to their communities, service-learning emphasizes a doing with perspective, leading to collaboration and mutuality. The reciprocal nature of this instructional approach makes it a fitting tool to engage students in critical consciousness about social issues. Multiculturalism in servicelearning helps raise students awareness of various social justice issues and prompts them to act toward social change in their communities. The increasing changes in demographics in K-12 classroom compels educator preparation institutions to include multicultural education in their programs. Education programs must incorporate cultural responsiveness, inclusion, and equity in their curriculum, especially those preparing future school leaders. Additionally, they must look for ways to build community-academic partnerships that allow their students to apply theories to bring systemic change to their institutions and the community. Service-learning offers opportunities for educator preparation programs and the community to build mutually beneficial relationships while responding to injustice and oppression. This presentation focuses on sharing best practices on steps taken to re-develop the servicelearning project in a graduate course by providing students with opportunities to engage in authentic experiential education with the potential to empower the community and address social problems. Titled Education and Social Issues, the course equips students with the knowledge and skills to move beyond acts of charity to address the root causes of inequality. Students are engaged in direct experience with issues of social justice they are studying in the class (for example, food insecurity, homelessness, and gender identity disparities) and are provided opportunities to analyze and help solve problems in the community in collaboration with community partners. Using critical reflections, students describe their service-learning experiences, naming feelings, relating the experiences to social justice concepts, and applying learning to course content. This course is required in the educational leadership program to fulfill its accreditation standard on diversity, equity, inclusion, and social justice. It contains a key assessment in which candidates engage in a service-learning project from a social justice lens. The course redesign began with faculty professional development on service-learning pedagogy, understanding the framework for service-learning course development, and through guided learning by an expert, developed and taught the course. This proposal demonstrates the possibilities that service-learning pedagogy can offer through its integration into a graduate course with a social justice paradigm. The presentation will address the key components of service-learning and its potential as a vehicle to promote social justice and deeper learning for students while increasing productivity in the operations of community organizations. In addition to excerpts from students reflections on their service-learning projects, the presenters share findings from a partners impact survey. ISSL 2024 85 The learning outcomes for this session are: Understand the history of service-learning and the challenges and benefits of using service-learning in a graduate course from the institutional, faculty, community, and students perspectives. Discuss how service-learning pedagogy can be used as a high-impact learning approach in support of students in any course. Learn the framework for designing a social justice service-learning course. Learn how the framework was implemented in a graduate program/course. Apply the knowledge learned to your course using an assigned template. The presenters share their experience integrating service-learning pedagogy with social justice in a graduate program as a best practice. Their journey begins at the institutional level with participation in a campus-wide service-learning fellowship. Their experience showed that if applied with fidelity, this strategy can effectively promote meaningful learning around diversity, equity, inclusion, and social justice for students. Doyin Coker-Kolo is Professor and Coordinator of Educational Leadership program at Indiana University Southeast. She is a recent Carnegie African Diaspora Fellow. Her areas of research include Program and Unit accreditations, Administration and Organization of Middle Schools, Multicultural Education, Brain Drain and Higher Education in Sub-Saharan Africa. Her recent publications include Deanship: The Art of Service and Shared Leadership (2018) In Hicks & Watson (Ed.). and The Role of Accreditation in Fostering Diversity in Teacher Preparation Programs (2014) in Sleeter, Neal & Kumashiro (Ed). Dr. Lynn Reed is an Assistant Professor of Educational Leadership at Indiana University Southeast where she teaches online and face to face courses in the graduate program. She has over 39 years' experience as a building and district level administrator. ISSL 2024 86 Indirect Service-Learning: Aims, Advantages and Best Practices. L. Borrero At its core, the goal of service-learning is to add value via meaningful student learning, community enrichment, and addressing social issues. While a preponderance of the literature on service-learning focuses on adding value via direct service with community partners, another approach that receives less attention is that of indirect service-learning. The process of indirect service-learning incorporates projects that use less hands-on contact with the community partner and, instead, allows students to use resources to address an identified community problem, often through research, advocacy, policy work, and other indirect methods. While clearly distinct from direct service-learning methods, indirect approaches to service-learning can nevertheless provide students with practical experience in addressing community problems and foster critical engagement with social issues, civic responsibility, as well as decision-making and self-reflection skills. This session will identify the aims of indirect service-learning, common approaches used, best practices, as well as benefits and challenges. Practical examples of indirect service-learning used by the presenter with her students will be discussed, as well as ways in which to adapt these projects to meet the changing needs of students and communities. Finally, in keeping with the conference theme, the session will culminate in a generative interactive activity that will draw upon how indirect service-learning can be intentionally used to transform communities, institutions, and students, especially during times of community uncertainty. Learning outcomes for session participants include articulating the tenets and best practices for indirect service-learning; describing the unique benefits and challenges of indirect service-learning; discussing the ways in which indirect service-learning can be used as a transformative experience for communities, institutions, and students; listing ways in which indirect service-learning could be used in their own courses to meet the needs of their communities and to support student learning. Dr. Lisa Borrero is Associate Professor in Health and Aging Studies at the University of Indianapolis. She has taught for over ten years in the areas of gerontology and health sciences, more than half of which have been in an exclusively online environment. Her scholarly interests include the qualitative exploration of self-concept among older women, the intersection of intergenerational learning and ageist attitudes, online service-learning, and gerontology education. ISSL 2024 87 Connecting AI with Service-Learning. M. Sass There are numerous ways for students and faculty to leverage AI in integrating course content with community needs. Utilizing AI systems like Chat GPT, Google Bard or Firefly, can guide faculty and students in creating meaningful service-learning projects. This workshop will discuss the ways that AI will help transform students and, assist in creating engaged citizens. Faculty will learn the following: Generating diverse ideas for service-learning projects. Incorporating and executing service-learning experiences within their course curriculum. Identifying social issues within their immediate community that students can engage with service-learning projects Gaining insights on reflection and the relationship their course connects to the community. Receiving step-by-step guidance on using AI resources. This session aligns seamlessly with the mission of creating a reflective learning environment that centralizes student voices while challenging their perceptions of service, action, and advocacy. AI's capacity to aid in community-based projects contributes new ideas that students can possess as well as show them how they can contribute to the planning, execution, and dissemination of knowledge. Margaret Sass moved to Boise to complete her educational specialist degree and her doctorate in education, curriculum and instruction. Once Sass graduated, she began work at Purdue University as the Service-Learning Director and established an undergraduate journal that highlighted student's research and projects in service-learning. Currently, Sass is employed as a Lecturer at Boise State University and a Service-Learning faculty fellow where she is currently designing a service-learning online institute for faculty. She is focusing her research on artificial intelligence and service-learning. ISSL 2024 88 Changing Knowledge, Awareness, and Stigma Through the Service-Learning Activity of a Mental Health Awareness Walk. E. Orr On October 21, 2023, Brigham Young University - Hawaii held its Fifth Annual Mental Health Awareness Walk as a service-learning opportunity for students in the Psychology Department. The primary goals of the Walk are to improve student knowledge and awareness regarding mental illnesses, decrease the harmful stigma that surrounds mental health, and increase the accessibility of mental health services across campus. This is especially valuable at our campus where nearly half of the student body is international, many of whom are from Oceania and the Pacific Rim. With so many diverse perspectives on mental health, it is important that we engage students in working together to break down stigma. The walk is grounded in psychological principle, applying theories of social psychology such as Biglers Intergroup Identity Theory, Allports Contact Theory, and Banduras Modeling Theory to establish stronger connections between students and deepen the understanding of mental health at our institution. The BYUH Mental Health Awareness Walk focuses on education as well as awareness, creating the structure for a true service-learning activity. When participants arrive at the walk, they are divided into groups of 10-12. Each group is assigned two peer trail guides to lead them on the walk. The trail guides are trained to model appropriate self disclosure and encourage healthy conversation about mental illness. The groups walk across campus to various presentation booths, where student presenters from the Abnormal Psychology class discuss factual information about some of the most prevalent mental disorders on college campuses. This past year included booths on Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, and Major Depressive Disorder, among others. Each booth has brochures for participants to take home that include potential causes, common symptoms, and examples of coping strategies. The final stop for every group is the Counseling Services office, where students have the opportunity to learn about the mental healthcare resources available on campus. After the Walk, students are invited to play games, watch performances, and discuss their takeaways from the event. The Mental Health Awareness Walk is an application of practiced social psychological theory directed toward reducing mental health stigma at our institution. As a part of the walk, all participants are asked to wear a red shirt. Anyone that does not have a red shirt is given a red jersey to wear. This common perceptual indicator helps to build unity in accordance with Biglers intergroup identity theory. We are all members of the same team and we are all there to support one another. Allports contact theory was also taken into consideration. In his theory, Allport outlined five conditions for change through direct contact, one of these conditions is equal status. Equal status is achieved in the Mental Health Awareness Walk through the use of student presenters and trail guides. Students are learning, but not by sitting down in a classroom and receiving another lecture. They are engaging in open conversation with their peers - some of whom may be trusted friends or classmates. Through this conversation, they are learning factual information about heavily stigmatized mental illnesses. Throughout the Walk, trail guides are instructed to lead a group discussion on mental health. Trail guides are trained to model appropriate self disclosure. This can take many forms such as sharing personal experiences with mental illness or discussing the information that was learned at the booths. This is an application of Banduras Modeling theory, which states that observing behavior plays a role in learning. The trail guides provide an example of healthy discussion for the participants in their group, who will hopefully follow suit. To measure student transformation as a result of the Mental Health Awareness Walk, we relied on the Beliefs Toward Mental Illness Scale (BMI), developed by Hirai & Clum in 2000. We administered the BMI to students before and after the walk and compared the results to a control group of students that did not attend the walk. ISSL 2024 89 With the data, we conducted a repeated measures ANOVA that demonstrated that the BMI scores varied significantly from pre-test to post-test [F (1,171) = 68.335, p < .001, eta^2 = 0.041] and from walk group to control group [F (1,171) = 14.843, p < .001, eta^2 = 0.068]. We plan on continuing to collect data on future walks to see if the effect continues. The presentation of the Mental Health Awareness Walk lends itself best to the 60 minute workshop format. We will begin with a brief 15 minute presentation on the Mental Health Awareness Walk. This presentation will provide background, establish the structure of the walk, and discuss our research. We will then divide the audience into groups and a presenter will act as a trail guide for each group. In small groups, we will spend the next 20 minutes playing games designed to generate conversation about mental health. For example, one game that we play is called fruit basket where players stand in a circle with one person in the middle. That person will call out a characteristic and everyone that shares that characteristic will rush to find another spot in the circle. The person that is unable to get a spot is now in the middle. Simple questions might be I have a dog or my favorite color is red ''. This game can easily be adapted with questions that foster appropriate self disclosure such as I struggle with anxiety sometimes or I have been to counseling before. Groups will then have a brief discussion about the stigma that surrounds mental health and its impacts. We will then regroup and for the next 15 minutes we will train the audience to be trail guides and presenters themselves. Our presentation will include a discussion about stigma, the application of psychological theory, and instructions on how to model appropriate self disclosure. The remaining 10 minutes will be reserved for questions and discussion. With this training, it is our hope that the audience will be inspired to apply similar interventions at their own institutions, inspiring further change through service-learning. Eric Orr, PhD. is an Associate Professor at BYU-Hawaii and a Clinical Psychologist, CEO of Kooalu Counseling LLC. ISSL 2024 90 Beyond Words: Service-Learning and Hip-Hop as a Language of Social Change. T. Jones, P. Jones, M. Voice, & G. Gee This abstract explores the synergistic relationship between service-learning and hip-hop culture, framing hip-hop not merely as a genre of music but as a dynamic language for expressing and addressing social issues. This research recognizes the power of hip-hop's linguistic and cultural elements globally, delving into the genre and language as an expressive medium that can be integrated into service-learning initiatives to facilitate deeper community connections and amplify the voices of marginalized communities. This workshop will merge the SPICES curricula (an acronym that stands for student-centered, problembased learning; integrated teaching; community-based; electives and systematic) with the language of hip-hop that uses SPICE (Social, Political, Intellectual, Cultural, and Economic) framework to dissect the ills of the world. The audience will engage professors, artists, storytellers, and linguists as they discuss the unique communicative aspects of hip-hop, encompassing music, spoken word, graffiti, and dance as tools for storytelling, social commentary, and economic change in marginalized communities globally. This workshop will examine hip-hop's potential to serve as a bridge between diverse global communities, fostering understanding, empathy, and collaboration within the context of servicelearning projects by answering how the language of hip-hop has connected the world to impact change. Through case studies and practical examples, this research will illustrate how hip-hop's language can be leveraged to co-create and share narratives that resonate with the experiences of individuals within underserved communities globally. The work also addresses the transformative impact of this integration on students, emphasizing the development of cultural competence, critical thinking, and a sense of social responsibility. By framing hip-hop as a language of social change, this abstract contributes to a broader understanding of service-learning as a vehicle for promoting community service, cultural expression, and dialogue. The fusion of service-learning and hip-hop as a language presents a dynamic and inclusive approach to education, enabling students to engage authentically with social issues, express their perspectives, and contribute meaningfully to positive change within their communities. Tasha Jones is a rare and wonderful artist who strikes a balance in a world so often lopsided. Jones is a student of life and a teacher of lessons. On stage, she tells the story of her life and, in doing so, tells the story of all women. She offers a perspective, poignancy, and insight in her writing that allows men to see themselves through her work and women to see themselves in it As Senior Vice President of Leadership and Equity, Dr. Patrick Jones leads The Mind Trusts implementation of our racial equity priorities and commitments. He also serves on our leadership team. Before joining The Mind Trust in 2018, Dr. Jones served as Director of Secondary Schools for Tindley Accelerated Schools, where he coached principals and oversaw the development of instructional systems at the Indianapolis-based network of six charter schools. Mann Voice is a native of Indianapolis, Indiana, a multi-hyphenatepoet and writer, spoken word artist and filmmaker, actor, hip-hop emcee, educator, and community builder. The spirit of her work finds its niche at the intersection of arts and activism. She has performed on diverse stages across the country in the power of the word and has taught and facilitated writing and poetry workshops widely. Gary Gee, based in Indianapolis, IN, is a multi-faceted artist whose primary focus is on drawing, but his artistic expression extends to painting, ceramics, mixed media, murals, and installations. Influenced by early rap and hip-hop culture, German expressionism, and cultural references, Gee's work reflects a deep interest in urban architecture, art history, and travel. Inspired by the character J.J. Evans from the show Good Times, particularly the on-screen paintings created by artist Ernie Barnes, Gee draws from a wide range of influences, infusing his pieces with a signature style and sense of humor. His ongoing series of handcast ceramic heads and skulls showcase a fascination with materials, incorporating multiple layers of glazes, luster finishes, acrylic, and spray paint ornamentation. ISSL 2024 91 Enhancing the 21st Century Skills: An E-Service-Learning Toolkit of Creative Pedagogies. L. Kojich & J. Gahimer In the contemporary higher education landscape, engagement in service-learning activities has been identified as assisting students in the development of soft skills related to the 21st Century Skills framework. These skills, abilities and traits contribute to the formation of socially responsible global citizens. The purposes of this presentation are to: 1. Describe the digital shift which allowed for continued community engagement in the ways of: virtual volunteering, remote projects and innovative means of collaboration. 2. Share specific e-service-learning strategies related to the 21st Century Skills that have been implemented by ourselves and those found in the literature. 3. Give specific examples and the advantages and challenges of developing asynchronous and synchronous service-learning experiences. Due to the COVID 19 pandemic, educators have had to make pivotal transformations in designing service-learning opportunities for students by leveraging digital platforms. E-Service-learning is a dynamic approach to traditional service-learning approaches as it broadens horizons and showcases the power of technology in maintaining social responsibility even in challenging times. The model facilitates inclusivity and cultural exchange regardless of physical boundaries. The 21st Century Skills, commonly referred to as soft skills, are deemed critical for navigating the complexities of todays contemporary workplace. As students engage in service-learning, they form a sense of their role in addressing challenging societal issues, and honing their ethical and moral compass. The 21st Century Skills are divided into three main categories: learning skills, literacy skills and life skills. First, instructors can design e-service-learning experiences that foster learning skills: critical thinking, collaboration, communication and creativity. These experiences allow students to develop a deeper understanding of community needs and cultural awareness. Second, literacy skills of information, media and technology are critical as todays students are challenged by digital transformations, and emerging technologies such as AI and Machine Learning. Finally, life skills including flexibility, leadership, initiative, productivity and social skills are nurtured through engagement with diverse communities. Students learn to navigate societal challenges and resolve conflicts, crucial for their professional and personal growth. In conclusion, e-service-learning can serve as a transformative platform for achieving what was once considered strictly a face-to-face endeavor. Integration of digital platforms acts as a bridge to connect the classroom content to the broader global community, developing future leaders committed to positive social change. These diverse pedagogical approaches combined with eservice-learning, leverage digital tools and creative methodologies in order to empower students, foster a sense of social responsibility and create meaningful impacts on the community. Learning Dr. Kojich is a board-certified clinical specialist in orthopedic physical therapy and is an assistant director of clinical education and student success coordinator in the Krannert School of Physical Therapy. She has ten years of teaching experience at the undergraduate and graduate levels and coordinates the service-learning course in the DPT curriculum. Dr. Gahimer has received numerous awards for her role in community leadership and servicelearning, including the University of Indianapolis Teacher of the Year award in 2012. She has presented at many international, national and local professional meetings and has authored multiple publications in the areas of service-learning, patient education and community health education. ISSL 2024 92 Service-Learning for Communities through Transformative Leadership and Culturally Expansive Learning. M. Glowacki-Dudka & R. Lordeni This session will address the areas 1) Emerging global theoretical perspectives that link to the student transformation into critical and engaged citizens; 2) The transformation of education and resilience of service-learning approaches through global crises and events; 3) Challenges incorporating servicelearning into higher education post global crises and events both practical and theoretical approaches. Transformative leadership has been used to foster change for individuals and groups in social systems within the broader community, to cultivate a sound base of leaders for improving community health, vibrancy, and to embrace change and diversity. A few of transformative leadership tenets are (1) to create an environment that has clear values, priorities, and high standards of ethics and morals; (2) to emphasize authenticity; and (3) to encourage collaboration and cooperation. By adding transformative leadership approaches to service-learning and community-engaged learning, communities can work together with higher education and grow both the students and the community members through meaningful activities. Its crucial to consider how these three leadership tasks embrace the role of culture and history regarding cultivating and improving leadership. Community leaders and university partners must work together to understand and master the local knowledge that can inform advocacy, social action strategies, and tactics in the topics of group dynamics, effective meeting management, group problem-solving, planning, and facilitation skills. Engestrm (2016) has argued that learning is either a process that transmits and preserves culture or one that transforms and creates culture (p. 36). By integrating transformative leadership with culturally expansive learning, community programs can transform and create cultures specific to the communities being served. In this type of program, the university can be a true partner the serves the needs of the community. Expansive learning focuses on the primacy of the community as the learner as opposed to the traditional concept of the individual as the learner. The theory begins with the premise that learners learn what is important and timely to them, but not yet known. Through collaboration and cooperation, the needed leadership knowledge and skills emerge. Community leadership processes refine themselves in response to the changing nature of economy, social structures, advancing technology, and the implications from the influence of historically White institutions and policy. For this workshop, we share examples and scenarios of how transformative leadership can work in tandem with culturally based expansive learning theory to address concerns from a post-pandemic condition, rapidly advancing technology, widening disparities, a knowledge-based economy, and oppressive systems of power. By combining these two theories, we can embrace the local history and culture of the community and work with them to develop programs and strategies for improvement from an asset-based perspective. Transformative leadership places an emphasis on authenticity. This theory analyzes what is constructed as authentic in the terms of the vulnerable community members. Expansive learning supports that learning must move beyond hegemony and understandings that serve to maintain status quo in the vulnerable communities. Authenticity is understood in the terms of horizontal movement, hybridization, and exchange between the different cultural contexts. Leadership through preserving the vulnerable communitys culture and local history develop the knowledge that is not yet known. It is fostered by advocacy, social action strategies, and tactics in the topics of group dynamics to challenge, and transform, the hegemonical structure serving to maintain racial status quo. This model that combines expansive learning using transformative leadership theory is based on empirical research, current presentations in the culturally based conference on learning and community improvement, and programs based in UNESCOs (2015) learning cities initiative. ISSL 2024 93 It also supports UNESCOs (2015) 2030 Agenda for Sustainable Development. This model responds to the increased call and encouragement for grounding adult and community education programs for community engagement and capacity building where community leadership is a vital component. Specifically, we will use this workshop, as a simulation and envisioning space for these approaches to be explored using case scenarios. First, we will share the ideas of transformative leadership and culturally based expansive learning theory to define and transfer them to practice. Next in small groups, we will provide 3 case scenarios that could benefit from integrating these approaches. The participants from each group will work together to derive possibilities and potential futures impacts and outcomes from the actions and decisions they present. Then, we will come together and share reflections from this activity and develop applications for this approach in their service-learning programs in order to support student transformation into critical and engaged citizens who are attuned to the culture of the communities in which they work and learn. Dr. Michelle Glowacki-Dudka is a Professor of Adult, Higher, and Community Education and the director of the educational doctoral degree in adult and community education in the Department of Educational Studies at Ball State University. Her research and practice are community-focused with attention paid to womens leadership, learning communities, community development, social capital, power and program planning, social justice, inclusive pedagogy, sustainability, and transformative learning. Dr. Ramo Lord is an Assistant Teaching Professor and the Director of the master's degrees in Adult and Community Education and Executive Development for Public Service at Ball State University. He has a PhD in Adult Education from The Pennsylvania State University with a focus on instructional design, adult learner needs and characteristics, adult learning theories, community engagement & capacity building, qualitative research, critical thinking, and workplace learning accompanied by years of research experience working with diverse populations. He has worked on several communitybased projects in vulnerable and impoverished communities to improve adult and community literacy, health, and vibrancy. ISSL 2024 94 9th International Symposium on Service-Learning The Role of Global Service-Learning in Transformational Leadership: Fostering Social Action & Vigilance Published by the University of Indianapolis ISSL 2024 95 ...
- Creator:
- Foulkrod, Marianna
- Type:
- Conference Proceeding