... Entry-Level Occupational Therapy Student Perceptions of Occupational Balance in Graduate School: A 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: Stephanie Bachman, OTD, OTR/L, CLA Copyright April 27, 2022 By: Stephanie Bachman, OTD, OTR/L, CLA All rights reserved Approved by: Penelope Moyers, EdD, OT, FAOTA Committee Chair ______________________________ Lucinda Dale, EdD, OTR, CHT, FAOTA Committee Member ______________________________ Laura Santurri, PhD, MPH, CPH Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Entry-Level Occupational Therapy Student Perceptions of Occupational Balance in Graduate School: A Qualitative Study Stephanie A. Bachman Department of Interprofessional Health & Aging Studies, University of Indianapolis Author Note I have no known conflicts of interest to disclose. Correspondence concerning this article should be addressed to Stephanie Bachman, Master of Occupational Therapy Program, Walsh University, North Canton, OH 44720. E-mail: sbachman@walsh.edu 1 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 2 Abstract Objective: The objective of this study was to examine how entry-level graduate occupational therapy (OT) students incorporate strategies to manage occupational balance, or a persons combination of activities in self-care, work, and leisure. Methods: Grounded theory methodology was used to develop a theory of the occupational balance of entry-level graduate OT students. Twenty-six students were recruited using convenience and maximum variation sampling. Open-ended interviews were conducted through videoconferencing. Data analysis through constant comparison of transcripts, field notes, and memos consisted of open, axial, process, and selective coding. A storyline narrative with diagrams displayed relationships among concepts while providing evidence to support inductively derived theoretical propositional statements. Results: Students in OT programs progressed through a continuous cycle of three phases of occupational balance during graduate school: occupational balance, balance disruptions, and return to occupational balance. A disruption in occupational balance resulted in students implementing strategies to return to occupational balance. Strategies included developing an individualized plan for organization, sharing experiences with cohort peers, and scheduling time for self-care. Internal contexts, including personal values, and external contexts, including COVID-19, shaped students use of strategies to manage an occupational balance disruption. Conclusions: Entry-level students in OT described cyclical phases of occupational balance experienced throughout the graduate program. The specific contexts, such as COVID-19 externally and personal values internally, influenced the occupational balance cycle and the strategies for return to occupational balance. Keywords: occupational balance, graduate school, occupational therapy student STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 3 Acknowledgements As I move toward the end of my time in this doctoral program, I am overcome with emotion. Reflecting on the amount of personal and professional growth I experienced makes me so grateful for all of the people in my life who made this possible. I would like to take this opportunity to thank the individuals who supported me through this journey. First, I would like to thank my husband, Frank, and my two sons, Edward and Joey. Your love, encouragement, and confidence in me helped push me to keep working toward my goal. I do not believe I could have accomplished this without the three of you by my side. I appreciate all of the pep talks and hugs you gave me, but most of all, the added work you took on so I could write! I would like to thank my parents, who first believed in me and pushed me out of my comfort zone long ago. Their ability to see my potential is what helped me get to where I am today. Next, I would like to thank my colleagues at Walsh University. Your support, assistance, and expertise were invaluable to me throughout this process. Dr. Pamela Ritzline, I am forever grateful you gave up your personal time to proofread my paper. And to the students, who helped me understand the importance of my own life balance, thank you! Last, but certainly not least, I would like to thank my committee. Each of you played such an important role in making this possible. Dr. Laura Santurri, you helped me find a committee! Your consistent positivity helped me persist. You inspire me to be more like you - a better leader in my academic role. Dr. Lucinda Dale, your revisions, suggestions, grammar pointers, and willingness to meet with me any time I needed it were so helpful. I always felt better about my progress after seeing your smiling face! And, Dr. Penny Moyers, you pushed me STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE to achieve more than I thought possible. I appreciate the little nudges you gave me to get over myself and just do it! I gained so much knowledge from you and will be forever grateful you were my mentor. I learned so much about the research process and professional writing while working on this project, but I learned even more about myself and what I am capable of achieving. With deepest gratitude, Stephanie Bachman 4 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 5 Table of Contents Title Page.1 Abstract2 Acknowledgements..3 Chapter 1: Introduction7 Problem Statement...8 Purpose Statement9 Research Questions..9 Significance of the Study.9 Chapter 2: Literature Review.10 Professional Burnout Among Occupational Therapists.12 Theories of Balance...14 Occupational Balance in Graduate School16 Strategies for Obtaining Occupational Balance in Graduate School.18 Measuring Occupational Balance......21 Chapter 3: Methods25 Study Design. 25 Participants.26 Setting27 Procedures..27 Study Rigor37 Chapter 4: Results..38 Chapter 5: Discussion..113 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 6 Theory of Occupational Balance.132 Study Limitations136 Implications for Education and Research137 Conclusion...140 References141 Table 1: Characteristics of Students by OBQ scores...154 Table 2: Most Frequently Used Occupational Balance Strategies by OBQ Score..155 Table 3: Propositional Statements Developed During Data Analysis.156 Figure 1: Phase Diagram......159 Figure 2: Conditional/Consequential Matrix of Graduate Student Occupational Balance..160 Appendix A: Initial Interview Guide...161 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 7 Entry-Level Occupational Therapy Student Perceptions of Occupational Balance in Graduate School: A Qualitative Study The transition from undergraduate to graduate school presents new challenges for students pursuing careers in the health professions (Govender et al., 2015). These challenges require exploration and integration of coping strategies while developing profession-specific practice skills (Govender et al., 2015). Graduate students report high-stress levels resulting from balancing academic requirements with financial and personal obligations (Myers et al., 2012; Pfeifer et al., 2008; Rummell, 2015; Willyard, 2012). Researchers who investigate student stress often focus on medical students and those in allied health professions other than occupational therapy (OT) (Enns et al., 2018; Myers et al., 2012). The literature lacks studies regarding the stress that entry-level OT graduate students experienced compared to the stress of students in other health profession programs (Govender et al., 2015; Malek-Ismail & Krajnik, 2018; McCombie et al., 2016). Graduate students may experience a lack of occupational balance in daily activities due to high academic demands in entry-level professional programs (Porath & Rosenblum, 2019). Students often reported spending more time in educational activities than self-care, work, or leisure pursuits (Porath & Rosenblum, 2019). Pfeifer et al. (2008) discovered that entry-level OT graduate students struggled with balancing academics, family life, and employment. MalekIsmail and Krajnik (2018) found that when entry-level OT graduate students took time for leisure activities or socialization, they perceived feelings of guilt and reported fear of falling behind. Occupations are the daily life activities in which people engage (American Occupational Therapy Association [AOTA], 2014, p. S6). Students who experience stress due to lack of balance between academic responsibilities and personal life may be more prone to stress STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 8 once acculturated into the OT profession. According to Costa (2018), a strong factor predisposing occupational therapists to burnout is the feeling of work infringing on home life. Workplace employee health initiatives are more mainstream due to a surge in mental health disorders, preventable diseases, and symptoms of burnout, such as decreased quality of life and poor work performance (Mattke et al., 2013; Page et al., 2014). The movement toward a healthier workforce led to a plethora of studies on well-being that include conceptual understandings of the meaning of balance in a persons life. Wilcock et al. (1997) introduced the term occupational balance and described the association between occupational balance and health. Occupational balance is instrumental to mental and physical health and feelings of well-being and life satisfaction (Wagman et al., 2012a). In contrast, authors state occupational imbalance causes fatigue, feelings of stress, and negative thought patterns (Christiansen, 2007; Yazdani et al., 2018). Occupational therapists typically refer to occupational balance as a healthy mix of activities in the self-care, work, and leisure categories of occupation (AOTA, 2014). Problem Statement The perfectionistic traits common in entry-level OT graduate students (Wagner & Causey-Upton, 2017), combined with their reported difficulty achieving occupational balance, place students at risk for burnout before they enter the profession. Professional burnout can manifest in physical, emotional, and behavioral symptoms (Costa, 2018). Occupational therapists who enter the profession demonstrating behaviors consistent with burnout are at a higher risk for mental and physical health problems (Costa, 2018; Poulsen et al., 2014). Burnout may manifest early in a therapists career if the person is not equipped with self-care practices to help cope with the high demands of a career focused on helping others (Maslach & Leiter, 2008). Faculty STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 9 should consider incorporating occupational balance in entry-level graduate programs and should demonstrate behaviors consistent with occupational balance to equip students for managing stress in the workplace and for avoiding burnout once assimilated into the profession. Purpose Statement The purpose of this study was to examine how entry-level graduate students in OT incorporate strategies to manage occupational balance in their role as students. The researcher inductively developed a theoretical explanation of the strategies students incorporated to achieve occupational balance and how these approaches evolved when students experienced a life role change while in the entry-level graduate program. The researcher also studied strategies students used to manage the student role during different semesters of the OT program. Research Questions The researcher sought to address the following research question and sub-questions: How do entry-level students in OT incorporate strategies to manage occupational balance in their role as a student in the graduate program? o What are the differences in the occupational balance strategies of OT students who report high, medium, and low occupational balance? o What happens to the way entry-level OT graduate students manage occupational balance when they experience a change in the expectations of their student role or other life roles? o For entry-level graduate students in different semesters of the OT program, how do the strategies for managing the student role change? Significance of the Study The findings from this research, along with the theory presented, may improve STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 10 understanding for both faculty and students of the challenges to occupational balance that entrylevel OT graduate students experience. These challenges the OT students experience during the entry-level graduate program may lead to disruptions in occupational balance and future problems of career burnout unless the student successfully negotiates these challenges. Additionally, an explanation regarding the achievement of occupational balance may assist faculty with designing curricula, providing guidance, and developing social supports that encourage the use of occupational balance strategies as students transition to and complete an entry-level graduate program in OT. Quality of life may improve as a result of remaining in occupational balance throughout the time in the entry-level OT graduate program, which could lead to richer educational experiences for students. Most importantly, graduates from entry-level OT programs may be better equipped with the knowledge and skills to recognize and avoid burnout as practicing occupational therapists. Literature Review Erlandsson and Christiansen (2015) defined balance as making adjustments or changes in an attempt to find equilibrium within a system (p. 118). Incorporating balance into life to achieve a sense of satisfaction is a concept foundational to the profession of OT. This researcher reviewed literature about balance and occupational balance theories for this section. The researcher suggested burnout among occupational therapists is a possible result of disruption in occupational balance. Finally, a summary is provided of the literature about occupational balance and strategies to improve this balance for entry-level OT graduate students. Researchers identified common conceptual components of occupational balance (Backman, 2004; Wagman et al., 2012a; Wilcock et al., 1997). Occupational balance is the contentment a person possesses concerning time spent in self-care, work, and leisure occupations STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 11 (AOTA, 2014; Backman, 2004; Wagman et al., 2012a; Wilcock et al., 1997). Yazdani et al. (2018) noted that occupations should have meaning to the person and be directly related to a persons necessary and preferred occupational roles. Yazdani et al. (2018) conducted a qualitative study of nine occupational therapists concluding that three components of doing should be considered when evaluating life balance: the person performing the occupation, the occupation itself, and the context in which the person is completing the occupation (p. 295). The value a person assigns to an occupation may differ from that of another person performing the same occupation (Backman, 2004). This individualized perception of occupations adds to the complexity of the concept of occupational balance and exemplifies the need to investigate each persons balance across all their occupations occurring in multiple contexts (AOTA, 2014; Backman, 2004; Yazdani et al., 2018). Meyer (1922) discussed the importance of balancing work and play in determining a persons self-worth. Wilcock et al. (1997) investigated the connection between health and living a balanced life. The researchers introduced the term occupational balance and defined it as a balance of occupations in the physical, mental, social, and rest categories of occupation (Wilcock et al., 1997). Wilcock et al. (1997) also determined that optimal occupational balance differs among people. Christiansen (2007) postulated that occupations need to provide a sense of purpose in life for a person to thrive and show resilience. A person achieves this sense of purpose through participation in a variety of self-selected occupations that are intrinsically meaningful to them (Westhorp, 2003). Each day, the chosen occupations may fluctuate depending on environmental demands, skill development, and motivation (Westhorp, 2003, p. 103). Occupational balance positively impacts overall physical health and feelings of wellbeing (Eriksson et al., 2011; Pettican & Prior, 2011; Wagman et al., 2012b). Pentland and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 12 McColl (2009) found balance to occur when a person participates in occupations that are meaningful and congruent with personal values, as well as meets the contextual demands on the person. A person must engage in occupations that help fulfill all life roles to report a sense of balance (Pentland & McColl, 2009). A mismatch between a persons desired and actual occupations increases the potential for physical and mental health problems to arise (Matuska & Barrett, 2019). These mismatches can occur due to unexpected changes or disruptions to a persons occupational pattern (Erlandsson & Hkansson, 2009). For example, increased demands at work may require a person to spend more time on work tasks and less on family obligations (Erlandsson & Hkansson, 2009). Problems in occupational balance results in reports of exhaustion, increased stress levels, and negative thought patterns (Christiansen, 2007; Yazdani et al., 2018), which may lead to feelings of burnout, especially in helping professionals, such as occupational therapists (Costa, 2018; Janus et al., 2018; Poulsen et al., 2014). Professional Burnout Among Occupational Therapists Reports of workplace burnout are prevalent, which led to the inclusion of the term occupational burnout in the newest revision of the International Classification of Diseases (ICD11) (World Health Organization, 2019). In a Swedish study of health professionals, including occupational therapists, Wagman et al. (2017) found 98.7% of participants reported they were highly satisfied with the meaningfulness of their daily work serving others. In contrast, participants were dissatisfied with the amount of time available to dedicate to rest and recovery (Wagman et al., 2017, pg. 21). A career helping others regain independence can be intrinsically rewarding; however, if a person does not receive adequate respite, continually giving of the self may lead to stress and professional burnout (Janus et al., 2018; Poulsen et al., 2014). Occupational therapists spend most of their time assisting clients with various limitations to daily STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 13 functioning, leaving very little time for self-preservation (Janus et al., 2018). Poulsen et al. (2014) found strong correlations of burnout with occupational therapists' perceptions regarding a high workload, an inability to detach from work when at home, and longevity in the profession between six and ten years. Similarly, Wressle and Samuelsson (2014) reported work-related stress among occupational therapists primarily from high workloads and less time allotted for personalized client care and attention. Warning signs of stress and burnout included fatigue, irritability, callousness, and diminished work attendance or performance (Costa, 2018). The results of these studies may lead to the conclusion that entry-level graduate students who experience challenges to occupational balance while enrolled in an OT program most likely will experience increased levels of stress and may begin to show signs of burnout before entering their professional careers. In 2008, the Institute for Healthcare Improvement introduced the Triple Aim of Healthcare to promote high-quality healthcare standards in the US (Berwick et al., 2008). The authors of the Triple Aim focused on the improvement necessary to advance the healthcare experience, address the overall health of populations, and reduce the cost of healthcare (Berwick et al., 2008). Bodenheimer and Sinsky (2014) and Sikka et al. (2015) proposed the addition of a fourth aim that involved improving the lives of the healthcare provider. A move to a more business-centered healthcare model may have contributed to increasing burnout among healthcare workers because organizational leaders focus on productivity and efficiency rather than the needs and wants of the client (Sikka et al., 2015). Advocates of the fourth aim highlight that healthcare workers who display behaviors consistent with work satisfaction demonstrate characteristics of teamwork, job engagement, and an improved ability to achieve the Triple Aim (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). Graduates from entry- STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 14 level OT programs who possess self-care practices to identify characteristics of burnout and who can integrate adaptive coping strategies may risk less burnout when encountering the daily challenges of employment as occupational therapists (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). Theories of Balance An emerging trend in organizations across the US is a focus on employee wellness (Mattke et al., 2013; Page et al., 2014). The emphasis on employee well-being results from escalating mental health conditions and preventable diseases, such as diabetes and heart disease (Mattke et al., 2013; Page et al., 2014). Administrators are integrating wellness programs into employee benefit packages in the attempt to offset the costs of preventable health conditions, improve the quality of life of employees, limit absenteeism, and thus, increase productivity (Benavides & David, 2010). The Centers for Disease Control and Prevention (CDC) (2019) provides resources to help companies establish programs to improve employee quality of life and make positive improvements to modifiable health risks. This nationwide movement towards a healthier workforce prompted researchers to investigate the meaning and importance of balance in a persons life. Researchers interchangeably use the terms life balance, work-life balance, and occupational balance. Definitions of the terms work-life balance, life balance, and occupational balance are similar in the literature. Rummell (2015) and Sirgy and Lee (2018) described work-life balance as an equilibrium among the time allocated for work or school-related and professional activities and the time dedicated to all other life roles. The increased stress that results from a disproportionate amount of time spent in work, school, and professional activities leads to decreased overall life satisfaction, unethical decision making, increased symptoms of job STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 15 burnout, and reduced attention to personal health (Rummell, 2015; Sirgy & Lee, 2018). Rummell (2015) found that the stress level related to problems in work-life or school-life balance was more pronounced in students enrolled in graduate psychology programs during their first or second year in a program. The author stated that students might not have adequate time to learn appropriate coping mechanisms and described the need for further research in this area (Rummell, 2015). Researchers, including in the literature specific to OT, used the terms occupational balance and life balance interchangeably. For this reason, identifying specific theories of occupational balance proved difficult. Many researchers (Enns et al., 2018; Malek-Ismail & Krajnik, 2018; Myers et al., 2012; Rummell, 2015; Willyard, 2012) characterized life balance as similar to occupational balance. Veenhoven (2009) defined life balance as a combination of lifestyle choices that produce the most happiness over time (p. 35). Matuska (2010) stated if a person meets their basic needs, regardless of the specific occupation, the person will feel they achieved life balance and contentment with life (Matuska, 2010). Matuska and Christiansen (2008) defined a balanced lifestyle similarly but added that the occupation must be sustainable within the context of his or her current life circumstances (p. 11). Westhorp (2003) described balance as engagement in a variety of chosen occupations that are meaningful to the person and promote health and well-being (p.103). The balance of occupations is unique to each person but should include mental, physical, social, emotional, and spiritual occupations (Westhorp, 2003, p. 104). Anaby et al. (2010b) explained that occupational balance includes all areas of life personal, work, and leisure. The authors investigated how people find balance among different activities in life, such as learning, playing, socializing, etc. (p. 82). They also indicated balance is subjective and based upon a STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 16 persons satisfaction with the chosen occupations (Anaby et al., 2010b). Wilcock and Hocking (2015) theorized that occupational balance encompasses lifebalance and work-life balance. The authors stated that occupational balance is a complex concept that can refer to individual people and populations (Wilcock & Hocking, 2015). Additionally, Wilcock and Hocking (2015) postulated that occupational balance fluctuates and depends on the circumstances and the environments where engagement in occupation occurs. Balance occurs when basic human needs are met and supported through a total configuration of occupation over time (Wilcock & Hocking, 2015, p. 309). Occupational Balance in Entry-Level Graduate School Researchers (Enns et al., 2018; Malek-Ismail & Krajnik, 2018; Myers et al., 2012; Rummell, 2015; Willyard, 2012) described the transitions of students enrolled in healthcare programs from undergraduate to entry-level graduate programs, including information about the level of stress students reported during their tenure in an entry-level professional graduate program. Entry-level graduate programs typically are year-round and require completion of up to 15 credit hours a semester in addition to mandatory fieldwork or clinical experiences (How Much Time Per Week, 2017). Multiple studies included reports from students about heightened stress levels while earning a graduate degree as the result of spending more than 50 hours per week in academic-related activities combined with ongoing personal and financial obligations (Myers et al., 2012; Pfeifer et al., 2008; Rummell, 2015; Sirgy & Lee, 2018; Willyard, 2012). In addition to the financial and time constraints that accompany enrollment in a graduate program, students who enter a graduate program directly after earning a bachelors degree often have to delay personal interests, such as getting married and having children, to focus efforts on academic pursuits (Benshoff et al., 2015; Di Pierro, 2010). Students who return to graduate STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 17 school after a hiatus or in preparation for a second career may be encumbered with caring for a child or an aging parent or supporting a family while financing their education (Di Pierro, 2010). Although researchers have investigated stress and coping in graduate students, most studies are from the social sciences, not OT (Enns et al., 2018; Myers et al., 2012). One exception is MalekIsmail and Krajnik (2018), who investigated balance among students enrolled in entry-level OT graduate programs during the first semester. Although a definition of balance did not emerge from this study, Malek-Ismail and Krajnik (2018) found students perceived challenges to occupational balance at the beginning of the first semester of graduate school, with the perception of balance fluctuating throughout the first semester. The continuous rebalancing (p.8) described in the research findings was dependent on social support, course workload, expectations of faculty, and each students level of self-determination (p. 13) (Malek-Ismail & Krajnik, 2018). High academic demands combined with a lack of time to adequately complete all requirements may decrease occupational balance among students in entry-level healthcare programs (Watkins et al., 2011). El-Ghoroury et al. (2012) surveyed students in graduate psychology programs to identify barriers to wellness. The researchers reported that 59% of the students identified poor work-school life balance and indicated this lack of balance disrupted their ability to function (El-Ghoroury et al., 2012). Rummell (2015) stated that students enrolled in graduate psychology programs reported dissatisfaction with the lack of importance placed on self-care in their educational programs and suggested an increased emphasis on self-care should occur throughout graduate school. Admittance into entry-level OT graduate programs is competitive, with less than 20% of applicants accepted in 2017 (Accreditation Council for Occupational Therapy Education STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 18 [ACOTE], 2018). Wagner and Causey-Upton (2017) reported that students accepted into these programs demonstrated high achieving behaviors and perfectionistic traits. These researchers found that students who identified as perfectionists reported a lack of exercise and limited time for eating and socializing due to the way they budgeted out-of-class time for academic coursework (Wagner & Causey-Upton, 2017). Students in entry-level OT graduate programs reported increased stress related to managing coursework, social relationships, and financial obligations (Govender et al., 2015; Pfeifer et al., 2008). Malek-Ismail and Krajnik (2018) conducted a qualitative study with 33 students in the first semester of an entry-level OT graduate program. The authors (Malek-Ismail & Krajnik, 2018) indicated that students described a cycle of adjustment (p. 7) when transitioning to graduate school. They (Malek-Ismail & Krajnik, 2018) further identified the overarching theme of turbulence and rebalancing (p. 7) as indicative of the first semester of the entry-level OT graduate program. Strategies for Obtaining Occupational Balance in Entry-Level Graduate School Researchers investigated the lack of life balance with students from medicine, athletic training, and nursing (Aufricht et al. 2019; Barrett et al., 2016; Cino, 2016; Schmidt & Hansson, 2018) but did not identify strategies to manage a disruption to occupational balance. Results of studies from the profession of OT included strategies students employ to manage stress, but researchers did not discern the effect of these strategies on the achievement of occupational balance (Govender et al., 2015; McCombie et al., 2016). Cino (2016) advocated the importance of teaching self-reflection as a component in the nursing curriculum to help students find balance in life. The author discussed the importance of self-awareness in leading a healthy life (Cino, 2016). By increasing self-awareness, students improved their ability to identify stressors and use personal coping strategies, thus improving STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 19 mental health to a level associated with a more balanced life. Specific suggestions for improving student mental health included scheduling mind-body activities and quality time with spouses and children. Cino (2016) also identified the importance of prioritizing healthy habits, such as sleep, proper nutrition, and exercise, to improve overall life balance (Cino, 2016). In the form of an accountability partner, peer support assisted participants with adhering to their established self-care plan and improving perceived life balance (Cino, 2016). Schmidt and Hansson (2018) completed a systematic review of the literature, combining the results of studies investigating the well-being of doctoral students. The researchers found that students reported the necessity of using coping strategies to manage stress to achieve physical and mental health (Schmidt & Hansson, 2018). Schmidt and Hanssons (2018) review addressed recommendations to improve well-being in doctoral students that included the use of social support networks, planned academic and personal activities to ensure adequate time, and engagement in an exercise program. Aufricht et al. (2019) provided suggestions for medical students to improve satisfaction with work-life balance and to avoid burnout while in graduate school. The authors proposed improving student-to-student and faculty-to-student communication and developing a support group or mentoring program for students (Aufrict et al., 2019). Another recommendation was for working professionals to meet with students and discuss the identification of early warning signs of burnout (Aufrict et al., 2019). Barrett et al. (2016) used qualitative methodology to investigate the perceptions of students in athletic training programs regarding their preceptors ability to maintain a work-life balance. Students observed that preceptors implemented strategies to improve work-life balance, which included setting priorities, asking for assistance from co-workers to manage work STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 20 demands, and sharing familial responsibilities with a supportive partner (Barrett et al., 2016). Students reported feelings of hope (p. 116) when faculty and preceptors modeled these behaviors that demonstrated the possibility for achieving work-life balance as a working professional (Barrett et al., 2016). Another outcome Barrett et al. (2016) reported was the importance of faculty mentoring students to improve their awareness of workplace expectations (p. 116) and to suggest methods to integrate work-life balance principles into life as a student. Tompkins et al. (2016) found students who perceived faculty support were more likely to report satisfaction with their graduate program and life in general while in graduate school. Students who believed they had support from faculty advisors and had a clear understanding of expectations reported fewer symptoms of burnout and increased satisfaction during their tenure in a graduate program (Clark et al., 2009; Myers et al., 2012; Rummell, 2015). Haertl (2008) described the learning process as a partnership between the educator and the student, enhanced by effective communication that included building trust and incorporating student-centered adaptations to meet course learning objectives. In a study of 2,279 graduate students, Evans et al. (2018) identified a strong negative relationship between faculty supportive mentoring and the rate of depression and anxiety among students. Rummell (2015) surveyed students in graduate psychology programs and discovered 44% reported faculty placed too little emphasis on self-care, with 18% of the participants suggesting their program needed to foster a deeper connection between faculty and students. Instructors in academic programs primarily focus on teaching discipline-specific knowledge students will need once they embark on their professional careers (Di Pierro, 2010). Graduate classrooms include a mix of students who enter directly after earning an undergraduate STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 21 degree and students returning to graduate school after a hiatus (Di Pierro, 2010). Often, the returning students manage issues, such as financial obligations, but also may be engaged in the role of parent to a child or caregiver to an aging adult (Di Pierro, 2010). These contextual circumstances outside of the academic realm may prove too much for students to manage on their own (Di Pierro, 2010); thus, assistance from a faculty mentor may be necessary to ensure student success. A dearth of literature exists specific to perceptions of interactions between OT faculty and students enrolled in entry-level OT graduate programs. Malek-Ismail and Krajnik (2018) found that students perceived that instructors in entry-level OT graduate programs taught content too quickly and deliberately planned for multiple assignments to be due concurrently. These factors led students to question the concepts of occupational balance and health that academic programs integrate throughout the coursework for becoming an occupational therapist. In addition, the students perceived the faculty did not practice the concepts they were teaching (Malek-Ismail & Krajnik, 2018). Measuring Occupational Balance A search of the literature produced three methods of measuring occupational balance (Anaby et al., 2010a; Dur et al., 2014; Wagman & Hkansson, 2014b). Anaby et al. (2010a) proposed definitions of occupational balance and imbalance as the patterns among a persons daily occupations. Balance is a state of harmony or congruence across a persons occupations, and imbalance is perceived disharmony, lack of fit, or interference among occupations (Anaby et al., 2010a, p. 281). The authors (Anaby et al., 2010a) used the Cross Impact Matrix (CIM) (Little, 1984) and the Intergoal Relations Questionnaire (IRQ) (Riediger & Freund, 2004) to measure the contextual factors impacting balance and the resultant satisfaction with a persons STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 22 life. The authors also used two subjective measures of well-being (Anaby et al., 2010a), The Satisfaction with Life Scale (Diener et al., 1985) and The Positive and Negative Affect Scales (Watson et al., 1988). They reported inconclusive findings with no correlations between the CIM (Little, 1984) and reported well-being (Anaby et al., 2010a). Anaby et al. (2010a) found the IRQ (Riediger & Freund, 2004) to be useful in identifying conflicting occupations. The authors defined conflicting occupations as those that take resources (e.g., time, money, and energy) away from pursuing another desired occupation (Anaby et al., 2010a). The authors recommended further research about the topic of conflicting occupations as their sample size was small (Anaby et al., 2010a). Dur et al. (2014) defined occupational balance as an academically defined construct lacking a relationship to the experiences of real people (p. 2). The authors (Dur et al., 2014) further explained that definitions occupational therapists developed are from researchers perspectives rather than from those who receive OT services. Dur et al. (2014) did not propose a definition of occupational balance but developed a tool, called The Occupational BalanceQuestionnaire (OB-Quest), through a qualitative study of healthy people and people diagnosed with an autoimmune disease. Based on the qualitative data obtained and a quantitative examination of the scale's internal consistency, Dur et al. (2014) developed the final 10-item questionnaire. The final version of the OB-Quest addressed seven components of occupational balance, four of which were not measured by other instruments (Dur et al., 2014). The four components unique to the OB-Quest were: challenging and relaxing activities, involvement in stressful activities and fewer stressing activities, the impact of health conditions on activities, and adaptation of activities to changed living conditions (Dur et al., 2014, p. 6). Initially, Dur et al. (2014) discovered low internal consistency of the OB-Quest. The STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 23 researchers separated several of the original components of the OB-Quest, which improved internal consistency (Dur et al., 2014). For example, the item challenging and relaxing activities was eliminated and replaced with too much demand and too little demand (Dur et al., 2014, p. 5). Adaptation of activities to changed living conditions was replaced with two items (Dur et al., 2014, p. 5) to differentiate balance differences when a person experienced a change in a state of health compared to a change in professional life or employment status (Dur et al., 2014, p. 6). Lastly, the researchers divided the rest and sleep component into two separate items (Dur et al., 2014, p. 5). After dividing these components of the OB-Quest, they (Dur et al., 2014) reported that the improved internal consistency challenged the unidimensional concept of occupational balance (p. 6) and concluded occupational balance is multidimensional (Dur et al., 2014, p. 6). Dur et al. (2014) also emphasized that researchers have not investigated occupational balance sufficiently and suggested further research to determine whether occupational balance is a continuum or whether balanced and unbalanced are separate constructs (Dur et al., 2014). Wagman and Hkansson (2014b) defined occupational balance as a four-part concept focusing on the variation in the occupational pattern, the amount of each occupation as well as the total number of occupations in relation to the available resources, and the meaningfulness in the occupations (p. 228). The authors (Wagman & Hkansson, 2014b) originally developed the Occupational Balance Questionnaire (OBQ) as a 13-item outcome measure. Information from focus groups provided data for the conceptual development of the instrument. The groups included women diagnosed with stress-related disorders and working men and women categorized as healthy (Wagman & Hkansson, 2014b). The researchers combined the results of the focus group data with information from a concept analysis of occupational balance to STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 24 develop the final 13-item questionnaire (Wagman & Hkansson, 2014b). Yu et al. (2018) used the OBQ, the 36-item Short Form Survey, version 2 (SF-36v2) (Ware, 2000), and a 10-item version of the Perceived Stress Scale (PSS-10) (Ezzati et al., 2014) to investigate relationships among occupational balance, stress, and well-being. The researchers reported a positive relationship between occupational balance and robust mental health and wellbeing. A significant negative correlation (r = -.72, p = .0001) was found between OBQ and PSS10 scores, but OBQ scores were significantly and positively correlated (r = .65, p = .001) with SF-36v2 Mental Component Scores (Yu et al., 2018, p. 122). Researchers developed measures of occupational balance (Anaby et al., 2010a; Dur et al., 2014; Wagman & Hkansson, 2014b) even though occupational balance is a complex construct that depends on the situational context (Anaby et al., 2010a; Dur et al., 2014; Wagman & Hkansson, 2014b). Although many authors explored occupational balance (Backman, 2004; Wagman et al., 2012a; Wilcock et al., 1997; Yazdani et al., 2018), definitions of occupational balance are varied and seem similar to other terms, such as life-balance. The original OBQ demonstrated favorable psychometric properties, but the authors recommended further studies to examine construct validity (Wagman & Hkansson, 2014b, p. 230). Hkansson et al. (2020) published the results of construct validity testing of the original OBQ. Participants in the study were general residents of Sweden. Testing occurred in two groups. The first group responded to the original 13-item OBQ. Results suggested participants could not adequately differentiate among the six response categories (Hkansson et al., 2020, p. 444). Based upon these results, the researchers decreased the number of response categories from six to four. The second sample responded to the questionnaire using the revised version of the OBQ. The results demonstrated good reliability of the new response categories with a Person STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 25 separation index of 0.92 (Hkansson et al., 2020). Two of the thirteen items revealed a problem with the ability to discriminate responses, and therefore the researchers removed these items. The present study included the resulting 11-item OBQ (OBQ11) with four responses categories. The present researcher's study addressed several gaps identified in the literature. The first is that most of the authors in the literature used the terms life-balance and occupational balance synonymously, and many researchers from the OT literature used the term life-balance (Matuska & Christiansen, 2009). Another gap noted is that researchers have not applied theories of occupational balance to entry-level OT graduate students. The researcher conducted the present study to explore entry-level OT graduate students occupational balance and examine how entrylevel OT students' experiences in a graduate program promoted or inhibited occupational balance. A theory of occupational balance was inductively derived to explain how some students find occupational balance, even under challenging circumstances, but others experience difficulty achieving occupational balance when encountering similar challenges. Lastly, this study addressed a gap in knowledge of effective strategies students in entry-level OT graduate programs use to achieve occupational balance. Understanding this information can help OT educators guide their entry-level students in developing practices that will foster occupational balance while in the graduate student role. Identifying effective methods to achieve occupational balance may equip OT students with the ability to continue using the strategies as entry-level practitioners and decrease the chance of burnout as an occupational therapist. Methods Study Design The researcher used a grounded theory approach to design this study and address the lack of evidence regarding how entry-level OT students define and achieve occupational balance STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 26 amid challenges encountered in graduate school. According to Corbin and Strauss (2015), researchers use data from grounded theory research to develop theoretical explanations of concepts that provide alternative perspectives. Information obtained through a grounded theory study can describe experiences that can help people develop a deeper understanding of a situation and effective methods to respond to it (Corbin & Strauss, 2015). Grounded theory is a methodology that researchers employ to examine a problem from a new viewpoint and to understand how different people approach a similar circumstance in different ways (Corbin & Strauss, 2015). The researcher of the present study did not find a theory in the literature to explain how some students in entry-level OT graduate programs find occupational balance but others experience difficulty, even when encountering similar circumstances. Given the utility of the grounded theory approach in providing a theoretical explanation of everyday phenomena (Corbin & Strauss, 2015), it was an appropriate methodology for studying occupational balance in entrylevel OT graduate students. Before initiating the study procedures, the researcher obtained Institutional Review Board (IRB) approval from the University of Indianapolis and Walsh University. Participants The researcher sampled participants in two phases. The researcher recruited participants through purposeful sampling to obtain a preliminary sample of entry-level OT graduate students (Creswell & Poth, 2018). The initial sample was a sample of convenience and included students in their second year of the full-time master of occupational therapy (MOT) program at the researchers institution. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 27 The researcher sought a more heterogeneous sample using maximum variation sampling once the researcher analyzed the data and developed initial categories of data (Creswell & Poth, 2018). Maximum variation sampling consisted of entry-level OT graduate students from other universities in any year of study in their program. The researcher recruited students from entrylevel master and entry-level doctoral OT programs for the second sampling. The researcher secured additional participants until no new concepts resulted from data analysis, and no established categories could be further developed (Corbin & Strauss, 2015). Inclusion and Exclusion Criteria The researcher included only participants currently enrolled in entry-level OT graduate programs in this study. The researcher excluded participants who were enrolled part-time in an entry-level OT graduate program or who did not speak English. Setting The researcher recruited a purposeful sample from a small Catholic university in the Midwest. The institution offers nine graduate programs, including a MOT program. Each cohort in the MOT program ranged between 32 and 36 students. Students enrolled in the MOT program on a full-time basis represented all regions of the US; however, a majority were local to the area. Maximum variation sampling included entry-level OT graduate students from other universities in the Midwest at various points in their academic journey. Procedures Recruitment The researcher included students in the second year of their program in the initial purposeful sample because the researcher no longer evaluated students in courses. Due to the researchers current role as the program director, the researcher planned to refer any student STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 28 issues of the research participants that arose to the school's dean for action; however, no issues developed during the study timeframe. The researcher utilized SurveyMonkey during the recruitment phase. SurveyMonkey is programmed to use multifactor authentication to access data, including complex password protection procedures (2020). SurveyMonkey staff include trained data security personnel who oversee network and system data (SurveyMonkey, 2020). They conduct regular internal and external penetration tests and, based on results, make security modifications as indicated (SurveyMonkey, 2020). SurveyMonkey (2020) is programmed to encrypt all data, including backups, to maintain confidentiality. The researcher initially recruited participants for this study via an email sent to students in the second year of the MOT program. SurveyMonkey was programmed to enable participants to proceed to the OBQ11 (P. Wagman, personal communication, May 11, 2020) (See instrument section for details). The researcher also included a link at the end of the survey to a Google calendar appointment page (Google, 2020) so the participants could schedule a virtual meeting for the first interview. Before each scheduled interview, the researcher sent a reminder through the Google calendar site of the interview date and time to the participants (Google, 2020). Instrument The OBQ11 (P. Wagman, personal communication, May 11, 2020) is an 11 item selfreport questionnaire with a four-step ordinal scale, ranging from strongly disagree to strongly agree. Wagman and Hkansson (2014b) indicated the questionnaire may be analyzed on an item level or as a summed score with a higher rating indicating higher occupational balance (p. 228). The original researchers assigned a zero to the lowest response category and a three to the highest response category. Therefore, the highest score possible using this instrument was 33. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 29 Wagman and Hkansson (2014b) determined content validity for the original OBQ using a content validity index, finding the instrument had a score of 0.90, indicating good content validity (p. 228). Internal consistency was tested with a sample of 67 participants (Wagman & Hkansson, 2014b), with Cronbachs alpha 0.936, indicating good internal consistency (Wagman & Hkansson, 2014b). The authors did not detect a floor or ceiling effect; however, construct validity needed further analysis (Wagman & Hkansson, 2014b). After conducting a study (n = 168) to assess internal construct validity, Hkansson et al. (2020) revised the original OBQ, removing two items and decreasing response categories from a six to a four-point Likert scale. The revised tool, the OBQ11, did not demonstrate any floor effects and had a small ceiling effect of 3% (n = 6) (Hkansson et al., 2020, p. 445). In addition, Hkansson et al. (2020) demonstrated the OBQ11 measures occupational balance less precisely at the extreme levels of occupational balance (p. 446). The authors also concluded that the OBQ11 might indicate a lower level of occupational balance than what exists for a person (Hkansson et al., 2020, p. 447). The researcher used the resulting OBQ11 (P. Wagman, personal communication, May 11, 2020) in the present study. Occupational balance was defined as high, medium, or low using the OBQ11 with 11 items and four response categories (Hkansson et al., 2020). The researcher assigned numbers to each response category using the same method as the developers of the OBQ (Hkansson et al., 2020). For this study, the researcher defined high occupational balance as a score greater than or equal to 24, medium occupational balance as a score greater than or equal to 18 but less than 24, and low occupational balance as a score less than 18. The researcher developed these groups of occupational balance scores using IBM SPSS (Version 26) software to select the best way to group the data into categories most congruent with their qualitative STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 30 responses during the data collection process. The developers of the OBQ11 have not published the questionnaire for use; therefore, the researcher contacted the developers for a copy of the questionnaire and to obtain written permission to use the questionnaire in this study (P. Wagman, personal communication, May 11, 2020). Data Collection The researcher collected data through one-on-one Zoom (https://zoom.us/) video interviews with each participant in a quiet environment conducive to audio recording to comply with COVID-19 pandemic guidance. The researcher incorporated a guide to facilitate the initial participant interview (Creswell & Poth, 2018); however, the initial interview was unstructured, using open-ended questions to provide participants an opportunity to speak openly about their experiences. The researcher developed the questions, and experts from the University of Indianapolis Doctor of Health Science program reviewed them and recommended revisions. The researcher revised the questions as suggested. See Appendix A for the interview guide. The researcher recorded video interviews through Zoom computer software that encrypts recordings with password protection (Zoom Security Guide, 2019). The researcher also audio recorded the video interviews using a password-protected cellular phone. The researcher documented field notes during all interviews. The interviews lasted an average of 49 minutes. Interviews continued until conceptual saturation was achieved (Corbin & Strauss, 2015). The researcher interviewed each participant at least one time. Through theoretical sampling, the researcher identified participants for additional interviews. Subsequent interviews were conducted with four participants to reach saturation and allow member checking to ensure trustworthiness (Krefting, 1991). The researcher did not utilize STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 31 an interview guide for subsequent interviews; however, focused open-ended questions required to obtain theoretical saturation were derived from ongoing analysis of the data (Corbin & Strauss, 2015). In addition to open-ended questions, the researcher used contrast questions (Spradley, 2016) for the successive interviews. Specific contrast questions consisted of rating questions, which compelled participants to rate, in order of effectiveness, methods of achieving occupational balance; dyadic contrast questions which asked participants to identify differences between two existing codes; and contrast set sorting questions, which encouraged participants to share how they perceived specific categories and codes to be similar or different (Spradley, 2016). The researcher documented in a reflective journal throughout data collection and data analysis (Corbin & Strauss, 2015; Creswell & Poth, 2018). The journal included personal thoughts about students ability to achieve occupational balance to guide further interview questions in subsequent interviews. The reflective journal also served as an audit trail to document the process of decision-making throughout data analysis (Creswell & Poth, 2018). Additionally, new thoughts or ideas that arose during the process were recorded in the journal to assist in the data analysis. Data Management and Analysis Information the researcher received from SurveyMonkey in URL format was maintained in a folder on the researchers computer separate from any other data to ensure confidentiality. The researcher used password protection on the computer. The researcher deleted all URLs from the computer upon completion of the study. The researcher deleted audio recordings on the cellular phone per IRB protocols. The researcher uploaded audio recordings from Zoom to the researchers password-protected STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 32 computer following each interview. The researcher used multiple features of Zoom to ensure information security, including encryption requiring a session key so only the researcher could access the audio files (Zoom Security Guide, 2019). The researcher transcribed all interviews from the Zoom audio files within one week of conducting the interviews to create a verbatim transcription and assigned each participant a code to de-identify the transcript (Creswell & Poth, 2018). The researcher reviewed each transcript within a week and sent a copy through e-mail for each respective participant to review for accuracy. The researcher asked participants to respond via e-mail to confirm the accuracy or to suggest revisions. After verifying the accuracy of each transcript, the researcher reviewed each again to gain an overall perception of the content before completing any coding processes (Creswell & Poth, 2018). Once the researcher completed this process, the researcher completed open coding of all transcripts using constant comparative analysis to compare the codes across transcripts (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher then organized common codes together to shape the initial categories of data (Corbin & Strauss, 2015; Draucker et al., 2007; Volstedt & Rezat, 2019). After the researcher established preliminary categories, the researcher used theoretical data sampling to identify students for subsequent interviews (Corbin & Strauss, 2015). The researcher identified five students from the convenience sample for a second interview. Four responded and engaged in open card sorting using the program Proven By Users (provenbyusers.com) to determine whether the researchers preliminary interpretation of the data aligned with the students interpretation (Spradley, 2016). The researcher entered the preliminary codes into the Proven By Users program and asked students to group the codes into categories. After completing the card sorting, the researcher contacted the participant and conducted a STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 33 second video interview. Subsequent interviews provided additional information about repeated patterns in the data and categories that appeared crucial to the developing theory (Draucker et al., 2007). After maximum variation sampling, the researcher e-mailed five participants requesting a second interview; however, no one responded to the request. The researcher, however, established credibility through other methods involving maximum variation sampling, triangulation of data sources, and member checking of initial transcript accuracy (Creswell & Poth, 2018; Corbin & Strauss, 2015; Krefting, 1991; Letts et al., 2007). The researcher also used a reflective journal to document thinking throughout the study as well as explained outliers in the data to ensure consideration of participant views (Krefting, 1991; Letts et al., 2007). The researcher used the axial coding paradigm of Corbin and Strauss (2015) to relate causal conditions, context, intervening conditions, action/interaction strategies, and consequences of the phenomenon of occupational balance (Volstedt & Rezat, 2019, p. 88). The axial coding phase involved constant comparative analysis to compare codes among transcripts and to reveal similarities and differences (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher grouped similar codes under a common word or phrase or category and added subsequent evidence to support the groupings the researcher discovered (Corbin & Strauss, 2015). By relating the data to the paradigm constructs, a deeper understanding of occupational balance occurred, and the researcher discovered new associations essential for theory development (Volstedt & Rezat, 2019). The researcher incorporated total summed ratings from the OBQ11 (P. Wagman, personal communication, May 11, 2020) into categories of high, medium, and low occupational balance to compare and contrast the strategies the participants utilized to maintain or return to occupational balance. A storyline developed based on the evolving categories using definitional STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 34 and hypothetical statements (Birks et al., 2009). Definitional statements explained the categories of data, and hypothetical or propositional statements explained relationships among categories (Birks et al., 2009, p. 407). The researcher continued to return to the storyline to ensure evidence from the data supported propositional statements and concepts within the storyline to further develop the theory. The storyline was adjusted accordingly when data were not supportive (Birks et al., 2009). The categories originally developed in open coding and analyzed through axial coding were revised during the selective coding process to shape the evolving theory. The researcher noted outliers in the data that the emerging theory had not addressed (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher expanded and further explained categories during selective coding to integrate the outliers into the emerging theory (Volstedt & Rezat, 2019), thereby improving the validity or the accuracy of the theory. To determine whether the categories that developed during axial coding fit with all of the other categories, the researcher asked questions, such as what is the research all about? and what seems to be going on here? (Volstedt & Rezat, 2019, p. 89). The researcher discovered situational actions or interactional strategies through the process coding (Corbin & Strauss, 2015, p. 283) that emerged as possible steps or phases the entry-level OT graduate students employed to achieve occupational balance. Based on the evolving theory and additional questions that repeatedly surfaced during data analysis, the researcher conducted additional interviews with the participants until conceptual saturation occurred (Corbin & Strauss, 2015). Corbin and Strauss (2015) defined conceptual saturation as the point where the researcher believes there is adequate data to describe each category fully, accurately represent the storyline, account for outliers, and identify gaps in the data (pp. 407- STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 35 410). Member checking occurred in the axial and selective coding phases. The researcher asked participants to review the evolving theory looking for gaps and any misinterpretations (Creswell & Poth, 2018). The researcher shared the participants interview transcripts, the results of the coding process, and the storyline to obtain feedback about the evolving theory (Volstedt & Rezat, 2019). For example, the researcher integrated contrast questions and card sorting (Spradley, 2016) to determine whether the participant's interpretation of the codes was congruent with the researchers interpretation. The request for member checking returned a 73% (19/26) response rate for initial interview transcript checking and a 40% (4/10) response rate for coding and storyline checking. The researcher sent three e-mails to participants who did not respond, requesting participation with member checking. The lack of response presents a threat to credibility; however, the researcher established credibility through other methods discussed in the study rigor section. The researcher set up an online card sort for member checking, using the Proven By Users site, and sent a link to each participant with a unique URL to complete the activity (Proven By Users, 2020). The researcher completed the card sort analysis immediately in the software using the groups view in the program that sorted the codes into the categories the students developed (Proven By Users, 2020). The researcher compared her preliminary categories to the student-generated categories and used the similarities and differences to develop contrast questions for the second interview. The researcher then scheduled a second interview with participants to ask contrast questions and record any additional information the participants wished to add after reading the data or engaging in card sorting. Once the researcher completed the second interviews, the researcher re-coded the data using open coding and constant STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 36 comparative analysis to compare the codes across interviews and with those previously established (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher then organized common codes together to create new categories of data and compared the new codes to the previously established codes (Corbin & Strauss, 2015; Draucker et al., 2007; Volstedt & Rezat, 2019). The researcher organized codes identified and supporting participant quotes in a codebook for open coding, diagrams to display the relationship of codes to categories, axial coding tables, memos, storyline memos, and process visuals resulting from all interviews (Buckley & Waring, 2013; Creswell & Poth, 2018). The researcher used memoing to develop concepts from the raw data and attempted to link the concepts through statements of possible theory (Corbin & Strauss, 2015). In addition, the researcher used an audit trail to document the researchers thought processes regarding the development of codes and theory construction (Creswell & Poth, 2018). Lastly, the researcher developed multiple visual representations of the evolving categories and theory to explain the relationship of the codes to each other (Corbin & Strauss, 2015). The researcher communicated with a data analysis expert from the University of Indianapolis, who has extensive qualitative research and data analysis background throughout the data collection and analysis process. The researcher and data analysis expert scheduled virtual meetings as needed to review the data collection and the open, axial, and selective coding processes during data collection. At the point of analysis where the researcher believed adequate codes and categories existed to finalize a theory, the researcher collaborated with the data analysis expert to determine the thoroughness of the analysis and identify any gaps or problems with integration (Corbin & Strauss, 2015). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 37 Once the data analysis expert was satisfied with the internal consistency and logic of the completed processes, the researcher used the guidelines of Corbin and Strauss (2015) to begin theory finalization. First, the researcher analyzed the theory for any discrepancy in the logic or problems with how the concepts fit together (Corbin & Strauss, 2015). The researcher examined the data categories to ensure they were thoroughly defined and consisted of variability to ensure saturation (Corbin & Strauss, 2015). Next, the researcher reviewed portions of the theory deemed to be lacking solid support and integrated additional data supporting the categories to strengthen the theory (Corbin & Strauss, 2015). Finally, the researcher disclosed factors that may limit the theory's applicability and disclosed areas for future study (Corbin & Strauss, 2015). Study Rigor The researcher established credibility through maximum variation sampling, continually recruiting new subjects to interview and attempting to re-interview subjects as needed to allow for data saturation (Corbin & Strauss, 2015; Krefting, 1991). The researcher triangulated data sources by recruiting participants from different universities at different points in the entry-level OT graduate education process (Krefting, 1991). The researcher incorporated member checking to ensure the accuracy of the information and increase the study's credibility (Creswell & Poth, 2018; Krefting, 1991; Letts et al., 2007). The researcher engaged in reflexivity using a journal to document the thinking throughout the study (Krefting, 1991; Letts et al., 2007). Lastly, the researcher explained any outliers in the data through refinement of the developed theory, thereby ensuring incorporation of all participants views (Krefting, 1991). To address transferability, the researcher described the sample while protecting confidentiality and provided information about the context of the study in detail (Krefting, 1991; Letts et al., 2007). Member checking strategies also determined whether the data were STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 38 representative of all members of the sample (Krefting, 1991). The researcher implemented an audit trail to increase the dependability of the study (Creswell & Poth, 2018; Krefting, 1991; Letts et al., 2007). The researcher utilized Kreftings (1991) re-coding procedure of waiting for some time before returning to the data and then re-coding, adding information from the participant card sorting interviews that verified codes and categories. This coding-recoding process helped ensure the codes were representative of the data and the participants experience, thus increasing dependability (Krefting, 1991). The researcher addressed confirmability using reflective journaling to identify and fully account for researcher bias (Letts et al., 2007). Triangulation of data across participants and interviews confirmed the conclusions (Krefting, 1991). A data analysis expert from the University of Indianapolis audited the coding and theory development process to ensure the researcher used proper procedures and clearly defined steps (Krefting, 1991; Letts et al., 2007). Results The sample size of 26 students resulted from convenience and maximum variation sampling. Sample characteristics are described in aggregate to maintain participant confidentiality. Twenty-four females and two males comprised the sample. The convenience sample consisted of thirteen students in their fourth semester of the program and the last didactic semester before level II fieldwork. Participants in the convenience sample were students from a post-baccalaureate entry-level MOT program. The maximum variation sample consisted of 13 students, 10 in an entry-level master program and three in an entry-level doctoral program. Five students were in the first year of entry-level graduate school, and one student was in the middle of the program. Five students STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 39 were in the last semester of didactic classwork before level II fieldwork, and two were in the final year of doctoral work. Overview of Findings The following results address the main research question and three sub-questions. For the main research question, How do entry-level students in OT incorporate strategies to manage occupational balance in their role as a student in the graduate program?, the results from the data analysis demonstrated that students progressed through three phases of occupational balance. The three phases are depicted in Figure 1 and include: occupational balance, balance disruptions, and return to occupational balance. Once a student experienced a disruption to occupational balance, the student needed to identify the disruption. Some students self-identified disruptions, but others received input that helped them recognize changes in their occupational balance. Students then had to desire a return to balance to be motivated to implement a strategy to achieve balance. Examples of strategies students integrated to achieve occupational balance included developing an individualized plan for organizing school work, sharing experiences with cohort peers, and scheduling time for self-care. The first sub-question, What are the differences in the occupational balance strategies of entry-level OT graduate students who report high, medium, and low occupational balance?, resulted in the data analysis revealing that most students reported feeling they were occupationally balanced even though their scores spanned across all occupational balance levels. See Table 1. As shown in Table 2, students in the high occupational balance category used more strategies for returning to occupational balance following a disruption than students in the medium and low categories. All students reported using trial and error to determine which strategy to use in novel situations, such as beginning a new course, experiencing a different style STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 40 of instruction, or taking a class online for the first time. Over time in the entry-level OT graduate program, all students indicated they learned to use information from past disruptions to help return to occupational balance following a similar disruption. For the second sub-question, What happens to the way entry-level OT graduate students manage occupational balance when they experience a change in the expectations of their student role or other life roles?, data analysis indicated that at different points throughout the entry-level OT graduate program, students encountered people, policies, changes in roles and expectations, or events that led to a disruption in occupational balance. Figure 2 displays the various internal and external contexts that influenced student occupational balance. These contexts interact in dynamic ways (Corbin & Strauss, 2015). The arrows on the diagram indicate this dynamic interaction. Each contextual layer influences the other layers in an ever-changing sequence of actions and interactions. As described in Figure 2, values and previous life experiences influenced how the students viewed a situation and formulated a reaction. Internal to their academic program, faculty and program peer interactions influenced whether an entry-level OT graduate student remained in a state of occupational balance when faced with challenges or whether a student experienced a disruption to occupational balance. Program policies, such as professional and academic standards, and university structure, such as semester length, also contributed to a students occupational balance. The availability of external support systems, such as family members and peers external to graduate school, also influenced students reaction to stressors and their ability to return to occupational balance after a disruption. Lastly, external circumstances, such as the COVID-19 pandemic, led to disruptions in occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 41 For the third sub-question, For entry-level graduate students in different semesters of the OT program, how do the strategies for managing the student role change?, data analysis demonstrated that occupational balance of students in entry-level OT graduate programs occurred under various conditions as noted in Figure 2. Students developed and integrated distinctive strategies for managing occupational balance disruptions during different periods of the entry-level OT graduate program. During the initial transition to graduate school, students experimented with more strategies to mitigate the disruption to occupational balance than they did in subsequent semesters. The first semester in an entry-level graduate program was overwhelming to most students. Not only were students beginning a new program, but they also had few, if any, friends and did not have any experience with the rigor of entry-level OT graduate school. Students in entry-level OT graduate programs developed knowledge of specific strategies to use when they experienced a disruption to occupational balance in subsequent semesters. By incorporating previous successful strategies, students could move back into occupational balance quicker than they did in the first semester. See Figure 1. An exception was the changes experienced from the COVID-19 pandemic, which created a disruption to occupational balance that students did not recover from quickly. Students equated the changes to the student role experienced during the COVID-19 pandemic, such as courses moving to an online format, to changes the students experienced during the initial transition to entry-level OT graduate school. The disruption that ensued required students to reexamine their strategies to return to occupational balance and, in some instances, to develop new strategies for this novel situation. Most of the OT students reported feeling they were occupationally balanced by the time they completed the entry-level graduate program. They learned how to integrate strategies, such STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 42 as sharing experiences with cohort peers, developing methods of organizing school work, and making time for self-care. Rather than wait for a disruption to occur, as they did at the beginning of the entry-level OT graduate program, students were proactive in employing strategies to continuously improve occupational balance and, therefore, experienced fewer occupational balance disruptions. How Do Entry-Level Students in OT Incorporate Strategies to Manage Occupational Balance in Their Role as a Student in the Graduate Program? To address the main research question, entry-level OT graduate students first discussed the meaning of occupational balance and the importance of identifying an occupational balance disruption in their lives. Students also discussed various strategies to assist in returning to occupational balance following a disruption. The Meaning of Occupational Balance is Expressed Through Personal Values and Past Life Experience Students in the entry-level OT programs first discussed the meaning of occupational balance in their lives as graduate students. All students appeared to have their own understanding of the term. Life experiences and personal values informed each students description of the meaning of occupational balance in life. Student Life Experiences Provide Them a Perspective of Occupational Balance. Students' life experiences in entry-level OT graduate programs influenced the meaning of occupational balance. Students whose caregivers provided schedules for them when they were younger understood time management and recognized the importance of optimizing time in entry-level OT graduate school. One student helped with the familys business and the care of a grandfather. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 43 I think in terms of time management because at home growing up the way our household is, I wake up and my grandfather has like a strict schedule that he has to follow that we would have to follow for him in terms of like food and stuff. Its our business too, we had like a motel. So I feel like in terms of, like, time management, it comes from a lot of that like growing up like them. (Interview 15, p. 12) Another entry-level OT graduate student expressed being more prepared for the workload required in a graduate program compared to some peers. The student enrolled in heavy course loads during the last two years of undergraduate education to graduate a year early. This experience helped with preparation to manage the intense academic requirements. I think that for the most part I did make that transition easier than most of my peers [because] I have taken over 20 credit hours for the last two years of undergrad. I knew I wanted to come to grad school, so I was going to do five years instead of six. So I've kind of been prepping in the workload sense. (Interview 13, p. 13) Other entry-level OT graduate students played competitive sports in the past. When dividing time between academics and sports, an imposed structure and an efficient use of limited time were necessary. Students reported they capitalized on the organizational and time management skills learned in the past when they transitioned to entry-level OT graduate school. One student explained, From my undergrad experience being a bio major, and I played volleyball, so my time management skills are like impeccable. I like to pride myself on that because Ive learned how, like okay, I have 15 minutes, lets finish this assignment and submit it. I dont use my 15 minutes to just like sit on my phone or something. (Interview 9, p. 3) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 44 Another entry-level OT graduate student, a past student-athlete, easily integrated the coursework into a daily routine. In addition, the student was accustomed to a full schedule with the ability to use free time better to complete academic work when busy playing sports, working at a job, or engaging in other activities. The student described using time efficiently as follows, I think from having an experience as being a student-athlete in college like where I felt like my whole day was just like jam-packed, and I didnt have a lot of free time to be like, hmm like should I do this right now? I was more productive with my time when it was more structured. Where like if I have more free time I think Ill be able to focus so much more energy on school, but I think when I have a job or something else going on, that forces me to use that open time to catch up on assignments and stuff. (Interview 21, p. 4) One entry-level OT graduate student reported a structured life throughout growing up due to engagement in athletics. However, once entering graduate school, a sport no longer distracted from academics; the student consequently studied more during free time. Although the student indicated a reluctance to obtain a job, the added structure improved the students study habits providing a finite time to complete homework. All my life has been so structured. Like my entire life, I played multiple sports. as well as school. This summer was the first time I didnt have like soccer to like be doing. I was just doing school. and I was like, yeah, I need something else to like keep me busy doing something. And while I kind of ... still wish I wasnt doing it [working a paid job] as much as I was doing it this summer, it was definitely out of necessity to like have something else to do. (Interview 10, p. 12) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 45 Another entry-level OT graduate student reported taking a year off to work in a job related to OT. The experience made the student more prepared for the expectations of graduate school. Most kids went to undergrad at my school so they're a little younger than me and they're fresh out of undergrad where Im a little older. I took a year off and like worked as a caregiver. Now I feel like I have a bit better understanding of how like a grad program would work as opposed to undergrad (Interview 14, p. 9). Student Personal Values Assist Students in Maintaining Occupational Balance. Students in entry-level OT graduate programs also described how personal values contributed to the meaning of occupational balance. For example, one student reported that family instilled the value of making time for self-care; therefore, self-care was essential for occupational balance. In my early years of undergrad, I did a poor job of that self-care and it affected me in a lot of ways. But, as I like experienced stuff and talked to people it just matured me. I developed a different way of thinking. I've come from a home that was like, you know, it doesn't matter how much money you have, or it doesn't matter you know how many friends, you think you have. If you don't take care of like yourself first and you know the inside. If you don't develop that, you're going to always be lacking. (Interview 1, p. 10) Multiple entry-level OT graduate students mentioned the value of time as contributing to the meaning of occupational balance. Some students explained occupational balance as an equilibrium of time divided among academics, self-care activities, and friends and family. One student reported satisfaction with occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 46 I would say its [life] balanced cuz I feel like I have time to go to the gym and then like go kind of do things that I want to do to with doing school and stuff too. (Interview 15, p. 13) Another entry-level OT graduate student explained how they spent free time positively influenced the perception of occupational balance. The student discussed the importance of time to engage in desired activities beyond academics. The freedom to spend free time in nonacademic activities, such as reading or listening to music, was crucial to the student. [Balance is] just like doing something that I want to do to truly have time where its like I can do whatever I want for the next, like 10 hours on a Saturday, or something like that. I really, really feel better like, if I can read a book for 30 minutes before I go to bed, or even just any time in the day. self-care, going for those walks, listening to music, calling friends and family. (Interview 24, p. 14) Another entry-level OT graduate student reported an internal push to earn high grades throughout earlier school years, creating a challenge for coping if receiving a lower grade in graduate school. This diminished threshold for accepting an undesirable grade caused disruptions to occupational balance while in the entry-level OT graduate program. It was just me like pushing myself, and like I freaked out. I did average. And I was like, I just, I don't do average. I don't like average" (Interview 10, p. 7). A firm understanding of values helped one entry-level OT graduate student make the difficult decision to postpone graduation to focus on personal health while planning for the birth of a first child. Im like adding expecting a child and that whole role demand and transition and everything. Ive actually decided to postpone my graduation because I wasnt STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 47 managing my time very well, and finding self-care time didnt exist. And having to make a really hard decision to say, I have to take time off, I have to say no to this thing [entry-level graduate school] that Ive been working towards, in order to take care of myself. (Interview 22, p. 7) Postponing Occupational Balance for a Temporary Disruption is Acceptable. Some entry-level OT graduate students agreed that a disruption in occupational balance was a certainty in graduate school, but the disruption was acceptable because it was temporary. One entry-level OT graduate student expressed thoughts about the short-term high demands of academic work as worthwhile to achieve the goal of becoming an occupational therapist. The student adjusted the weekly work schedule to meet coursework demands. Aside from like relationships and family, school is probably the most important thing to me right now. Just because I know its temporary, and I mean, its shaping the rest of my life right now. So if I have a huge assignment and I can only work two hours a day [at paid employment] this week I will work more next week or something. So I make everything else flexible. (Interview 13, p. 15) Similarly, another entry-level OT graduate student discussed the necessity to devote as much time as possible to studying in graduate school, explaining time for leisure would come after graduation. If the opportunity is there, why wouldnt I take it to better my grades, because theres always going to be time to read for leisure later, but I am in school now for a year and a half (Interview 26, p. 8). One entry-level OT graduate student expressed thoughts about the future as an occupational therapist helped motivation. Envisioning the future, working one job, and having free time to enjoy chosen activities made the amount of time spent studying worthwhile. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 48 I know 100% that I work too much. And thats academic work and work work. But again, its a short term, temporary sacrifice for eventually, Ill have a big girl job, and I wont have to work a part-time job, and I will come home, and Ill be able to just like join a formal running club or go to like a class that I really enjoy. But for the moment, its very much like a short-term sacrifice for long-term gain for me. (Interview 26, p. 14) Occupational Balance Disruptions Can be Identified Entry-level OT graduate students reported the importance of understanding when they were experiencing a disruption to occupational balance so they could act to regain a sense of balance. Most students were able to identify aspects of their behavior that indicated a disruption. Other students reported peers or family members helped them identify when they needed to integrate a strategy to regain occupational balance. Students Self-Identify Disruptions to Occupational Balance. All entry-level OT students acknowledged a disruption to occupational balance during their graduate education. Some recognized the disruption while it occurred; others identified the disruption when they reflected on an event or a specific time period. One entry-level OT graduate student realized a lack of occupational balance occurred after the first two semesters. The student reported the decision to study during free time, including weekends, resulted in reduced socialization with friends. The student explained the strategy to complete academic work increased stress. I definitely prioritized school first and second semester more than anything, and I felt I didn't have time for social life. I wasn't seeing my friends. The first semester, I'd go home Friday, but I'd be doing homework all day Friday. Saturday Id spend studyingI wasn't hanging out with my friends; that just stressed me out. (Interview 5, p. 6) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 49 One entry-level OT graduate student reported engaging in academic tasks nonstop during the first semester. The student indicated completion of schoolwork rather than management of selfcare needs resulted in a decline in health. In the first semester, I would do basically school all the time. I gained quite a bit of weight because I didn't really take a lot of time for myself, or I would just get something that was really easy to eat so that I could only do school. (Interview 13, p. 15) One entry-level OT graduate student described an inability to concentrate during class, which the student thought was normal, and initially attempted to manage alone. However, after confiding in a physician, the student initiated a plan to remedy the problem. I'd sit in class, and all I could focus on was like the homework that I needed to do, or the work that I needed to do for work [paid employment]. And I'd sit there and spiral and completely zone out of class and it was something that like I silently dealt with and thought it was normal and I went to my doctor finally, and she was like yeah that's not normal. (Interview 3, p. 15) Similarly, another entry-level OT graduate student reported an inability to focus indicated an occupational balance disruption. For example, after studying, the student discovered the lack of recall of the content reviewed. The student recognized that time engaging in an activity outside of academics improved attention with schoolwork. Past a certain time of like me like staring at my notes I'm just like, I'm not retaining anything. So I'd be like nothing's getting done so I might as well do something I like until I'm in a better state of mind. (Interview 2, p. 8) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 50 One entry-level OT graduate student described experiencing moments of anxiety and self-doubt, which contributed to the realization of the need to take breaks from studying to engage in something outside of academics. "I think I just kind of came to it [knowing I need to take breaks] because I just like, like, well, I mean, had a couple of like freak out moments like where I was just like panicking. I was like, I can't do this" (Interview 8, p. 7). Another entry-level OT student also reported a mental and physical response to stress during graduate school. The student reported heightened anxiety with the increased workload that resulted in an inability to sleep. The student explained, I get very overwhelmed when I know I have like a lot I need to do. And if I can't get it all done I get very anxious and then it's like, all I can think about. And then I can't shut off and then it's hard to sleep. Usually I don't sleep that well if I have like a huge test or something I don't sleep well at night. (Interview 5, p. 11) Other entry-level OT graduate students reported disengagement from social situations signaled an interruption in their occupational balance. For example, one student typically accepted social invitations from peers. When the student declined an invitation, the student reflected and assessed the situation. Out of character behavior indicated the need to change the situation. I also noticed it in like the social aspects of like if somebody invites me to something, and I pass it up, and Im continuously passing it up or saying no Im too busy. I sit back [because] Im not that type of person who would say that kind of thing. (Interview 22, p. 14) One entry-level OT graduate student attempted to participate in social events during the first semester of the graduate program but focused on the homework waiting rather than enjoying STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 51 the situation. I wasn't really enjoying myself [first semester] because I was thinking about things that were going to be due and stuff" (Interview 4, p. 9). Similarly, another entry-level OT graduate student reported a desire to engage in self-care activities but instead spent the time thinking about academics. I wanted to take time for myself. But when I would take time, all I could do was think about school. Like I should be doing this, I have an assignment, like I could never actually relax and turn my mind off" (Interview 7, p. 4). One entry-level OT graduate student described feeling guilty with less than perfect performance on an assignment or exam during the first semester. The student perceived a lack of trying to succeed when not engaging in academics constantly. I felt guilty if I wasn't working on homework the first semester because I realized like sometimes if I didn't get you know, that 100% on a test, like I could have put more time in or studied more, or worked on an assignment. I felt like I wasn't doing my best if I wasn't working nonstop. (Interview 13, p. 4) Another entry-level OT graduate student reported taking time to watch a movie with roommates or to go for a walk during the week. Spending time in these self-care activities provoked feelings of guilt at times, but the student recognized this time as necessary for self-care and productivity and did not compromise the self-care time. During the week I sometimes feel guilty about like hanging out with my roommates when maybe I could be doing something more like productive. What is productive? Because people would say watching a movie and taking care of yourself is productive. I definitely have felt like guilty but in the end Im always happy that I chose to like take care of myself. (Interview 20, p. 12) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 52 Fluctuations in occupational balance throughout the graduate program helped one entrylevel OT student learn to recognize a disruption to occupational balance. In addition, the preferred feelings elicited when in occupational balance motivated the student to take steps to remain in a state of occupational balance. I know what balance feels like, and I value that, and I think going through those seasons of balance versus no balance, when I get to the places where Im not, I have a lot more insight or self-awareness, to be like, something's not right, I need to make changes. Knowing what balance feels like makes me want to be more balanced. (Interview 22, p. 14) Other entry-level graduate students reported the OT program helped them recognize challenges to occupational balance in their lives and to develop a plan to remedy these challenges. For example, one student valued and desired exercise but did not take the time to follow through with regular exercising. Completing a life balance inventory as a course requirement provided insight to restart an exercise program. We did a life balance inventory, and that made me realize some things that I wasn't making time for working out. That was something I had completely abandoned the first semester, and I really wanted to make the time for that because if I didn't I would just spend all of my time reading, and I don't think I would have ever stopped for a break. So I started to do that [work out]. (Interview 11, p. 7) Another entry-level OT graduate student was in the same program and completed the same occupational balance assignment. The results helped the student make changes that improved occupational balance throughout the remainder of the time in the entry-level OT graduate program. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 53 Id say it's much more balanced now (fourth semester) than at the very beginning of the program. Um, some of that I think is having to do with actually like taking a life balance inventory, and seeing what is balanced and unbalanced and where I need to improve. (Interview 4, p. 11) Other People in a Students Life Can Identify Disruptions to Occupational Balance. Some entry-level OT graduate students indicated they did not realize a disruption to occupational balance due to schoolwork until other people suggested the possibility. For example, a video chat with a father who was inquiring about the weeks activities led one student to reflect on present study habits. The student indicated studying as the only activity of the week. And my dad was like, you do realize that not every single person in this program is sitting home studying like every second? Like, you need to do something other than studying. You're going to be miserable (Interview 6, p. 11). As the student began talking to peers, the student discovered other students were not spending as much time on academics. Instead, they were engaging in activities outside of studying. When I talked to other people they weren't like, oh, I just studied like all weekend, I didn't do anything. And then I started to think about, like, what did I used to do like in undergrad? I used to go to the gym. I used to go with my friends on the weekends. I used to go to the football games [and] basketball games. And now I'm basically just studying all the time. (Interview 6, p. 11) Simultaneously, the entry-level OT graduate student analyzed the impact on mental and physical well-being from the extended periods spent studying and concluded changes were necessary. When I got here, I didn't do any physical activity. I barely was like making time for like STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 54 eating and socializing and I realized how mentally draining and exhausted I was (Interview 6, p. 10). Another entry-level OT graduate student experienced panic attacks several times a week during the first semester of graduate school. I was having panic attacks at least five times a week. And curling up in my bed and like sobbing, and so just wasn't productive and I wasn't happy (Interview 3, p. 6). Finally, the students mother suggested the student was working too hard in the entry-level OT graduate program and was risking the students health as a result. I had some very serious conversations with my mom about how you can't fill someone else's glass up when your glass is empty (Interview 3, p. 6). One entry-level OT graduate student reported setting high personal expectations but was not meeting the desired academic goals. My parents [were] like there's nothing wrong with sometimes being average it's okay. And they're the ones who are kind of more like stop being so hard on yourself (Interview 10, p. 7). Moving home during the COVID-19 pandemic provided the student with a new perspective on the situation. The student explained, I think living with them [parents] this summer was one of the best things for me because they'd be like, you need to take a break from the computer. Like go get dinner. Go do something. You need see your friends. What are you doing? Stop doing homework. (Interview 10, p. 7) Similarly, another entry-level OT graduate students spouse suggested the need to prioritize time based on personal values rather than compromise self-care to spend more time on academics. My husband's a PhD student, too, so he understands the graduate level, understands the demand. But he's huge in just taking a step back and saying hey I don't think you're doing well. You need to evaluate this. Don't you have this value of self-care? I STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 55 haven't seen you read a book. Ive seen you work until like 11 pm and you would never do that before you would have stopped work at 7 pm. (Interview 22, p. 8) Students Implement Strategies to Return to Occupational Balance Most disruptions to occupational balance appeared to occur during the first-semester transition to graduate school, but students reported fluctuations in occupational balance across the entire entry-level OT program experience. Students identified adaptation strategies, experiences, new thought processes, and support systems that helped them regain a sense of occupational balance throughout their time in entry-level OT graduate school. Students reported using various strategies depending on their current circumstances and past experiences. Students in OT Adapted Methods for Learning to Improve Their Effectiveness and Efficiency. When a disruption occurred, entry-level OT graduate students described the development of strategies to help them adapt to the novelty of their situation. One student explained the need to develop different study habits because previous methods were no longer adequate for the OT graduate program requirements. Once I got into graduate school, it was, it was a whole new ballgame. I had to retrain myself on different study habits and really breaking down content each day, making sure that I was focusing on things long term so that I could fully understand the process and be able to apply them. (Interview 3, p. 6) Similarly, another entry-level OT graduate student learned to employ more effective study habits to filter essential unfamiliar concepts. For example, the student used study time learning novel information rather than repeatedly reviewing information already learned. Even if I knew a topic, I was spending all the time reading every single word of every single chapter. I would like go through and highlight, and then I go through and take STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 56 notes. And like I was spending a lot of time looking at the same information and it was sticking with me, but not because I was looking at it, the four times, like I just had already known it. And so I like I got into better methods of highlighting less, writing down only like new information, things I didn't know, more important information. (Interview 10, p. 4) Another entry-level OT student indicated finding a way to organize school work was crucial to success in graduate school. I know people in the class who color code every single thing we have to do and thats overwhelming to me. And I know people who dont write anything down in the program and theyre still killing it. So just finding that that medium or finding that mode of kinda tracking information. (Interview 1, p. 5) Entry-level OT students reported taking advantage of situational factors to help improve their occupational balance during their time in graduate school. For example, several students reported the benefits of a weekday without class to complete the assignments for the current week or start the course work for the upcoming week. One entry-level OT graduate student devoted a day off to catch up on school work, engage in self-care, or socialize with friends. Fridays we don't have class. So usually in morning on Friday I do some of the assignments that are due during the week so I can prepare and maybe not have to spend all weekend on something. Or I might just take time for myself and relax, or maybe meet people. (Interview 4, p. 3) Another entry-level OT graduate student had Fridays free from classes and spent the time to rest and complete assignments for the week. "I actually don't have any class on Friday at all STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 57 thissemester, which is nice. So, Friday, I can just sleep in, and hopefully finish up everything and turn everything in (Interview 14, p. 4). Students Use Support Systems to Assist with Managing Disruptions to Occupational Balance. Entry-level OT students reported the support of family, faculty, supervisors, and peers was vital to persisting in graduate school. In addition, students reported needing others for financial and emotional support. Entry-level OT graduate students reported cohort peers sometimes created anxiety, but were critical in offering moral support, study assistance, and motivation during difficult periods. Students Seek Parental Support to Assist with Managing Disruptions to Occupational Balance. Parents were instrumental for several entry-level OT graduate students to maintain or regain occupational balance. For example, one student explained how parental financial support helped with acclimation to graduate school. In addition, the student acknowledged reduced stress without having to worry about buying food, paying rent, or purchasing textbooks. The student also reported support from parents, friends, and others was motivating throughout time in the entry-level OT graduate program. My family has helped a lot. My parents, especially, because even though I am um paying for grad school, they're allowing me to like live at home still. And I don't have to worry about rent or anything. Or my textbooks they'll help take care of that. Just knowing that somebody is encouraging me. My friends and boyfriend and people around me, they want me to do well. So I think that's more like encouragement and support that way. (Interview 4, p. 10) Several entry-level OT students reported turning to their mothers for support when overwhelmed with the demands of graduate school. One student stated, If I'm really stressed STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 58 out, I always call my mom. Always. So, she'll just calm me down like you're fine. Like, calm down. You'll be fine (Interview 5, p. 11). In the same way, another student called their mother during periods of high stress. The student explained these conversations helped to recognize the importance of self-care. I always like would call mom like if I was freaking out about school stuff, and you know she's I guess she's kind of the one that got me to just be like, you need to relax. You need to take time for yourself at the end of the day. You know, not to go overboard studying sometimes. So it was kind of, I guess, her helping me realizing that I couldn't constantly be studying, like I needed to do something for myself. (Interview 8, p. 8) The mother of another entry-level OT student helped with experiences of self-doubt about succeeding in the graduate program. The mother provided encouragement and helped the student analyze alternatives should the fears be realized. I also went to my mom, I'm really close with her. And she just kind of always told me it would be okay. And I'd be like, what am I going to do if I get kicked out? And she would kind of talk me through like okay, you're not going to get kicked out. But if you do we can come up with a plan. Theres other options. So just kind of knowing that my life would [not] be over if something happened, kind of made me be like okay, you'll be fine. (Interview 12, p. 8) Students Seek Faculty Support to Assist with Managing Disruptions to Occupational Balance. Several entry-level OT students discussed the positive impact faculty had on their experience in the graduate program. Faculty accessibility was important to one student, who indicated that knowing faculty were available was reassuring even if not needed. The student explained, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 59 [Faculty] being supportive, and knowing that that support is there if we need anything, has been so beneficial. I knew that I could knock on anyone's door, and drive them bonkers, and ask them a million questions, and they would all get answered. (Interview 3, p. 8) Another entry-level OT student found the relationship with the faculty advisor to be a vital part of beginning graduate school. Initially, the student did not know anyone, so spending focused time with the advisor helped improve the students comfort with the transition. I know before coming like the we each got like advisors, which are faculty members. So I think that kind of like allowed like one on one time with your advisor at least like, if you don't know anyone else, you have that faculty member to kind of go to and like get comfortable with and stuff too. (Interview 15, p. 7) When one entry-level OT graduate student did not do well on an exam, the student met with the professor to discuss the grade. The professor shared some of the struggles from when the professor was a student, which created camaraderie with the professor, increasing the students self-confidence in the course. I think talking to my professor, like she had also let me know like, she didn't always do the greatest whenever she was in the same like position as I was. And I think hearing that, and learning that type of thing was helpful to me because it made me feel like I wasn't alone and that this is normal. (Interview 11, p. 11) Another entry-level OT graduate student explained the importance of visiting professors during office hours to discuss course content. The student described the benefits when faculty expressed concern for their well-being as people. In addition, faculty who were accommodating when life circumstances arose in a students life contributed to a sense of well-being. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 60 Thereve been times, where Ive wanted additional feedback and Ive gone in for office hours and they've talked to me. Yeah and even just understanding from you know, a personal level even just little things like you know somebody having to be out of town for a funeral and just being understanding of are you okay, like stuff like that. (Interview 23, p. 7) One entry-level OT graduate student observed the faculty model occupational balance. The student described a professor stepping down from a leadership position because it took her away from things she enjoyed in life. The student realized if someone in an esteemed position took action to improve her self-care and happiness, the student should do the same. Ive also seen my academic advisor model the work-life balance. She was our program director for a while. It like ripped her away from the things she enjoyed, and she end up stepping down back into a professors position. Seeing her say Im not happy at this level, I need to take a step back, was good for me because I felt if this person, at this level, is willing to do that for their health for what makes them feel satisfied and fulfilled, like I should be able to do that too. (Interview 22, p. 9) Faculty Who Do Not Provide Support to Students Contribute to Occupational Balance Disruptions. Conversely, other entry-level OT graduate students did not perceive a connection to faculty and often perceived increased stress at the thought of interacting with them. This increased stress disrupted occupational balance. One student reported faculty wanted to meet with students to discuss courses but stated it was difficult to develop relationships with faculty. The student explained, "it's hard to talk, the professors. They want us so badly to talk to them, and it's like, well, they're so intimidating" (Interview 7, p. 6). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 61 One entry-level OT graduate student indicated faculty could have assisted the students more during the transition to the graduate program and the move online secondary to the COVID-19 pandemic. The student explained faculty listened when students revealed their mental health needs; however, the faculty did not act upon the information. In addition, many students experienced an occupational balance disruption and needed support from faculty regarding concerns. The student suggested minor changes, such as decreased speed of courses and staggered due dates, which could have improved the student experience and occupational balance. I do think they could have done something more to help us. There were several times that we all opened up about our mental health and it felt like we were being heard, only to have nothing come out of it. There needs to be more actual listening and accommodations for our mental health and how we are currently feeling about the pacing, the layout, and the assignments included in the curriculum. We wanted to be heard. Instead, we were heard and given opportunities to speak, but then they would move on like everything was normal, even though some of us cried opening up to them. A lot of us had a hard time transitioning from undergrad and transitioning online with COVID-19. (Interview 25, p. 14) One entry-level OT graduate student suggested that faculty needed to consider many students had mental health concerns when they began the OT program, and the stress of the graduate program compounded them. The student suggested faculty needed to be aware that most of us before coming into grad school already struggled with anxiety or perfectionism, depression, things [like] that. And then obviously those things get worse when were under stress. So just having that realization (Interview 2, p. 4). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 62 Another entry-level OT graduate student reported frustration with the lack of availability of professors. For example, the student discussed one instructor who canceled office hours but did not offer alternative times to meet. The student stated the lack of accessibility often interfered with completing assignments promptly and created an occupational balance disruption. You can reach out to them [professors], but then you have to fit around their schedule (Interview 17, p. 12). Another entry-level OT graduate student expressed an understanding that professors took steps to help students prepare for the rigor of graduate school; however, in reality, this attempted help often overwhelmed students and instead disrupted occupational balance. The student provided the example of graduates who came in and shared their entry-level graduate program experiences with the new cohort of OT students. Rather than feeling comforted, students left the meeting questioning their ability to succeed in the program. I think they've [instructors] had to adjust a lot. I think they thought that they were helping in a lot of ways, when in reality they were making us more stressed out. I think my generation is definitely more stressed out just naturally. So having a new graduate from our program come and say, there will be semesters where you're on top of it, and you have a great system for studying, and then the next semester it doesn't work and we're all like excuse me? So really we left that meeting going, so Im going to fail. I'm not reassured um but, like, I think, to them that that was helpful to have our peers talking to us. It's like, no actually that was terrifying. (Interview 19, p. 12) Developing and Maintaining Peer Relationships Assist Students in Managing Disruptions to Occupational Balance. Entry-level OT graduate cohort peers were vital to students occupational balance. One student reported the relationships developed within an entry- STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 63 level OT graduate program cohort assisted with a disruption to occupational balance to move away from believing they were not performing to personal standards on an assignment. The student explained that comparing grades with peers developed a sense of camaraderie. Knowing another student experienced a similar academic difficulty helped the student cope with a substandard grade and led to improved occupational balance. My group of friends, like we typically share grades with each other. So it really makes you feel better if like someone else did poorly too. Knowing other people did bad as well, like makes you feel better about it. (Interview 18, p. 10) Studying with peers was a valuable learning strategy for another entry-level OT graduate student who described seeing a parallel between problem-solving course content with other students and working through patient cases with a care team once becoming an occupational therapist. I think that talking it [course content] aloud with a peer has really helped, and I can see how that really translates to practice because I often see in my work environment [therapy aide] different therapists discussing specific issues and treatments and things like that. And so just hearing it out loud, and processing with somebody else I think has been something that I'm so glad has developed over the course of this program. (Interview 11, p. 9) Several entry-level OT students recognized that socialization was a strategy they could employ to help them regain occupational balance in graduate school. For example, one student indicated studying during free time was the main way to succeed in entry-level OT graduate school. The student explained that being around others outside of her entry-level OT graduate program and engaging in non-academic activities helped divert attention from school work. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 64 I think the easiest way to like distract from that [feeling a student needs to always be doing schoolwork] is being around other people. We have like a game night, that's like really good mental break for me, because Im no longer thinking about the things I need to get done, it's like really concentrated, and just like having fun, and what we're doing in that moment. (Interview 25, p. 13) Similarly, another entry-level graduate student expressed the importance of friends in the OT cohort. The student indicated others who had similar experiences provided a sense of hope. These companions provided support in times of stress and helped the student regain occupational balance to complete the graduate program successfully. The student explained, I feel like I need those people to continually lift me up. Having that close knit relationship with people who understand what you're going through um is very beneficial. I honestly could not have made it out without my friends in the program. (Interview 3, p. 7) One entry-level student reported the importance of having peers in the graduate program to discuss the stress experienced in the OT program. The student explained that friends who graduated from their undergraduate education and went to work did not understand the entrylevel graduate program experiences and, therefore, could not assist with improving occupational balance. One of my best friends was in speech path. So I'd like call her, and she would get like the grad school aspect of it. No one gets it unless you're in grad school. So a lot of my friends at home like are in business. And so theyre stressed at work, and just can't relate. (Interview 5, p. 11) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 65 One entry-level OT graduate student avoided certain peers because of their negativity about the program. The student explained, I feel like sometimes my peers go down a pessimistic view of our program and the teachers. And so sometimes I try to just steer away from that because I don't really want their group consensus (Interview 17, p. 13). Another entry-level OT graduate student also commented on the negativity of the cohort in the group chat they used to communicate. As a result, the student left the group to avoid undue stress and disruption to occupational balance. People would say something like oh well, the teachers grading so subjectively, or once or twice, it was much harsher than that. And it was just like okay Im done. I don't need to be in here [group chat]. It was mostly just drama, and everybodys feelings about every assignment, and it's just a lot less stressful to not be in it. (Interview 24, p. 9) Similarly, another entry-level OT graduate student indicated listening to some students discuss class assignments created feelings of unease. The student chose to avoid interacting with these peers to avoid undue stress. The student explained, I am very limited in who I talk to about class frustrations anymore. Like right now, um, they are going crazy about the assignment details that we don't know for assignments that are due this week. Um, and so, honestly, the group chat is really just chaotic. (Interview 17, p. 12) One entry-level OT graduate student expressed the importance of finding peers who had a similar approach to completing assignments to maintain a state of occupational balance. The student described peers at the ends of a continuum those who completed assignments exceptionally early and those who procrastinated starting them. Finding peers who managed STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 66 assignments in a similar way, however, was difficult. The entry-level OT graduate student reported that interacting with students who viewed deadlines differently was stress-inducing and caused disruptions to occupational balance. I think that we also as like a cohort, and a class really stressed each other out. People will finish things really early, and then you have the people who finished things like the last second. And I think like we struggle with like finding that balance, and finding other people who are like in that middle range. (Interview 10, p. 9) Participating in Multiple Occupational Roles Contributes to Student Occupational Balance. Several entry-level OT graduate students provided information about the influence of participating in multiple occupational roles on their occupational balance. One role to improve occupational balance that students discussed was working at a job. Some students reported obtaining paid employment, so they had something to focus on other than school. Developing relationships outside of school, and having a physical location to engage with others that was not home or school, helped improve their sense of occupational balance. Work provided benefits that a focus on schoolwork alone did not afford them. In addition, as one student described, working at a job provided a sense of purpose and improved overall mental health. And then second semester I decided to get a job. Just because like I wanted to work and like I wanted to just do something out[side of school]. And I learned, like my study habits too that way. Now being able to do my schoolwork, and then, like, Ill go to work and like Ill focus on work because the first semester I did it [only focused on schoolwork], and like it was not good for my mental health. (Interview 8, p. 11) Several entry-level OT graduate students described the importance of engaging in more than one life role, so they did not define their identity solely as a student. Personal happiness and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 67 acceptance by others required engagement in more than the student role. As one student stated, You cant let one facet of your life overrule everything else, because then youre just not going to be happy, and youre not going to like, be like, somebody others want to really be around (Interview 6, p. 10). Participating in multiple occupational roles provided a sense of occupational balance for entry-level OT graduate students, who also reported an inherent need to engage in activities outside of their academics. I just I have a lot of interests, and I never want to limit those interests (Interview 19, p. 11). Another entry-level OT graduate student compared feelings about occupational balance to a future career as an occupational therapist. Thats kind of what like OT is about, the different roles and identities and all of that. People arent just like defined by one like characteristic of themselves, and that you know people have a broad scope of identities that contribute to who they are, and they [identities] are all are important. (Interview 2, p. 10) Engaging in and exploring other desired occupational roles equated to this entry-level OT graduate student's sense of identity and a view of successful occupational balance. The student explained, I value the balance and kind of see the importance of not just being like my only identity is being a student, and kind of being like, Oh, like there is other parts to me that I have time to explore. (Interview 2, p. 5) Getting a job helped one entry-level OT graduate student regain a sense of normalcy in life. The student stated it was enjoyable to be around people again after the limited socialization during the COVID-19 pandemic. Engaging in work evoked feelings of competence. Additionally, the student enjoyed that the work was not mentally challenging and therefore was a nice contrast to the intensity of coursework. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 68 I am very excited about having a job right now, like that's been really great to be like in person somewhere else, and like meeting new people and just getting to like see people again. But it's also in an environment that like I really love It's so easy, and a nice place where I can go, and like mostly not mess anything up. (Interview 21, p. 15) The student also indicated that working at a job helped improve efficiency with using free time to complete academic assignments. The student explained, I think when I have a job or something else going on that forces me to use that open time to catch up on assignments and stuff I think Im more disciplined about it (Interview 21, p. 4). Another entry-level OT graduate student worked during the graduate program but purposefully obtained a job outside of OT to take a mental break from academic work. The job choice improved occupational balance as it provided the opportunity to explore another life interest and forced the student to spend time in something other than academics. A huge portion of my work life balance was um I purposefully got a job at a place that had nothing to do with anything occupational therapy. I worked at a garden center because I liked horticulture, plants, that kind of thing. I worked there on the weekends. And that was nice for me, because I could be like well I can't study from eight to six because Im working. I wanted that like totally different thing to not be OT related to give myself a break. (Interview 22, p. 13) Some entry-level OT students chose to postpone obtaining a job until the second semester to allow themselves time to acclimate to the academic rigor of graduate school. As one student stated, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 69 I kind of chose just to not work my first semester, just because I knew the course load was going to be extremely crazy, and I just wasn't going to be able to fit it in. I didn't really want to stress myself out too much. (Interview 8, p. 6) Another entry-level OT student also expressed belief in not working during the first semester of graduate school. The student explained, I purposely didn't work [first semester] because I didn't really know the rigor of the grad school program because I knew it wasn't going to be like undergrad. I knew it required more work and more time, and so I didn't want to overwhelm myself at the beginning. I wanted to give myself a chance to kind of get in the groove of things and kind of understand grad school before I took on another responsibility. (Interview 9, p. 5) Students who Made Time for Self-Care Demonstrated the Ability to Minimize Disruptions to Occupational Balance. Several entry-level OT students experienced a mindset shift during their time in the graduate program that changed their perspectives toward taking care of themselves. They developed strategies to help regain occupational balance during periods of high stress. For example, one entry-level OT student started to keep a gratitude journal while in the graduate program after experiencing severe periods of being overwhelmed accompanied by panic attacks. The journal helped to refocus energy on the good things in life, which helped manage the stress related to academics. I needed to find something that was good and find the peace in each day, and that [gratitude journal] helps me cope, just because I was just seeing and hearing so much negative. (Interview 3, p.14) Another entry-level OT student focused on the end goal of becoming an occupational therapist during the difficult times during graduate school. To help with coping, the student concentrated STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 70 through spiritual reflection on the difficulty gaining acceptance into the program and why becoming an occupational therapist was important. I thanked God every day that I was in the program because it was a rigorous application process. I was thankful to be there, and even though some days were more difficult than others, I knew that this was the profession that I wanted to pursue and I knew why I wanted to do it. (Interview 11, p. 16) One entry-level OT graduate student learned that fatigue at the beginning of a week indicated the need to stop working on homework earlier in the evening to rest. The student explained, At the beginning of the week if I know I'm just completely exhausted like I'll kind of, call it quits for the night. And I'll just say, I'll get it done tomorrow or whatever (Interview 8, p. 8). Planning a self-care activity in their day provided some students with the accountability to follow through. For example, one entry-level OT graduate student found that tracking everything in a planner for the week helped visualize and schedule workouts to ensure completion. The student explained, I have a planner. So, I write everything in, and then I try to put in like during the week when I will plan in my workouts" (Interview 11, p. 6). Similarly, two other entry-level OT graduate students also scheduled time in their planners to exercise. On Tuesdays when I have like no time, and I have to find time to work out, I put that in there [in a planner] (Interview 12, p. 5). "In pink here [in Google calendar] I put my personal events. Here you can see I went on a walk with my, my roommate and the neighbors downstairs. So that was in there (Interview 17, p. 7). Another entry-level OT graduate student explained using a calendar alarm as a reminder to go on a run. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 71 I also have in my phone calendar, like every other day, I have an alarm go off, so it reminds me to like go on a run. And so sticking to that Im also like, oh my gosh that's in my schedule, I need to do that too. (Interview 20, p. 5) One entry-level OT graduate student gradually scheduled more integrated self-care time. The student began by planning time one evening a week to watch TV with some friends. I made small changes to like incorporate more time for myself. I started going to a Bachelor watch party every Monday night with some of the girls in the class. And that was my like socialization my like break from studying. And then as it [time in the program] progressed, I just realized like, how important it is to not let one aspect consume your life. (Interview 6, p. 10) The entry-level OT graduate student explained that progression through the program provided a sense of value for time away from academic work and led to steps to ensure time for self-care. The student scheduled time every day for relaxation, which improved contentment with life. So now I've been more like aware and conscious of, like, making sure I either schedule time to do things for me or just, like, make sure that I'm not hyper focusing on one thing. Like I try right now, every single day for an hour I like set aside time to just go for a walk outside, and if I finish my walk earlier than an hour when I get home I can like, do whatever I want and just really relax. (Interview 6, p. 10) Some entry-level OT graduate students found that using the weekend to rest helped them achieve occupational balance. One student explained, I try really hard not to do things on Sunday. Its kind of my chill day kind of a recharge day (Interview 24, p. 4). Another entrylevel OT graduate student also took a break from academics on the weekend. The student completed homework during the week to spend the weekends in leisure and social activities. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 72 Weekends are normally um less school for me because I kind of try to do all my homework during the week. So I like to work out and hang out with my friends, see my boyfriend, see my family, stuff like that, kind of more relaxing. (Interview 9, p. 2) Knowing When to Seek Professional Assistance Helped Students Manage Disruptions to Occupational Balance. Two entry-level OT students reported heightened anxiety in the graduate program that interfered with their ability to regain occupational balance. Both explained they needed to begin medication therapy as a strategy to cope with the anxiety. The first entry-level OT graduate student explained daily medication helped with remaining calm in stressful situations. The student further explained, So I've been put on medicine and I have a very good, like emergency one in case I start to spiral because it does still happen, but a lot less. Im a lot more mellow" (Interview 3, p. 16). The second entry-level OT student also started medication while in the graduate program but did not attribute the cause directly to the stress of academics. Since childhood, the student experienced anxiety and realized managing it independently took a lot of energy away from other endeavors. At the beginning of entry-level OT graduate school, the student discovered other students struggled with anxiety and sought treatment. It [seeing a doctor to get on medication] happened in graduate school, but I don't think it's because of graduate school. It was just I finally was ready to address it [anxiety], and realized that it was taking up a lot of my mental capacity. I finally feel like I can sit down and breathe and Im not like going 100 miles an hour. Talking to other students in the program, a lot of people have medication, and then also just being an OT and learning about people. People receive OT for anxiety and depression. I was like STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 73 oh, this is an actual thing, and nobody's going to think that Im lesser-than because of it. (Interview 26, p. 13) What are the Differences in the Occupational Balance Strategies of Entry-Level OT Graduate Students Who Report High, Medium, and Low Occupational Balance? To address the first sub-question, entry-level OT graduate students completed the Occupational Balance Questionnaire (OBQ11) (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) electronically after signing the consent form. The researcher scored the OBQ11 using the scale provided by the questionnaire (P. Wagman, personal communication, May 11, 2020). Twenty-two students completed the questionnaire and the researcher analyzed their interview responses along with their OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) score to determine whether patterns emerged between the OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) score and occupational balance strategies. For the purpose of this research study, the researcher developed three categories of occupational balance based on OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) scores; low (score 17), medium (score 18 to 23), and high (score 24). Table 1 displays a summary of the characteristics of entry-level OT graduate students in each category of occupational balance. Entry-level OT graduate students who scored in the high occupational balance category were fewest in number (n = 4) and students who scored in the medium occupational balance category were the highest in number (n = 11). Entrylevel OT graduate students who scored in the low range of occupational balance were in the middle (n = 7). Even though the scores on the OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) differed, during the interview process, 19 of the 22 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 74 students reported they believed their life was occupationally balanced and only three students reported they were not occupationally balanced. Eighteen of the 22 entry-level OT graduate students who completed the questionnaire reported involvement in paid employment. Types of jobs and the flexibility of the hours were variable within and among the three groups of students. The numbers of students who used working as a strategy for occupational balance were similar across the three categories of scores on the OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020). Three out of the four entry-level OT graduate students who scored in the high balance category reported time off between their undergraduate and graduate education. The students indicated the time off assisted them with making the transition to graduate school. Even though the sample sizes for each category of the OBQ11 were small, none of the students in the low occupational balance category reported a gap in time between undergraduate and graduate education. Taking time off between undergraduate and graduate education could lead to occupational balance in graduate school. For example, one entry-level OT graduate student who took a gap year before graduate school described being older than the other students in the cohort. The student indicated this was an advantage because the students life experiences increased security in the learning process, which helped maintain occupational balance, even during difficult stages of the program. I will say I think Im like easily the oldest person in my cohort And so I think that's given me [a different viewpoint]. And maybe it's just like life experience or being a little bit more comfortable being out of my comfort zone that has made my experience a little bit different than some of the other girls. I just feel like a little bit less self-conscious I guess at this point like in my life. (Interview 21, p. 12) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 75 All groups of occupational balance involving entry-level OT graduate students employed a variety of occupational balance strategies and adapted the strategies to the specific situation the students encountered. For some strategies, only one student used the particular approach; however, more than 50% of students in each category of occupational balance used several of the same strategies. Table 2 outlines the most regularly used strategies of occupational balance common to each group of entry-level OT graduate students. All groups integrated three strategies to promote occupational balance, including shared experiences with cohort peers, an individualized plan for organization, and scheduled time for self-care. Of interest, the number of commonly used strategies of occupational balance corresponded to the score on the questionnaire. For example, entry-level OT graduate students who scored in the low category of occupational balance incorporated the least number of strategies of occupational balance. Additionally, the total number of strategies increased by each score category. The students who scored in the high category of occupational balance shared some strategies with students in the middle category of occupational balance, but the students in the high category also integrated unique strategies. What Happens to the Way Entry-Level OT Graduate Students Manage Occupational Balance When They Experience a Change in the Expectations of Their Student Role or Other Life Roles? To address sub-question two, entry-level OT graduate students discussed how changes to life roles influenced occupational balance. Students also experienced changes in their occupational balance due to the COVID-19 pandemic. Additionally, several students expressed the importance of reflecting on current and past experiences to identify new ways of viewing their present situation. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 76 Changes in Life Roles During the Graduate Program Influence Occupational Balance Several entry-level OT graduate students reported experiencing changes to life roles that influenced their occupational balance. Many entry-level OT graduate students reported the need to obtain paid employment to offset some of the costs associated with graduate education. One entry-level student worked at a job from the start of OT graduate school. The student reported the work schedule interfered with academics. Because of the extended hours, I had to kind of push my school assignments back I ended up having to do a lot of the assignments and a lot of the schoolwork over the weekend, which impacted my ability to kinda engage in the activities I wanted to with my friends. (Interview 1, p. 3). Another entry-level OT student worked at a job since starting graduate school. When the COVID-19 pandemic forced entry-level graduate courses online, returning to live with parents was necessary for the student. The summer semester was light on credit hours. The student had more free time without classes to attend. These two factors led the student to work more hours than previously in entry-level OT graduate school, thereby disrupting the current occupational balance. During summer, since we went to all online, I actually went home, and that's when Iworked about 25 to 30 hours a week at a pool. I thought I [had] lots of time, like we dropped down in credits again, and then I think we had Fridays off, and I was like, okay, like I should get a job. And my boss was like, oh great, and scheduled me like at least five days a week, which is not what I was hoping. I was hoping like maybe three. So that was summer was really crazy for me. (Interview 10, p. 3) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 77 After returning to campus and resuming a coaching position at the university, the entry-level OT graduate student found occupational balance returned. So, moving back up here and getting back into coaching and then being at that 12 credit hours my life has calmed down a little bit" (Interview 10, p. 3). Another entry-level OT student worked at a job during the graduate program but stopped working when the COVID-19 pandemic began. An initial disruption to occupational balance occurred as the student tried to organize time between work and academics with the transition back to work during the final semester of the program. At first, like when I went back to work this semester, I was like all over the place again because I work a lot. But now that I'm like in like my fourth week working back there I know what like timeframes I have to get stuff done. So I'm pretty good with it. But yeah, at first it's stressful because it's like you work all day, and like, then I'll come home, and I'm like, oh, I still have stuff to get done. (Interview 8, p. 6) Several entry-level OT graduate students reported a flexible employer assisted with lessening their stress. One student recalled experiencing last-minute course changes that interfered with a work schedule. They're very flexible [work], which is helpful to be able to say, hey, I can't work Tuesdays now because they just made us a class from two to four (Interview 7, p. 8). Another entry-level OT graduate student reported the supervisor permitted the student to clock out to attend a virtual class. My boss lets me kind of just go into his office, and I just Zoom into class. So, it's pretty nice. I just kind of clock out and then clock back in after class" (Interview 8, p. 2). A third entry-level OT graduate student had a supervisor who considered the students academic requirements. The supervisor permitted the student to call off on a scheduled workday to prioritize academic assignments. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 78 Im very lucky that like if I have homework tomorrow, I could just tell my boss I have like so much school work to do that I cant come in, and she'll be very understanding, and then like she'll just say it's fine. (Interview 15, p. 11) Other entry-level OT graduate students reported completing some homework during work, which significantly decreased their stress. For example, one student worked as a therapy aide for a physical therapy clinic and reported that the supervisor allowed homework completion to occur among work duties. The student explained, While I'm at work, if I have a break between patients, Ill sit there and like my boss like lets me have my computer. So yesterday when I was working I was doing an assignment for school (Interview 8, p. 4). Similarly, another student was a receptionist at a gym, and could work on homework during less busy periods. I work at a gym. I would just sit at the front desk. I'm actually really lucky because I am able to do some of my homework there. So during those four hours when I'm not doing anything, I am allowed to get some homework done. (Interview 9, p. 3) Working as a nanny afforded another entry-level OT graduate student flexibility to complete academic requirements while the children were napping or engaging in online school work. The kids nap from two to four every day so I do my homework. The kids are also homeschooled, so if they are both on their computer doing their homeschool work, I'm allowed to have like books out to read or study or do whatever. (Interview 12, p. 2) One student became pregnant with a first child during the capstone experience, near the projected graduation from the entry-level OT graduate program. The student described the challenge of finishing a doctoral degree but also desired to enjoy preparing for the birth experience with a spouse. The student expressed the belief in a lack of time to read books for STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 79 expecting parents or engage in other self-care practices, which signified that the student was not occupationally balanced. I was like, okay, my due date is in two months, and I have these things I want to learn, and Im just like, am I never going to learn them? When I have something I want to do, but I can't find the time to do it, that sometimes is an indicator to me that I might have too much on my plate or not balanced enough ... It's like reading an extra book or telling myself, I can afford a half-hour walk outside, and saying no, I can't. I can't afford that. I can't find that space. Like that's in my mind. Im like something's not there if I can't find the time, so that's usually an indicator for me. (Interview 22, p. 14) Another entry-level OT student lived with parents to save money while in graduate school. The students father was caring for grandparents, so the student assumed some of the responsibilities at home that the father typically completed. My grandma just broke her leg, so she just came home, and my grandpa has like severe dementia, and so my dad is kind of like taking over the responsibilitiescaring for them So that's why I've kind of stepped it up, helping in the kitchen and cleaning and making sure that like everything's okay around here so that he can worry about everything over there and not worry about anything at home. (Interview 9, p. 5) The entry-level OT graduate student indicated the increase in household responsibilities disrupted occupational balance; however, the student did not focus on the lack of occupational balance but instead thought of adaptations that would enable adjustment to the situation. The student explained, It kind of just, it is what it is. So you got to make it work. I try not to stress myself out about it because I know that like this situation can't change. So I just kind of got to adapt STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 80 my my life right now until everything kind of settles down with my grandparents. (Interview 9, p. 5) Another entry-level OT graduate student discussed a similar situation at home. At the time of the interview, the student lived with a parent. However, the students sister, who lived in another state, visited for an extended period. The student explained, My sister's home right now, and she had her [ACL]surgery like two weeks ago. We're all kind of helpingShe's pretty dependent at this stage, and so I think we've all been kind of trying to take turns with helping her with basic things and getting to like physical therapy appointments and stuff. (Interview 21, p. 5) The entry-level OT graduate student reported positive feelings from having a sister home they could not visit during the COVID-19 pandemic. The time with family was a welcome respite from academic demands. It also alleviated some of the isolation associated with the stay-at-home orders. We didn't see her at all during the pandemic, so we do not take like family time for granted. So Im like more than happy to like have just a chill weekend at home with them. (Interview 21, p. 8) The entry-level OT graduate student stated having the family together again was nice and viewed the situation as positive. We get like three bonus months with her, which I guess, we didn't see her all of last year, so yeah, I have my whole family under the roof now, which has been a good thing (Interview 21, p. 2). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 81 Experiencing the COVID-19 Pandemic Created Traumatic Disruptions That Significantly Challenged Occupational Balance and Required Altered Strategies to Manage When the public health officials enacted the stay-at-home orders (Acton, 2020; Wolf, 2020) in response to the COVID-19 pandemic, entry-level OT graduate students experienced a disruption in their occupational balance. The orders forced people to stay at home and OT courses to move online; consequently, entry-level OT students experienced similar feelings as when they first transitioned to graduate school. Suddenly, the way they attended class changed. Anxiety levels increased for students who reported a mentally and physically challenging time. Previously implemented strategies for regaining occupational balance were no longer adequate. One entry-level OT graduate student shared these feelings in reaction to the COVID-19 pandemic. I feel like lately, especially with being in this wonky format and trying to figure things out after COVID, it's been a lot more difficult and a lot more unbalanced. And I feel a lot more stressed and a lot more exhausted, just mentally and physically. (Interview 3, p. 5) One entry-level OT student expressed feelings of being overwhelmed with the unpredictability in graduate school. The COVID-19 pandemic contributed to this state of mind, but the political climate combined with the amount of work to complete for school added stress. We just have a million things to do, and then the stress of COVID, and the election year, and just so much uncertainty. It was a lot (Interview 19, p. 12). The methods entry-level OT graduate students used to prepare for class and study were no longer effective as more distractions surrounded them at home than when they studied on campus. For example, one entry-level OT graduate student described a lack of experience with STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 82 online learning as a barrier. The student recognized the need for more self-discipline than when attending class face-to-face. The student explained, And then our second semester started out like really great, and I was like, okay I can do this, and then COVID happened. So then halfway through, we started online, and then we're like, okay, I don't know how to do this. I don't know how to have class online. I don't know how to keep myself disciplined at home. If I have a break [on campus], I can just do an assignment versus if I have a break at home, I'm like hmmI could take a nap or something. (Interview 7, p. 6) Similarly, another entry-level OT graduate student enjoyed having a plan and was uncomfortable with unforeseen changes due to the COVID-19 pandemic in the schedule because these changes decreased the sense of control over life. I do not like it when things are changed. I like having the syllabus. I like knowing what's going on, and then, when, at the last minute, they're like the speakers this day and not this day, is not a thing I love to happen. (Interview 25, p. 8) Entry-level OT graduate students reported being home all of the time resulted in difficulty setting boundaries between academics and other aspects of life, such as relaxing. One entry-level OT graduate student completed most studying on campus before the COVID-19 pandemic, using time at home for repose. The student described the frustration with the move online as follows, Trying to figure out that separation between school, and like just relaxing and having time [for myself]. [Before] I could pretty much just associate school with okay, I was in the classroom, or I was on campus studying. Whereas now my bedroom is also STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 83 school, so just finding times where it was like okay, I need to focus now, but also times where like I can just relax. (Interview 23, p. 5) The comfort of attending class from home also negatively influenced entry-level OT graduate students ability to focus on academics. Students reported avoiding comfortable positioning during homework completion and attendance at virtual class sessions. The added distractions of television and family members also impeded concentration at home. One entrylevel OT graduate student discussed the experience of attempting to complete academic work at home. I'd go somewhere that wasn't like in my house or sit at the kitchen table so it's not as comfortable, even though, like your back hurts, you're not in a comfy bed where youre gonna like fall asleep. It's hard to work at home because there's like a couch and a TV, and my grandma's there, and it's easily distractible at the house. (Interview 7, p. 3) Family also was a factor in another entry-level OT graduate students productivity with homework during the stay-at-home orders. The student indicated other people in the home impeded adherence to a schedule and attention to the academic tasks needing completion. The student stated, I didn't focus as well. So I would like do something, go get distracted by my family, come back do some more. So my schedule is off. And I was at home, and my mom would just be coming in. My brother was home, like a lot of lot was going on. (Interview 5, p. 4) Another entry-level OT graduate student reported when professors moved courses online, they continued teaching as though everything was normal. Meanwhile, the student did not make the transition effortlessly and spent most of the day on the computer to complete the required STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 84 coursework. Being on the computer for extended periods challenged the student and was an unhealthy practice. When we had the shutdown with the pandemic there was not a very easy transition to online classes with the professors. They just kind of went about things business as usual, just over a screen. I found myself waking up at like 6 a.m. and being on my computer until after midnight just trying to get everything done, and I was like, this isn't healthy. (Interview 19, p. 9) One entry-level OT graduate student reported changing the organization method used when institutions moved courses online secondary to the COVID-19 pandemic. The uncertainty that accompanied virtual coursework created anxiety. In addition, the student indicated apprehension regarding diminished in-person conversations and time to practice therapeutic techniques. My organization changed, so that caused me some anxiety. I just was a little unsure of like what it was going to be like virtually. I liked having like an assignment done, and going and talking to a professor and say, hey, this is what I have, is this correct? And I like that face-to-face interaction that I get so, I was like, worried about that. And I like the hands-on stuff. So I was very worried about those kinds of things. (Interview 12, p. 6) Another entry-level OT graduate student also experienced difficulty with the transition to online courses. The student discovered that course changes negatively impacted organizational coursework strategies, resulting in uncharacteristically forgetting to submit completed assignments. The lack of interaction with peers also contributed to this atypical behavior because they no longer discussed assignments and course content. The student explained, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 85 Shifting from in-person to online was not without struggle. There were assignments that I would complete, but I wouldnt turn them in because the schedule would change, or I just dont have that in-person time to talk with my peers, and say hey did you guys do this assignment? And kinda discuss what we were thinking, and just what we were taking away from each class. So it was a lot harder for me to at first to kinda grasp on everything. (Interview 1, p. 4) The move to online courses occurred quickly, and entry-level OT graduate students found instructors often made changes to accommodate the unplanned format. For example, assignment instructions and due dates changed to adapt to the virtual learning environment. These changes reportedly exacerbated students' anxiety and the uncertainty they were already experiencing. One entry-level OT graduate student explained, It kind of stresses me out if I think about what's going on next month, especially nowadays, it seems like the curriculum is just adjusting and changing like so frequently" (Interview 14, p. 2). Another entry-level OT graduate student learned not to plan as much as before the COVID-19 pandemic. In addition, the student learned to adjust organization techniques to the frequent schedule changes, thus experiencing less stress when they occurred. Ive learned that you can't [plan ahead] because it's constantly changing. Like we have these presentations that are coming up, and I think our schedule changed twice since the beginning of the semester. So Im just like, as it comes, Ill write it in [my planner] because if I write it in pen and then it changes, Ill be all messed up. (Interview 20, p. 6) Other schedule changes that occurred moved weekday courses to the weekend for some entrylevel OT graduate students. As one student shared, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 86 We were supposed to have our orthotics class on Mondays and because of the pandemic, we've changed it. So instead of having a normal lecture-lab weekly on Mondays, which was what we signed up for, instead were doing mostly online lectures, and then we are meeting three times in Friday [and] Saturday [in] pairs. (Interview 17, p. 4) Entry-level OT graduate students with scheduled appointments outside of their academic life reported increased frustration when changes to class schedules occurred with little notice. One student reported feeling these changes were unfair and problematic, creating the need to call and reschedule other commitments. I have one professor who just keeps changing everything, and I understand it's because she has [guest] speakers, but like there are some times that I like had appointments planned, and she's like, sorry, this is no longer at night, now we have to do this morning thing, because I know you guys all have a gap. Which is unfair to people who are working but I have so many medical appointments that it's like I now have to call three different locations and change my appointment. (Interview 25, p. 8) Some colleges and universities eliminated extended breaks from class and ended the fall semester early in an attempt to finish coursework before the end-of-year holidays. However, this accelerated timeline was hurried to the entry-level OT graduate students and created extreme fatigue. One student described feelings at the time. Right now, we don't have any like scheduled breaks. The last semester we didn't have a fall break, and then we started a week early, so we were fitting four months of school into three and a half. So there was like that two week extra that we were trying to fit in STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 87 and we were just burnt out. So like you don't sprint a marathon, but right now we're sprinting a marathon, and we're exhausted. (Interview 19, p. 12) Another entry-level OT graduate student endured a similar experience with moving schedules at the university in the fall and the spring semester. In the fall, they moved the start date forward. They moved the end day in December forward, and then they took our breaks. And then they did the same thing in this semester, but the reverse, so like we started really late in January. We get out about the same time, but it's because they cut out like all spring break. (Interview 24, p. 5) In addition to the changes associated with academic courses, the stay-at-home orders accompanying the COVID-19 pandemic impeded the ability to socialize with others. For example, one entry-level OT graduate student reported, Before COVID, I would go kind of spend time with my grandparents, and kind of get them out of the house, and we would walk around their development and whatnot. But I haven't seen them since March (Interview 13, p. 7). The lack of socialization also limited entry-level OT graduate students ability to develop connections with program peers, leaving some students feeling secluded and unhappy. One student provided an interpretation of the experience. We're all lacking social connection. I would love to be able to like drive out and see friends more. I think Id definitely be happier if I got to spend like in-person time with my cohort and forming relationships. I just know from past experience that, like when Ive been in more like isolated periods of my life, I just think Im overall less happy. (Interview 21, p. 14) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 88 Similarly, another entry-level OT graduate student limited the time spent with a significant other during the early months of the COVID-19 pandemic. The risk of contracting the virus and not attending lab courses contributed to the students decision. We would visit each other more if it wasn't for COVID. He [significant other] doesn't want to risk not being able to go to lab, and neither do I. Were both in very hands-on health care professions, so we need that lab time. (Interview 19, p. 14) The lack of socialization that accompanied the transition to online courses also influenced inter-cohort relationships among entry-level OT graduate students. Students expressed difficulty developing comfort with each other and professors, which limited effective course discussions and student confidence levels. One entry-level OT graduate student described the experience as follows, I think the more challenging thing has just been the fact that our cohort hasn't really gotten to know each other personally and do a lot of like social things that normally the first years do. It took our class a lot longer going into the first semester to just kind of like speak up in class more. I think we all just kind of felt uncomfortable, and didn't know each other and were obviously intimidated that like it's our first year in like a doctorate program, and like you can't see our faces or anything. (Interview 21, p. 6) In contrast to the difficulties many entry-level OT students faced, shifting from in-person to online courses lessened one students stress level in graduate school. The student perceived there was less activity in life to manage when attending class virtually. The student further explained, Yeah, I do [perceive I can fit everything in I need to do]. I think with like the virtual classes, there's more of like a, I don't want to say like lackadaisical, like it's more like I STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 89 can just kind of like lay in my bed and be in class So I don't feel like I have to like I have so much going on all the time because I just kind of like pull out my computer and like I'm in class So I almost feel like if it was just like normal times, it would be more overwhelming And so it's almost been nice in that sense, but also like I wish it was back to normal. (Interview 16, p. 7) Another entry-level OT graduate student also described a more relaxed atmosphere with online classes. Sometimes we dont even have our cameras on, so it can be pretty casual on there [synchronous video course session] (Interview 14, p. 3). The COVID-19 pandemic impacted entry-level OT graduate students academic lives as well as their ability to work. Some businesses closed as the result of the restrictions placed on them. Many entry-level OT graduate students lost their jobs, which impacted their ability to engage in social events. As one student explained, With COVID, it's just been hard. Im used to working a few different jobs, just to try and make ends meet. Last year, I had five different jobs. They all gave me enough money to have some flexibility with what I could do [with my friends], whereas now I only have two [jobs], so I have a little bit less flexibility. (Interview 19, p. 6) Another entry-level OT graduate student experienced a similar job loss secondary to the COVID19 pandemic. "I worked at Burlingtons the first semester and then Panera up until the beginning of summer semester, and then the pandemic hit, and that threw a wrench in everything" (Interview 1, p. 12). The student found another job, but it was not an ideal location and at times compounded the stress of entry-level graduate school. [Now] I drive like 40-45 minutes, you know every time I have to work, um, which kinda comes out to be four days a week. Figuring out a way to avoid or minimize the STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 90 X factor, so traffic or an accident or terrible weather, just figuring that out [adds stress]. (Interview 1, p. 6) Another entry-level OT student was a cross country student-athlete and a graduate student. The COVID-19 pandemic disrupted the students schedule. Weightlifting sessions and long runs, typically scheduled and performed in a group, had to be completed independently. The student completed the requirements with a friend on the team to assist with accountability. What Im used to is like a structured routine. My roommates on the team as well, so like typically, we will do [runs] together if we can it helps us like get out of bed a little easier. And then, the lifts, we have to do two lifts a week, and again, those are independent. We're just expected to get them in. (Interview 18, p.4) Conversely, the move online secondary to the COVID-19 pandemic reduced another entry-level OT graduate students test anxiety. Previously, the student listened as others discussed the examination content they studied, making the student question current study habits. The student was not exposed to these conversations online. Additionally, the student experienced less noise in the home environment than in the classroom, making it easier to concentrate. But now also it's [anxiety] definitely decreased with more online and the anxiety around exams is so much less because Im logging on to the lockdown browser to take the exam online, and I can't hear people flipping, or I can't hear people like chattering right before the exam starts of oh, do you remember what these seven steps are? ... That is so much less and its so nice. (Interview 26, p. 9) One entry-level OT graduate student reported the move online helped to learn that engaging in activities outside of academics would not impact grades. I feel like having that STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 91 [classes] online allowed you like, oh, I'm just gonna watch Netflix. Oh, well I did that, and it turned out okay like I still got everything done (Interview 7, p. 6). During the COVID-19 pandemic, one entry-level OT graduate student indicated professors made an extra effort to maintain personal contact with students. They also provided information about self-care to help students cope with the move online. This semester Ive got like three professors that are every week they're posting like wellness tips, self-care, or doing check-ins. So they've really gone above and beyond, really, I think, to make sure they still connect with us on a personal level. (Interview 24, p. 11) Reflecting on Past Graduate Program Experiences Helped Students Manage Disruptions to Occupational Balance When an occupational balance disruption occurred, entry-level OT graduate students described the importance of personal reflection on past and current circumstances to assist in viewing their circumstances differently. For example, one student initially integrated strategies that cohort peers used to study. Over time, the student realized the need to develop an individualized approach to studying in graduate school. The student learned to accept some peers studied longer or differently; and over time, developed self-trust in choosing study habits, regardless of what others were doing. What works for X student is not going to work for Y student, and you need to be okay with the differences. Just look at who you are as an individual, what you need to do, and do it - not do what other people are doing (Interview 22, p. 11). Another entry-level OT student reported a similar realization but explained it was the second semester of the graduate program before accepting less than perfect grades became STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 92 easier. The student did not believe the grades earned reflected time studying, so a lower grade took increased time to accept. I think that was so hard for me at first. I definitely think that it really didn't come to me to like be able to accept that [not earning all As] until around the second semester with the neuro course. I went into that professor's office, and talked about it and just, I know that was like a big point for me because it was to the point where I was almost emotional about not getting the grade that I thought that I was going to because of how hard I had studied and how long I had spent on it. (Interview 11, p. 10) Another entry-level OT graduate student discovered a lower grade in the graduate program signified something different from undergraduate education. In undergraduate courses, the student explained that students often studied material for a test and then advanced to the next topic, regardless of performance or understanding. In entry-level graduate school, a lower grade meant a student needed to review the material to ensure understanding. The need to study differently to learn the material adequately might be necessary. If you get a lower grade it means you didn't gain some of the information, and now you just need to go back and learn that information for your benefit. In undergrad, you just got the F, or the A, and you moved on to the next exam. It wasn't about going back, and really learning the information. So it was a huge shift to be like oh this lower grade or this higher grade, they represent something different. (Interview 22, p. 12) Another entry-level OT student explained past high performance in undergraduate education informed the academic goals set in the graduate program. The student realized these expectations were unrealistic and also unnecessary. The student learned to relax expectations for STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 93 achievement in entry-level OT graduate school. The student realized future employers would not inquire about grades, so expecting perfection was unnecessary. There were definitely times I felt anxious, and it was kind of unnecessary to have those expectations for grades because when you get out of OT school, they're not going to be like, so what was your GPA in OT school? (Interview 20, p. 9) One entry-level OT graduate students understanding of occupational balance in the program evolved from experience with a disruption to occupational balance at the beginning of the program. No matter how busy you kind of are as a person, you have to make time for a wellbalanced life In undergrad, I was pretty into fitness. Like me and my friends would go to the student rec center and go to the workout groups three times a week. And then, when I got here [entry-level graduate school], I didnt do any physical activity. All I did was study. I barely was like making time for like eating and socializing. Um, and I realized how mentally draining and exhausted I was. I just realized like, how important it is to not let one aspect of life consume your life. (Interview 6, p. 3) One entry-level OT graduate student indicated gaining insight into personal capabilities during the first semester, which increased self-confidence and success in future courses. Overcoming that first semester when I didn't know if I was going to pass anatomy, to passing it, I was like, okay, if you got through a class that was this hard, that was this much, you can get through your other classes. (Interview 12, p. 11) Another entry-level OT graduate student gained a similar understanding. The student stated, I think once we do it, there's like, yeah, I can do this (Interview 4, p. 10). One entry-level OT student explained the difficulties experienced at the beginning of the graduate program were STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 94 valuable experiences. Overcoming problems increased self-confidence. After completing a course, the student experienced more contentment than if the process had been stress-free. I just feel like grad school is such a journey that you learn so much on, that you want to struggle in the beginning, just so it feels so much better at the end when you finish it" (Interview 7, p. 18). Another entry-level OT graduate student recognized competition with peers was no longer existent. Instead, studying with others provided multiple viewpoints on a topic and allowed students to share their strengths to enhance the group's learning. But then you kind of realize that you're all in this together. And it's not really me versus you. It's like, let's study together instead of studying apart so that I can get your perspective on things because everyone has different perspectives on things when you learn and I liked learning that I could study with my peers, instead of like competing against them, so that I can get their knowledge and like their perspective on things. (Interview 9, p. 10) Similarly, another entry-level OT graduate student developed an appreciation for the different backgrounds of cohort peers. The student learned to leverage the strengths of others to help understand the complex material instead of creating comparisons and feelings of competition with each other. Everybody's going to have the thing that they're a little bit better at like because of their experience. My cohort classmates, who took the kinesiology undergrad, they're going to excel in biomechanics and anatomy just a little bit more than me because their background is just in that kind of stuff. (Interview 22, p. 10) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 95 For Entry-Level Graduate Students in Different Semesters of the OT Program, How Do the Strategies for Managing the Student Role Change? To address the third sub-question, entry-level OT students discussed how their occupational balance fluctuated across the graduate program. Entry-level OT students explained the differences in occupational balance they experienced at the beginning, middle, and end of the graduate program. Additionally, entry-level OT graduate students explained shifts in occupational balance that occurred from the beginning to the end of a single semester. Occupational Balance Fluctuates Within the Graduate Program Experience Entry-level OT students described moving from periods of occupational balance to disrupted occupational balance multiple times while enrolled in the graduate program. Contributing to these fluctuations were unfulfilled personal expectations, decreased comfort with peers and instructors, intensified academic requirements, expanded responsibilities outside of academics, and the diminished ability to implement support strategies. Entry-level OT graduate students appeared more likely to experience a disruption in occupational balance when experiencing changes in more than one area of life or as a reaction to an external circumstance, such as the COVID-19 pandemic. In addition, if the student did not possess adequate coping skills to manage the situation, the lack of occupational balance often intensified to a level requiring external support to shift back toward occupational balance. Occupational Balance Fluctuates From the Beginning to the End of the OT Program. Entry-level OT graduate students discussed the differences among occupational balance in the first semester of the graduate program compared to subsequent semesters. Transition to the graduate program was challenging for students and for many reasons often disrupted occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 96 The First Semester of the OT Graduate Program Creates a Disruption to Occupational Balance. Each entry-level OT graduate student in the study experienced an interruption in occupational balance; however, the reasons for the disruption were varied. For example, one entry-level OT student reported diminished occupational balance during the initial transition to the graduate program due to the differences between graduate and undergraduate professional and academic requirements. The time students were required to be on campus combined with extensive course requirements were complex changes. The student stated, In undergrad, I had a lot less assignments due, and I felt like I just was in class a lot less (Interview 6, p. 5). In addition, the student described that the difference in course delivery impacted stress levels. Another big change was the speed at which some of the courses moved. And not only were we expected to know certain things for class, we had a quiz every class, which I found to be really like nerve-wracking. (Interview 6, p. 7) Another entry-level OT student reported a similar experience with the transition to graduate school, explaining little need to study during undergraduate education and, it wasnt until like grad school where I really had to study because everything was so new and some things didnt make sense um or we were just being tested a different way than before (Interview 4, p. 3). Several students reported feeling they should devote any free time to studying in the first semester of the entry-level OT graduate program. For one student, knowing subsequent coursework built on knowledge from the first semester intensified self-expectations for performance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 97 I feel like I have to do like my absolute best with like all the assignments we have. Like I have to make sure I really read through everything, or Im not going to be able to, like, move on to the next topic that we do. (Interview 8, p. 5) The professional and academic standards of entry-level OT graduate programs created unease in students and contributed to students setting high expectations for themselves. Entrylevel OT students noted that they believed they needed to perform flawlessly with coursework during the first semester of the graduate program and that anything less than perfect resulted in feeling like a failure. One entry-level OT graduate student described this fear as follows, Sometimes I was afraid of being the one that did the worst on something. I mean, there's always going to be that person in the class, and you kind of really never want to be that person" (Interview 11, p. 10). Another entry-level OT graduate student reported, I definitely think, at times, I felt anxious about that, like achieving those grades. I think it like it pushed me to work a little harder. There were definitely times I felt anxious (Interview 20, p. 8). The academic standards of programs also contributed to diminished occupational balance during the first semester of entry-level OT graduate school. Several entry-level OT graduate students described placing high expectations on themselves for academic success. One entry-level OT student reported high self-expectations throughout life that intensified as the result of the academic requirements of the graduate program. I think some of it is just how I've always grown up. Um and just like part of my own like psychology. I just I placed expectations on myself and probably other people too. But I think our program also places like a really high like standard for us. I think that it's just something [name of University] has. So I think some of his school some of its just my own like personality. (Interview 4, p. 6) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 98 The entry-level OT graduate student reported that even with the high personal standards, the student did not complete all academic tasks during the first semester. The student reported feeling angry and anxious about the unfinished work. If I don't get done, then I feel overwhelmed, or a lot of the times Ill be mad at myself if I didnt like meet the high expectations I put on myself" (Interview 4, p. 6). Another entry-level graduate student expressed a high level of stress at first in reaction to the requirements of the OT program with regards to the minimum grade point average along with the difficulty of classes. The student explained, In my program, like a 79.5 if you get that or lower on an assignment, you have to redo it, whereas in like college in undergrad, even if you got a 70 that still was passing. So I think it just added a little bit of anxiety to me, that like I wanted to make sure I did my absolute best on everything. (Interview 6, p. 9) The uncertainty that accompanied the transition to graduate school, combined with the minimum grade point average requirement, created an occupational balance disruption for one entry-level OT student. The student explained the feeling as follows, Our first semester is your first semester of grad school. Its stressful, and you just cannot find time to fit all the readings and all the assignments in. You dont know whats going on half the time, and youre just scared that youre going to fail out of the program. (Interview 7, p. 6) Another entry-level OT graduate student devoted more time to academics during the first semester because friendships had not yet formed. The student was learning the nuances of the entry-level graduate program and did not have acquaintances to fill free time, so the student focused on schoolwork to satisfy engagement needs. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 99 I hadnt like found my friend group. And so I think like in order to like compensate for that, like, not knowing where your place is, a lot of students will just like do [school] work all the time. (Interview 16, p. 11) In addition to the pressure entry-level OT students perceived from the increased course load and high professional and academic standards of graduate school, listening as peers discussed their study habits created feelings of self-doubt and caused a disruption to occupational balance. Entry-level OT graduate students questioned their methods of studying when they discovered peers studied longer or reviewed extra material before exams. One student explained, So there's a lot of pressure to be like, well you know [someone else] put in five hours to study for this exam, but I reviewed it in 20 minutes, and I feel confident about it, like does that mean I need to put in another four and a half hours to be at the same level? (Interview 22, p. 11) Another entry-level OT graduate student explained that performance on an examination was stressful compared to that of peers. The student indicated this information added to the pressure to achieve As in graduate school, and created an occupational balance disruption. The assignments [in the learning management system] will have a little bar that tells you this is what the best grade in the class was, and here's what the worst grade in the class was, and here's the average, and here's you. And, like, I always find myself looking at it, which is probably a terrible habit, but I do anyways. You know, so yeah, I think I do set high expectations. (Interview 24, p. 13) The added dimension of professional behavior expectations in the graduate program increased the pressure to perform at a higher level than in undergraduate studies and interfered with another entry-level OT students occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 100 And then you also needed to make sure you're having professional behaviors. I think that also scared me, like knowing that I needed to make sure that I looked like the part to come to class and stuff. Um, because like I didn't have to do that in undergrad. I could just kind of show up looking like whatever, um, and so that was definitely a big change for me. (Interview 6, p. 7) Some entry-level OT students were challenged to adapt to the structure of the graduate program and the mental flexibility the curriculum required of them. For example, one student disliked the rigidity of the graduate course schedule. Instead of registering for courses that fit into life, life had to fit around a dictated course schedule. The lack of control over the schedule created a disruption to the students occupational balance. Your schedule is set. Sometimes you have like an hour or so in between class when you can get something done. But otherwise, I feel like you're pretty much stocked with classes and you figure out when to do your homework or studying around that. (Interview 12, p. 4) One entry-level OT student described frustration with unplanned class obligations that arose during graduate school. In addition, the student explained the lack of advanced communication about changes created difficulty with planning and led to a disruption in occupational balance. There are a lot more unexpected class obligations. Maybe it's specifically, the way that this programs setup, but they don't always tell you about all of the fieldwork requirements that are needed at the beginning of the semester. And so sometimes things pop up. (Interview 17, p. 9) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 101 In contrast to most OT students, one entry-level student reported occupational balance improved at the beginning of graduate school. Before graduate school, living at home with an elderly grandparent, combined with assisting the family in running a business, afforded little private time. Being away from family in the entry-level graduate program allowed for concentration on personal needs and engagement in desired activities. At home I feel like its a lot harder because theres so much to do at home. I feel like I have a lot more free time in the grad school. Its easier for me to make time for myself because its just me to focus on. But when Im at home, its like I had to help my mom. My grandpa lives with us, my dad and everyone too. And I have to watch the business too that we have. (Interview 15, p. 3) Being in the Middle of the OT Graduate Program Led to Improved Occupational Balance. Entry-level OT students described feeling more comfortable with their study methods and organizational skills after successful completion of the first semester of graduate school. They also developed confidence as students and relaxed the extreme expectations they set during the first semester. In addition, one entry-level OT graduate student recognized the importance of learning to adapt organizational methods of managing coursework to course schedules to enhance feeling prepared throughout the semester. Every semester you kind of start out a little bit unorganized and then learn how to organize and fit in the balance. I reassess every single semester because there are schedule changes, and it was definitely harder before I knew every professor, because there are definitely like differences in how you're going to do assignments and what you're going to be doing, and the expectations. (Interview 11, p. 14) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 102 Another entry-level OT graduate student also reported increased competence with organization of time and integration of activities outside of academics. The student explained, Beginning of second semester, I kind of got my bearings with how grad school worked. And so then I would, while looking at my school calendar, plan things to do with my friends. So knowing I don't have a have an exam this upcoming week, but I have one next week. So like let's go out to dinner with my friends and hang out with them the weekend I don't have an exam. (Interview 9, p. 7) Similarly, a third entry-level OT graduate student reported relaxed personal expectations of working on academic assignments at all times outside of class. The student also found the chosen method of organization assisted with this process of occupational balance. First semester [I] would have been like, when are you gonna get this done? How are you going to get this done? And you're gonna have to stay up all night tonight to get it done, kind of thing. Now, I would be like, eh, you can find time tomorrow to do it. So I've definitely become more lax, but I've also become more organized in a sense. (Interview 12, p. 10) The entry-level student reported decreased expectations for perfection contributed to feelings of success in the OT graduate program. I think that first semester, I was very in like hyper-focus, like all or nothing mode, like this has to get done. This has to be perfect. I was just like everything has to be done almost perfectly in order to make it out of this alive. (Interview 12, p. 11) Familiarity with course instructors and how to approach them also helped decrease anxiety. The entry-level OT graduate student went on to explain, Comfort with the professors is there, yes, where I feel more comfortable like asking them, hey, we didn't talk about this STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 103 assignment now can you explain it to me or send out a broader email to class (Interview 12, p. 12)? Another entry-level OT graduate student identified understanding a professors teaching style and preferences for completion of assignments positively contributed to occupational balance. I think that you learn how a professors style is as you go, and that changes how you're going to do certain assignments and the way you're going to write things, so I think [it] definitely was harder to adjust whenever I didn't know all the professors. (Interview 11, p. 14) One entry-level OT student perceived increased confidence in later semesters of the graduate program due to improved organization and prioritization of academic work. These factors combined with improved efficiency with completing the work contributed to a healthier occupational balance. The student explained, I feel like I have a better balance now (3rd semester), and with me being better at scheduling things and setting priorities. Its just like less work, and Im more confident in myself (Interview 2, p. 3). Improved occupational balance occurred for one entry-level OT graduate when obtaining the ability to retain foundational content, which allowed easier application to subsequent coursework. The student also developed more efficient methods for studying after the first semester. I think in the first semester of grad school I was taking a lot longer to read more thoroughly I would take really detailed notes. As I got further along in the program, I realized I don't need to take all those notes because I understand what is going on. It's not all new, its kind of more applying. (Interview 4, p. 2) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 104 Connecting course material to OT practice was more stimulating than learning basic, introductory information for the entry-level graduate student. In spring [second] semester, I think it was less of just the basic foundations of occupational therapy, and more applying it, so it felt like it was more fun, like learning that kind of stuff. So I think that kind of helped, it was more interesting. (Interview 4, p. 8) As time went on, another entry-level graduate student indicated familiarity with the language of OT and retention of the information from previous semesters. As a result, the student spent less time looking up terms and definitions in subsequent semesters of the graduate program. Sometimes it's not in-depth reading, especially like the further you go because it's like stuff you've already kind of learned about, so it's not like you need to read every single word on the page; you can kind of like skim. (Interview 7, p. 7) Being at the End of the OT Graduate Program Led to Improved Occupational Balance. Entry-level OT students often perceived the greatest occupational balance during the last semesters of didactic coursework in graduate school. One student stated, I definitely think that now I can organize my time and I'm able to do things and like balance my life (Interview 6, p. 7). The entry-level OT graduate student explained that the move from exam-based assessments in the early semesters to project-based assessments in later semesters improved occupational balance. The student finished assignments at convenient times, working around the students schedule. Additionally, the student reported the inability to identify a precise moment when adequate preparation for an examination occurred, whereas assignments seemed to have a definitive endpoint. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 105 As my program has progressed, it's [balance] shifted. The first two semesters were heavily exam-based. And then as the program has progressed, it's [assessment] moved less from exams and more towards assignments. That's like less stressful because I know when an assignments due, and I know that I if I have a big event coming up, I can work on that assignment a week ahead of time. Whereas an exam, um, even if I studied a week ago, if I had an event the day before the exam, I would still be like freaking out that I should have been like studying stuff last minute. (Interview 6, p. 6) Another entry-level OT graduate student reported a similar feeling. I wasn't as nervous to start this [third] semester as I was like even spring [second]. I'm definitely more comfortable. I know what to expect (Interview 5, p. 8). The entry-level OT graduate student further explained, It [balance] gets better as the semesters go on. Everything just clicks a lot more like especially now that we're in our third semester (Interview 5, p. 12). One entry-level student perceived occupational balance during the fourth and final semester in the OT graduate program. The student attributed the feeling of occupational balance to enrollment in fewer credit hours than in the first semester. Additionally, fewer hours in class equated to a feeling of more free time, although, in reality, the decreased time in class was only two hours per day. The student learned to value extra time during the COVID-19 pandemic when without a commute to school and realized the difference the extra time made in the day. The student explained, I feel like it [life] is [balanced] for sure. And I think it's because we have less credits this semester than we did first semester. And so I know that I don't have to stay in class for three hours a day, twice a week. Like I have, it's normally like two hours of class. And so that kind of allows me to have two more hours in my day, and you don't realize how STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 106 much two hours is until I didn't have to drive it come COVID because I was like, I have all the time in the world. (Interview 9, p. 13) Another entry-level OT student explained the organization methods that evolved throughout the time in graduate school. For example, moving online during the COVID-19 pandemic helped students develop a more relaxed approach to planning the day. When I first came into grad school, I planned everything by the hour. I was very like, I need to know what Im doing at all times. I think that was because we were on campus, and it was so structured that like I needed that. Since going online, Ive changed completely, like the way that I plan out my day. (Interview 25, p. 6) For one entry-level OT student, the success experienced in previous semesters led to improved belief that continuing to do well in the graduate program was possible. I have more trust in myself. Um that I've that I'm able to do what like, I need to do and what's expected of me because I've done it throughout this whole program (Interview 2, p. 4). Another entry-level graduate student emphasized that application of skills beyond the didactic classroom reinforced the process to become an occupational therapist. This realization improved the students selfconfidence. The student stated, I think we felt smarter, because now we know things. And we've seen actual patients, a little bit We're applying what we're learning so I think it made it seem a little easier (Interview 4, p. 8). One entry-level OT student perceived the need to achieve a high grade point average from the start of the graduate program. This opinion resulted from past experiences of competing with others for high grades. However, by the fourth semester, the student expressed an understanding that to become an occupational therapist only required successful completion of the coursework, fieldwork, and certification exam regardless of the grades earned. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 107 When you realize that like your GPA in grad school like isn't a thing. And that it's whether you graduate, pass your fieldwork, pass your board exams. You get the same letters at the end of your name, whether you got a 4.0 or 3.8. And so I think that's where my mindset changed. (Interview 9, p. 11) Similarly, another entry-level OT graduate student explained reconceptualizing the fear of failure over time. The student learned that poor performance did not equate to failure but simply indicated that expectations were not met. I definitely think like coming into the program that like our whole cohort, everyone was like they needed to be perfect. And I feel like everyone was working [at their academics], like stressing so hard. They're like, oh no, like I missed this, I failed, you know. And it's like you didn't really fail; you just didn't do as good as you wanted to. (Interview 15, p. 6) Another entry-level OT student reported time spent in a level I fieldwork setting during the last semester of the graduate program improved occupational balance. The student explained, Right now, I feel like my life is probably the most balanced it's been since being in grad school. I've really enjoyed being able to go out on fieldwork. I think that honestly, that has probably brought me the most balance in my life because I'm able to see what all this is working towards, and like that, I love what I've been doing. (Interview 10, p. 11) The entry-level OT graduate student further explained that fieldwork clarified the rationale behind coursework. The fieldwork helped the student to visualize the future and gain the importance of integrating occupational balance into life as a student. This fall has just been like a weight was lifted off my shoulders like because I've been able to see it and do it [OT practice during fieldwork]. And so I think like I'm able to see STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 108 the value of the school and the classroom and like spending the time to do the assignments, but also spending the time to like take care of myself. And I found a much greater balance right now than I like had had the past like three semesters. (Interview 10, p. 11) The confidence gained from level I fieldwork experiences improved occupational balance for one entry-level OT graduate student. The student reported feeling surprised by all they knew when participating in fieldwork. This recognition helped the student to stop worrying about coursework. The student realized understanding the material from the coursework would result in progression throughout the program. Going in [to level I fieldwork] and kind of realizing how much I actually do know. And like I felt confident in myself. So that's definitely like a booster of like like, I know what I'm doing. Like, I'm good. I don't need to stress myself out. I'll get my work done. So content-wise I'm not worried because of like seeing my grades, and like being in fieldwork, and kind of like having that realization. (Interview 9, p.13) Other students reported feeling the most occupational balance near the end of the entrylevel OT graduate program. One student stated, Honestly like now, as I prepare to like take boards and do [level II] fieldwork, for the most part, Id say I feel like Im in good balance" (Interview 18, p. 13). Another entry-level OT student attributed improved occupational balance to comfort with peers, professors, and knowledge of the profession toward the end of the graduate program. Improved efficiency with studying also contributed to the sense of occupational balance. I think just being more comfortable with each other and with our professors. I think we felt smarter because we now, we know things. Also I can do a lot more in a shorter STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 109 amount of time versus reading a few chapters, and that taking me like a week to read the chapters, take notes, and understand it. (Interview 4, p. 8) In the fourth and final semester of didactic coursework, one entry-level OT graduate student achieved the ability to take personal time without feeling coursework was jeopardized. The student explained relaxing and enjoying free time would not have been possible in previous semesters. And so that's [relaxing] something I can finally do now [final semester]. If I want to watch a Netflix episode, or if I want to go to the dog park, I can turn my brain off for 30 to 45 minutes and actually enjoy my self-care. (Interview 7, p. 4). Similarly, one entry-level OT graduate student indicated an ability to relax and enjoy the educational experience for the first time since the start of the program by the last semester of coursework before level II fieldwork. The student stated, Im allowing myself to be comfortable in the situation Im in (Interview 1, p. 4). Some entry-level OT graduate students reported feeling unproductive or having low selfconfidence proceeding into the final semester of coursework. Although one student reported being more relaxed in the last semester, the student also experienced feelings of forgetting to do something. The student stated, I guess it's kind of like PTSD from previous semesters like something's due, something has to be done. And it's weird to not have that. So, I guess that's why I feel a little bit unproductive" (Interview 1, p. 10). The beginning of the final semester brought feelings of uneasiness for one entry-level OT graduate student. The student attributed the feelings to the unknown circumstances of the future. The student explained, So like right now, [self-confidence] is a little low just because like it's a new semester. We're doing new stuff right now, and I don't have feedback on anything yet. And I'm STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 110 looking ahead at our objectives for level I fieldwork this semester and then like our level twos and think, wow, I have to actually do real work. Not that stuff wasnt real work before, but this is like real OT work, and it feels overwhelming. (Interview 4, p. 10) Occupational Balance Fluctuates From the Beginning to the End of a Semester. Entry-level OT graduate students reported occupational balance changed from the start to the end of a semester. Some students perceived improved occupational balance at the beginning of the semester. In addition to low academic demands at the initiation of a semester, the break between semesters contributed to feelings of occupational balance for one student. The student explained, In the beginning of the semester, I feel like Im on top of things. Ive had a break leading up to it, be it summer or winter break. But its always lighter in the beginning of the semester as well. (Interview 19, p. 13) One entry-level OT graduate student described organizing time during the first weeks of a semester. First, the student analyzed courses and determined which would be more difficult based on the content. Then the student estimated the time necessary to complete the associated work for each course. Lastly, the student planned time to study accordingly, allotting more time for the courses perceived to be more difficult. Getting a feel for the classes the first couple weeks for me, it's what's harder for me to understand? Like what class is going to be more difficult for me to retain the information? And then I would either spend more time on that class, because I knew that the other class is easier to understand the material. And so then I'd prioritize my time that I do my homework with the amount of work that comes with each class, and how hard the material is for me to like understand and retain. (Interview 9, p. 8) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 111 For other entry-level OT graduate students, the beginning of a semester created anxiety. Looking ahead at the assignments and the amount of work required for one course was daunting, leaving one student with feelings of insecurity about the ability to complete it. I just get super, super overwhelmedgoing over it all at once. It just breaks my spirit because you just have a lot of moments where youre like, Im not going to be able to get all this done (Interview 21, p. 9). Another entry-level OT graduate student reported improved occupational balance after the first weeks of a semester once course expectations were understood. The student stated, Being in the middle of a semester feels good to me. Like, I know whats coming up. I know what the professor expects, I know about when to expect grades back (Interview 12, p. 12). In contrast, another entry-level OT graduate student perceived less occupational balance once midterm exams passed as the result of a heavier academic workload at the end of the semester. I would say once midterms roll around is when I start feeling like I do not have enough hours in the day to get everything done that I need to. Um, yeah, so I think it definitely varies from week to week, and the point in the semester as well. (Interview 19, p. 13) One entry-level OT graduate student explained confidence improved with progression through a semester, which gradually decreased anxiety. As the semester kind of progresses, I definitely start to feel more confident, and then I can look at what's required in that, you know assignment, or what I do know for the assignment right now, and just kind of see how much I've almost like grown in that semester already. So I feel less anxious as a semester goes on for sure. (Interview 13, p. 16) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 112 Similarly, another entry-level OT graduate student also described improved feelings of self- assurance at the midpoint of a semester. The student specified comfort with the familiarity of the course content and expectations along with the rate of instructor feedback. The student explained, being in the middle of a semester feels good to me. Like, I know whats coming up. I know what the professor expects. I know about when to expect grades back (Interview 12, p. 12). One entry-level OT graduate student described fluctuations in perceived occupational balance throughout a semester. The student explained occupational balance was dependent on the amount and quality of academic work completed. Additionally, the student identified procrastination with completion of assignments led to feelings of failure. The student stated, Its kind of a process. Some days yeah, you feel really confident. Youre productive and you know are doing really good, and then other days you feel like youre overwhelmed or things are coming up and youve procrastinated on them and youre not feeling very successful. Its just, its a process. Maybe waves of like the ups and downs its more steady versus big high ups and way low downs. (Interview 4, p. 11) Summary of Results The researcher discovered entry-level OT graduate students progressed through three phases of occupational balance during their time in the program: occupational balance, balance disruptions, and return to occupational balance (See Figure 1). Once an entry-level OT graduate student experienced a disruption to occupational balance, the student needed to acknowledge the disruption and experience a desire to return to balance. For instance, some students actively made the decision to postpone occupational balance as they viewed the disruption to be a temporary aspect of being in graduate school. The desire to regain occupational balance led most STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 113 of the students to implement a strategy to achieve balance. Examples of strategies students integrated to achieve occupational balance included development of an individualized plan to organize school work, shared experiences with cohort peers, and scheduled time for self-care. At different points throughout the graduate program, entry-level OT students encountered people, policies, changes in roles and expectations, or events that led to a disruption in occupational balance. Student values and previous life experiences influenced how the students viewed a situation and formulated a reaction to manage the occupational balance disruption. Students altered the strategies they integrated for managing occupational balance disruptions during different periods of the entry-level OT graduate program. During the initial transition to graduate school, entry-level OT students experimented with more strategies to mitigate the disruption to occupational balance than they did in subsequent semesters. As the graduate program progressed, entry-level OT students developed knowledge of specific strategies to successfully manage a disruption to occupational balance, which enabled the students to transition back to occupational balance quicker than they did in the first semester. One disruption that was an exception to this typical change process was the challenges to occupational balance experienced from the COVID-19 pandemic. The disruption from COVID-19 was characterized by a slow recovery of occupational balance. By the end of the entry-level graduate program, most OT students reported achieving a state of occupational balance. They learned to be proactive in the use of strategies to improve occupational balance and therefore experienced fewer disruptions to occupational balance. Discussion The purpose of this study was to examine how entry-level OT students incorporated strategies to manage occupational balance in their role as a graduate student. Data collected STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 114 through interviews with 26 students enrolled in entry-level OT graduate programs were gathered and analyzed to inductively develop a theoretical explanation of the strategies that students used to achieve occupational balance. Additionally, the purpose was to determine how these approaches for returning to occupational balance changed when students experienced an alteration to life during the entry-level graduate program. The researcher also gleaned insight into the strategies students used to manage the student role during different semesters of the OT program. Table 3 lists the propositional statements developed during data analysis. These statements explain the relationships among the data categories of the researchers induced theory of occupational balance. The researcher was not able to locate any other study employing the grounded theory methodology to provide a theoretical explanation of the occupational balance of entry-level OT graduate students. Researchers used various terms to describe the concept of balance, including occupational balance, life balance, and work-life balance, often interchanging the terms. Comparing the findings of this study to other studies proved difficult due to the inconsistent use of terms. Regardless, propositions that appear unique to this study include: Other people in a students life can identify disruptions to the occupational balance of students Experiencing the COVID-19 pandemic created traumatic disruptions that significantly challenged occupational balance and required altered strategies to manage Reflecting on past entry-level OT graduate program experiences helped students manage disruptions to occupational balance The findings from this study have implications for OT students and educators. A specific focus on the phases of occupational balance experienced, the contexts that influence occupational STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 115 balance, and the strategies integrated to overcome a disruption to occupational balance throughout an OT program may benefit students and educators. How Do Entry-Level Students in OT Incorporate Strategies to Manage Occupational Balance in Their Role as a Student in the Graduate Program? Entry-level OT graduate students interviewed for this study expressed various meanings they attributed to occupational balance and its importance in their lives. The life experiences brought into the entry-level OT graduate program prompted how students viewed occupational balance. Matuska and Christiansens (2008) model of lifestyle balance supports the findings in this study that past events influence current views of occupational balance. Although they did not discuss occupational balance specifically, the authors suggested that lifestyle balance exists as a range of occupations a person engages in throughout life, expecting variability in the degrees of satisfaction from the experiences. Similarly, the personal values the entry-level OT graduate students expressed in the present study contributed to maintaining a state of occupational balance. Entry-level OT graduate students who had the value of balance instilled in them during the formative years demonstrated a desire to remain occupationally balanced. Eklund et al. (2017) also discovered a relationship between engaging in occupations that support personal values and reported occupational balance. Eklund et al. (2017) provided evidence of the connection among a persons inherent personal values, choice of occupations, and sense of occupational balance. Matuska and Christiansen (2008) also discussed the importance of engaging in valued occupations, explaining that they contribute to a persons optimistic view of self and perceived lifestyle balance. Wagman et al. (2021) added that occupational balance is a subjective term and can vary significantly among people depending on the personal meanings a person ascribes to the term. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 116 All of the entry-level OT graduate students interviewed for this study described a disruption to occupational balance during the program. Several OT students expressed an understanding that the situation was temporary and was an expected part of the graduate program experience. The OT students perceived their balance would return to a more acceptable state upon graduating and embarking on a career as an occupational therapist. They expressed the belief that the short-term disruption was tolerable. Malek-Ismail and Krajnik (2018) conducted a study of MOT students during the first semester of the graduate program and reported students were willing to surrender some of their occupational balance for the short period of graduate school. Matuska and Christiansen (2008) suggested that people who are satisfied with how they use their time and are working toward important personal goals may perceive they are balanced even when devoting a disproportionate amount of time to one occupation. Similarly, Yazdani et al. (2018) emphasized that occupational balance is a constantly changing process and is dependent upon several factors, including stage of life (p. 295). Entry-level OT graduate students may perceive they are occupationally balanced even when managing rigorous academic workloads because they expect to spend the majority of time on schoolwork at this stage of life. Malek-Ismail and Krajnik (2018) reported findings that OT students in their study conveyed the ability to identify when the anxiety of the graduate program interfered with personal relationships and academic performance. Most entry-level OT graduate students interviewed for the present study stated they recognized when they were experiencing a disruption to occupational balance. This recognition enabled students in the present study to implement one or more strategies to overcome the disruption and return to a state of occupational balance. Similarly, Van Veld et al. (2018) conducted a study with students in the first year of a doctor of physical therapy (DPT) program. The authors discovered that students who were STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 117 conscious of negative feelings about the graduate program could think intentionally about the positive aspects of their experience. Changing their thought process helped the students proactively modify their current circumstances to promote a positive outlook. A unique finding of the present study was that occasionally an OT student could not identify a disruption to occupational balance and required input from family, friends, or faculty to realize a change was necessary. Entry-level OT graduate students in the present study who experienced a disruption to occupational balance implemented various strategies to return to a state of occupational balance. The data analysis of the strategies students utilized resulted in five categories and are used to organize the discussion: adapting methods to effectively and efficiently learn using support systems participating in multiple occupational roles making time for self-care knowing when to seek professional assistance Entry-level OT graduate students implemented distinctive strategies during various stages of the program depending on the circumstance causing the disruption. Students utilized a trial-and-error approach to select a strategy at the start of the program. Students were able to reflect on past experiences and incorporate a strategy that was successful previously as they progressed through the program. Students in OT Adapted Methods for Learning to Improve Their Effectiveness and Efficiency Students interviewed for this study discussed the importance of developing a system to organize coursework in the entry-level OT graduate program that fit their unique style and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 118 habits. They explained that trying to adopt another students method of organizing school work was not helpful, and often, the method used in undergraduate education also was inadequate. Coursework organization, including any preparatory work, assignment due dates, and test dates, helped students distribute time among their courses. A system of organization also ensured students allotted sufficient time to lengthier assignments. For some students, a good method of organizing also helped students integrate socialization and self-care into their schedules without feeling they were subtracting from their academic work. Malek-Ismail and Krajniks (2018) findings supported the concept of developing an individualized organization system. The authors discovered that entry-level OT graduate students changed the way they organized their time from general to more detailed schedules to improve occupational balance (Malek-Ismail & Krajnik, 2018). Likewise, Matuska and Christiansen (2008), in their model of lifestyle balance, discussed how chosen occupations need to help a person to organize their time and energy in ways that enable them to meet important personal goals and renewal (p. 11). The researcher of the present study deduced that when OT students were able to organize time to increase their graduate school success, they reported improved occupational balance. Students in the present study also expressed the need to adapt their study habits in entrylevel OT graduate school. For example, several students explained memorizing material led to success in their undergraduate education but was not adequate for graduate school. Malek-Ismail and Krajnik (2018) reported similar findings in their study. Entry-level OT graduate students reported poor study practices in their undergraduate education because recall of information was sufficient for a test (Malek-Ismail & Krajnik, 2018). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 119 Students in the present study identified the need to learn the material to apply it in current and future classes in the entry-level OT graduate program and later as they transitioned to practice. Determining how to learn and retain material was an arduous process that OT students navigated throughout the first semesters of graduate school. Once they established a method that worked, they could apply this approach across their graduate courses. Although learning new methods for studying was stressful, students saw the value in retaining information to enhance their future careers as occupational therapists. In addition, entry-level OT graduate students perceived the material as more relevant than their undergraduate education. Malek-Ismail and Krajnik (2018) found that entry-level OT graduate students demonstrated intrinsic motivation and perceived [graduate] school as valuable and worth their time and effort (p. 14). In addition, Matuska and Christensen (2008), in their model of lifestyle balance, suggested a persons occupations should lead to feelings of competence. In the present study, entry-level OT graduate students who could integrate effective study methods to learn the academic concepts experienced success and increased confidence. Using Support Systems Like Govender et al. (2015), entry-level OT graduate students in the present study depended on the support of other people in their lives when they experienced an occupational balance disruption. Some students relied on peers intrinsic to and extrinsic to the entry-level OT graduate program to assist with difficult situations (Tompkins et al., 2016). Other students discussed their experiences of balance disruptions with family, supervisors, or faculty members. Van Veld et al. (2018) noted that DPT students in the first year of a doctor of physical therapy program commonly sought family and friends to ask advice or express frustrations with the STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 120 program (Van Veld et al., 2018). Hearing another persons perspective on a situation often helped the DPT students shift their mindset toward a more positive outlook. Several entry-level OT students interviewed for this study discussed the importance of parental support during their time in graduate school. Similarly, Tompkins et al. (2016) reported students perceived family as being one of the strongest supports for graduate school. MalekIsmail and Krajnik (2018) also reported entry-level OT students in their study perceived family as a vital support system in graduate school. Parents of students included in the present study encouraged and demonstrated an unrelenting belief in their child that increased self-confidence to continue in the program, even when students believed they could not succeed. When entrylevel OT graduate students in the present study experienced an occupational balance disruption resulting from an unexpected grade, family were nonjudgmental and provided a different perspective to assist with understanding the situation. In the present study, students also explained their family emphasized self-care and helped them realize the need to engage in activities outside of academics. Entry-level OT graduate students interviewed for this study expressed the importance of relationships with faculty members. Some OT students perceived faculty to be intimidating at first, but most stated faculty assisted students with the transition to graduate school. Connecting with a faculty advisor was especially important to students who did not know anyone else in their cohort. Van Veld et al. (2018) noted first-year entry-level DPT students reported seeking faculty support more in the second and third semesters of the program compared to the first semester. Malek-Ismail and Krajnik (2018) also described the benefits of faculty assistance with the transition to entry-level OT graduate school. Students in the first semester of an MOT program STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 121 perceived faculty were supportive and genuinely concerned about their well-being (Malek-Ismail & Krajnik, 2018). Entry-level OT graduate students in the present study expressed a sense of reassurance with the knowledge that faculty were available to discuss course content and assignments. Consultation with faculty provided students with confidence as they navigated unfamiliar coursework. Schmidt and Hansson (2018) conducted a literature review with discovery that faculty support positively influenced a students commitment to the academic work, consequently benefiting the students outlook. Rummell (2015) examined students in a graduate psychology program and found students who perceived a greater connection and mentorship with faculty had increased positive perceptions of the program (p. 394). One entry-level OT graduate student in the present study observed a faculty member model occupational balance, which provided the student with the confidence to set boundaries and practice self-care. Tompkins et al. (2016) concluded that a method to improve graduate student appreciation for self-care is to model the practices for them. In another study, first-semester entry-level OT graduate students observed an incongruence between self-care teachings in their program and the actual practice among the faculty (Malek-Ismail & Krajnik, 2018). Some entry-level OT graduate students in the present study perceived a lack of support from faculty that contributed to occupational balance disruptions. Students reported faculty seemed unaware of the stress students experienced as they entered entry-level graduate school. Faculty often compounded an occupational balance disruption with overwhelming amounts of information. Faculty often seemed narrowly focused on the course they were teaching instead of considering examination and project due dates that may coincide with those of other courses. This finding was similar to that of another study that explored the perceptions of first-semester STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 122 entry-level MOT students. The MOT students indicated they believed faculty intentionally scheduled assignments to be due simultaneously (Malek-Ismail & Krajnik, 2018). One student in Malek-Ismail and Krajniks (2018) study explained faculty listened to mental health concerns of students but did not offer any assistance for success. The results of a study conducted with students in a graduate psychology program also supported this finding (Rummell, 2015). Forty percent of students surveyed for the study reported faculty in their program did not respect their opinion. Rummell (2015) also found students desired an improved relationship with faculty in their graduate program. In the present study, other entry-level OT graduate students reported faculty frequently do not honor their posted office hours, leaving students feeling overlooked. In the present study, students in entry-level OT graduate programs described peer relationships as crucial to survival in the program. Peers understood the demands of the graduate program and could provide encouragement and suggestions relevant to the circumstances. Eklund et al. (2017) supported this finding that supportive social networks can improve participation in occupations and contentment with occupational balance. Malek-Ismail and Krajnik (2018) also noted entry-level OT cohort peers to be the primary support for firstsemester MOT students as they shared the same experiences and could relate to student emotions. Govender et al. (2015) reported one of the most common coping mechanisms OT graduate students used to manage stress was social support. In the present study, socialization with peers outside of the entry-level OT graduate program was important. Peers outside of the graduate program provided a distraction from academics that helped students engage in self-care practices. Tompkins et al. (2016) supported the importance of peers outside of the graduate program. They ascertained that graduate students STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 123 perceived the support they received from cohort peers and those outside of their program as equally important in their success (Tompkins et al., 2016). At times, entry-level OT graduate students in the present study reported that their cohort peers contributed to an occupational balance disruption when they voiced complaints about the program or projected their stress onto other students. Malek-Ismail and Krajnik (2018) also reported some entry-level OT graduate students expressed beliefs that cohort peers contributed to increased stress, although this finding was not a significant theme that emerged from their study. They explained some students imagined excessive worrying over class work was contagious (Malek-Ismail & Krajnik, 2018, p. 13). These authors (Malek-Ismail & Krajnik, 2018) described group work as distracting to students, compelling some to separate from their peers and select solo work instead. Similarly, Schmidt and Hansson (2018) performed a literature review to examine doctoral students well-being and discovered students could view peers as a support as well as an additional stressor. Participating in Multiple Occupational Roles Students in entry-level OT graduate programs interviewed for the present study discussed engagement in multiple occupational roles and the meaning to their occupational balance. Students expressed the belief that engagement in more than one role contributed to identity and helped them trust their identity was more than being a graduate student. Following a content analysis of existing literature completed in 2017, researchers identified a theme of occupational balance as having a mix of occupations (Eklund et al., 2017, p. 47), which demonstrates support for students to engage in more than one occupational role. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 124 Making Time for Self-Care Students in entry-level OT programs interviewed for the present study indicated that they gained an appreciation for self-care throughout their graduate program. Several reported ignoring personal needs during the first semester of the graduate program, and were often overwhelmed with the rigor and expectations of their program. Van Veld et al. (2018) reported a similar finding in students in an entry-level DPT graduate program during their first semester of graduate school. The DPT students reported that the time they spent in exercise decreased the first semester, stating they believed that all free time needed to be devoted to academics (Van Veld et al., 2018). Over time, entry-level OT graduate students in the present study learned the value of self-care, including leisure and socialization. They used personal time to cope with the stressors of graduate school. Van Veld et al.s (2018) finding supported the importance of student engagement in self-care. After the first semester, they reported that DPT students increased their engagement in exercise as a coping mechanism to mitigate the stress of graduate school. Schmidt and Hansson (2018) supported the importance of engaging in self-care practices during graduate school. They discovered that doctoral students engaged in exercise, yoga, and self-reflection as coping mechanisms for graduate school. In a model of lifestyle balance, Matuska and Christiansen (2008) stressed that a balanced lifestyle should include occupations that are healthful, meaningful, and sustainable (p. 11). Integrating self-care into life is beneficial to the physical and mental health of students. Cino (2016) reported that nursing students who made time for personal self-care had improved family relationships (p. 15). The findings of these studies support the addition of self-care promotion in graduate program curricula. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 125 A study investigating self-care practices among psychology graduate students indicated sleep hygiene decreased stress levels, but a relationship between engagement in exercise and lower stress was nonexistent (Myers et al., 2012). This finding contradicted the present study because entry-level OT graduate students specifically discussed finding time to exercise as a consistent form of self-care. Knowing When to Seek Professional Assistance Some of the students interviewed for the present study mentioned seeking professional assistance to manage anxiety during entry-level OT graduate school. They pursued counseling services indicating discussion of obstacles and concerns with an impartial third party was beneficial. Van Veld et al. (2018) noted that DPT students sought counseling services after the first semester of entry-level graduate school. In the present study, other students obtained medication to help manage panic attacks and anxiety. Other students in the present study required counseling and medication to successfully navigate the rigor of graduate school. What are the Differences in the Occupational Balance Strategies of Entry-Level OT Graduate Students Who Report High, Medium, and Low Occupational Balance? Entry-level OT graduate students completed the OBQ11 during the informed consent process (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020). During the interview process, 19 out of 22 students indicated they believed their life was occupationally balanced; however, scores on the OBQ11 varied. When the students completed the questionnaire, they answered 11 questions about current occupational balance. Some of the questions related to satisfaction with the variability of occupations and the amount of time spent in relaxation. The possibility exists that even though students spent a majority of their time on academic work and did not relax as much as they would like, the students still perceived STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 126 occupational balance at this particular point in time when they completed the questionnaire. Anaby et al. (2010a) suggested occupational balance and occupational imbalance are not two opposing attributes, but are two distinct dimensions that can co-exist (p. 285). The researcher postulates from the results of the present study that student lives are dynamic and influenced by multiple contexts at any given point during the entry-level OT graduate program. The results led the researcher to determine that personal values, past experiences, program requirements, internal contexts, external contexts, and student support systems provide meaning to feelings of balance and underscore the importance of strategies students use to mitigate occupational balance disruptions. Myers et al. (2012) suggested that personality and beliefs about self-care practices influence self-care and stress levels. These dynamically changing variables are distinctive to the person, demonstrate the fluctuations in occupational balance, and contribute to difficulty measuring occupational balance (Myers et al., 2012). However, measuring occupational balance at specific points in time and considering simultaneous contextual factors may provide insights into the impact of current circumstances on perceived occupational balance (Myers et al., 2012). Similar to the present study, Malek-Ismail and Krajnik (2018) concluded that students move through periods of imbalance and balance as they transition from undergraduate to graduate education. However, Malek-Ismail and Krajnik (2018) did not quantify occupational balance using the OBQ or study students after the first semester of graduate school; therefore, comparing the present study to the results these authors found was not possible beyond the first semester. The researcher of the present study only discovered one study investigating the use of the OBQ11. The researchers in that study examined the construct validity of the OBQ11 (Hkansson STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 127 et al., 2020). The researcher in the present study did not examine the quality of the instrument but categorized the participant responses into high, medium, and low categories to compare and contrast occupational balance strategies across the three groups. Additionally, other researchers used the original OBQ to examine persons from a more extensive age range (Hkansson et al., 2020; Wagman & Hkansson, 2014b; Yu et al., 2018) or with a specific diagnosis, such as rheumatoid arthritis (Wagman et al., 2020). Two exceptions were studies addressing the occupational balance in adults in Sweden (Wagman & Hkansson, 2014a) and health professionals in Sweden (Wagman et al., 2017). The authors did not find any significant differences among summed scores on the OBQ; however, Wagman and Hkansson (2014a) reported a significant positive correlation among three specific items on the OBQ and self-rated health and life satisfaction. These findings suggest that individual OBQ items may provide more useful information about managing occupational balance than the summed scores. What Happens to the Way Entry-Level OT Graduate Students Manage Occupational Balance When They Experience a Change in the Expectations of Their Student Role or Other Life Roles? Students in entry-level OT graduate programs interviewed for this study discussed several changes in their life roles that disrupted occupational balance. One of the changes was paid employment. Students secured a job for various reasons, including the necessity to afford living expenses. Backman (2004) suggested that occupational imbalance occurs when necessary and desired occupations intersect. These occupations can impede each other when an OT student does not allot enough time to entirely engage in one or both of them. If work interferes with the completion of academic work, a disruption to occupational balance may occur. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 128 Entry-level OT graduate students in the present study experienced other life roles that included planning for the birth of a child, caring for an ill family member, and assuming household responsibilities, all of which led to an occupational balance disruption. Yazdani et al. (2018) confirmed this finding by discussing potential causes of occupational balance disruptions, including role imbalance, responsibilities, and priorities at present (p. 293). These contextual factors diminish a persons control and may interfere with personal goals, disrupting occupational balance. Students in entry-level OT graduate programs interviewed for the present study indicated the COVID-19 pandemic was one of the major disruptions to occupational balance they experienced in school. Students experienced stress and anxiety when the COVID-19 pandemic began, similar to when they first transitioned to entry-level OT graduate school. Identifying an occupational balance disruption of equal or higher magnitude to the disruption that occurred during the initial transition to the entry-level graduate program was a unique finding to the present study. Previous authors did not discuss a major disruptive event like the COVID-19 pandemic for students in OT programs or in any other disciplines. Additionally, the researcher of the present study did not locate any studies investigating entry-level OT graduate student reactions to the COVID-19 pandemic. Students in the present study had to change their method of organization when the mode of delivery switched to virtual rather than in-person instruction. Students reported that they had to develop new study habits because their previous habits were no longer adequate. Mitschke et al. (2021) reported graduate students experienced personal challenges related to the COVID-19 pandemic, including higher levels of stress, feeling overwhelmed with responsibilities, and having difficulty concentrating on their classwork (p. 51). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 129 The unpredictability of changes when campuses closed and academic courses moved online was an overwhelming experience. Kee (2021) conducted a qualitative study to investigate the experiences of students in graduate programs during the COVID-19 pandemic. Kee (2021) reported students perceived a loss of control in their lives when governors across the country enacted stay-at-home orders. The author also noted that graduate students experienced heightened anxiety over the unpredictable nature of the move online (Kee, 2021). In addition, social isolation created a barrier to support systems, and many activities for self-care were no longer possible. Other authors also discovered that decreased interaction with others, including graduate program peers, created psychological disturbances for students (Varadarajan et al., 2021). Students in the present study enjoyed attending in-person classes as in-person attendance helped them focus on the course material and enabled the ability to distance themselves from the many distractions in their homes. As Kee (2021) reported, graduate students perceived face-toface courses helped them stay organized, promoted peer relationships, and improved course content discussions. Entry-level OT graduate students perceived their study habits and organization methods were no longer adequate, and planning was impossible due to the ongoing changes occurring in their academic lives when courses moved online. Several OT students expressed beliefs that a boundary between their academic and personal lives was nonexistent because their home became their classroom. Kee (2021) found graduate students believed the COVID-19 pandemic disrupted their work-life balance as they were using their homes for their personal and academic lives. In the present study, focusing on a lengthy online class or demonstrating the discipline to complete academics was difficult for some OT students. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 130 Similarly, Octaberlina and Muslimin (2020) reported students conveyed that the number of distractions in their homes was a barrier to online learning. Conversely, some entry-level OT graduate students in the present study reported improved occupational balance with the move to online learning. For example, several entrylevel OT graduate program students explained their commute was abolished. Students perceived they had more time to get homework completed because they did not have to engage in self-care routines to attend class in person. Varadarajan et al. (2021) also reported positive outcomes of the COVID-19 pandemic, including increased time for learning, self-care, time with family, and decreased time commuting to attend class. Students in the present study expressed the importance of personal reflection to assist in returning to occupational balance following a disruption. A finding unique to the present study was that students reflected on past experiences in the entry-level OT graduate program to help formulate appropriate responses to occupational balance disruptions. They also discussed changing their perspective away from seeking perfection and toward integrating personalized approaches to studying to improve performance in graduate school. Malek-Ismail and Krajnik (2018) stated entry-level OT graduate students demonstrated increased accountability for their actions by the end of the first semester of graduate school. Additionally, they explained that students realized they still could become an occupational therapist with less-than-perfect academic performance (Malek-Ismail & Krajnik, 2018). For Entry-Level Graduate Students in Different Semesters of the OT Program, How Do the Strategies for Managing the Student Role Change? Occupational therapy students interviewed for the present study experienced varying levels of occupational balance throughout their time in the entry-level graduate program. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 131 Students identified causes of occupational balance disruptions that included the start of the graduate program and the start of a new semester within the program. Personal responsibilities, comfort level with peers, and external circumstances influenced whether students experienced a disruption and the success with which they were able to integrate a strategy to return to a state of occupational balance. Occupational therapy students in the present study overwhelmingly described the first semester of the entry-level graduate program as the semester that caused the most occupational balance disruption. Students experienced new academic requirements and unfamiliar course structures and assessments in the first semester. Malek-Ismail and Krajnik (2018) confirmed that students reported a high level of life imbalance in the first semester of the OT graduate program (p. 8). Rummell (2015) also concluded students in graduate psychology programs experienced the heaviest academic workloads and the most stress in the earlier years of graduate school (p. 394). This finding contrasts with Govender et al. (2015), who discovered fourth-year OT graduate students reported the most stressors in the entry-level graduate program. In the present study, most of the OT students in the first semester managed disruptions initially through trial and error of various strategies they developed or other people suggested. Occupational therapy students in the first semester discussed spending increased time on academics, which translated to little time for self-care or leisure. They also perceived a lack of time to develop social connections, contributing to occupational balance disruptions. As entry-level OT graduate students in the present study learned to navigate graduate courses and developed relationships with peers and professors in later semesters, occupational balance disruptions lessened. Phillips (2010) supported this finding in a grounded theory study STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 132 investigating the stressors of nurse anesthetists. The author found stress levels lessened and coping skills improved as students progressed through the graduate program (Phillips, 2010). In the present study, several entry-level OT graduate students described the beginning of a semester as disruptive due to exposure to new course content and new instructors. However, OT students became more comfortable with faculty and graduate program expectations as each semester progressed. Van Veld et al. (2018) discussed similar findings in their study. Students in a DPT program reported increased confidence in their ability to respond to stressful situations in the entry-level graduate program as they progressed through three consecutive semesters (Van Veld et al., 2018). Most entry-level OT graduate students in the present study perceived balanced lives by the end of the program. They reported increased time for socialization and self-care activities. Theory of Occupational Balance The researcher of the present study created a new theory of occupational balance for entry-level OT graduate students using a grounded theory approach. See Figure 1. The meaning of occupational balance is unique to each OT student based on personal values and life experiences. Occupational therapy students experienced micro and macro influences to occupational balance throughout their time in an entry-level graduate program. Whether a disruption occurs from these influences depends on the combination of various contextual factors the students may experience at the time of the occurrence. See Figure 2. Entry-level OT graduate students must identify their situation and its influence when occupational balance is disrupted. Students analyze situations either without help or with the assistance of others. Once the students are aware of the disruption in occupational balance, they must desire to return to a state of occupational balance and then consciously determine to do so. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 133 Recall that some students accepted occupational balance disruptions as acceptable because engagement in education was temporary. The return to occupational balance occurs through various strategies based upon the magnitude of the disruption and whether the students experienced something similar in the past. Finally, the students remain in a state of occupational balance until another disruption occurs as long as they continue implementing their chosen strategies. At that point, when another occupational balance disruption occurs that challenges the effectiveness of current strategies, the process of identifying the disruption, implementing new or modified strategies, and returning to occupational balance begins again. See Figure 1. The researcher did not find any other grounded theories in the literature of occupational balance in entry-level OT graduate students. A majority of the research on occupational balance focused on the concept of occupational balance (Westhorp, 2003) or on various definitions of occupational balance (Eklund et al., 2017; Yazdani et al., 2018). Other authors explored self-care practices graduate students used to assist in stress management (Myers et al., 2012) or described the role of coping mechanisms in altering stress levels in students enrolled in helping disciplines (Enns et al., 2018). However, the authors of these studies did not discuss occupational balance or life balance. There was one study where the authors investigated the occupational balance of entrylevel OT graduate students (Malek-Ismail & Krajnik, 2018). However, the authors interviewed students only in the first semester of an entry-level OT graduate program. They did not develop a theory of occupational balance, but their data analysis provided evidence that students experience different stages of occupational balance in the first semester of the graduate program (Malek-Ismail & Krajnik, 2018). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 134 Results of the present study advance the information from Malek-Ismail and Krajnik (2018) with the researcher able to identify specific strategies entry-level OT graduate students used to regain occupational balance. The researcher also was able to ascertain the role of faculty in the occupational balance of students. Furthermore, some students in the present study were unable to independently identify the need to make a change to return to occupational balance, a unique finding of this study. Another distinctive finding is that students who experienced a disruption to occupational balance may reflect on strategies used in the past to help them regain occupational balance. Lastly, the COVID-19 pandemic created an unexpected disruption such that most students described the resulting occupational balance disruption as difficult to manage. The information gleaned from students regarding the strategies to return to balance after a major disruptive event is also an original finding of this study. The researcher of the present study found that entry-level OT graduate students desired to engage in various occupations as a method to ascertain occupational balance. Additionally, participation in additional occupations outside of their student role promoted happiness and occupational balance. These findings align with Westhorps (2003) concept of occupational balance that people engage in multiple occupations to promote health and well-being (p. 103). Students in the present study conveyed the importance of determining the occupations in which they engaged to improve occupational balance. Westhorp (2003) also discussed the value of people controlling how to divide their time among occupations. Westhorp (2003) concluded people needed to engage in occupations that involve mental, physical, social, emotional, and spiritual components. In contrast, entry-level OT graduate students in the present study did not discuss spirituality specifically as it relates to occupational balance, except as an indirect reference. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 135 Westhorp (2003) did not discuss disruptions to occupational balance, but provided a model for achieving occupational balance. Westhorp (2003) discussed the need for a person to decide on essential occupations and how to engage in them by saying yes or no to activities. Results from the present study supported this concept in Westhorps (2003) model. Entry-level OT graduate students in the present study often reported the belief that academics were most important and thus did not have the option to say no to academic work. However, a focus on academics often led to an occupational balance disruption. As a result, students discovered they needed to say yes (Westhorp, 2003) to more self-care activities and other occupations if they desired to return to a state of occupational balance. Westhorp (2003) also described that a person must consider the effect of environmental change (p. 105) as needed at any point in the cycle to achieve occupational balance. Similarly, the results from the present study led the researcher to suggest that micro and macro contexts pressure a student to achieve occupational balance as indicated in the conditional/consequential matrix described earlier and shown in Figure 2. Matuska and Christiansen (2008) support the present study in their model of lifestyle balance. The authors discussed five aspects of occupations that lead to the perception of a balanced lifestyle. In their model, the authors explained that a persons choice of occupations must meet basic human needs, offer possibilities for developing relationships with others, encourage feelings of self-confidence, promote meaning in life, and assist in meeting selfestablished objectives (Matuska & Christiansen, 2008). Aligning with Matuska and Christiansens (2008) model, entry-level OT graduate students in the present study reported occupational balance disruptions when they could not engage in self-care practices or interact with peers or family. They also experienced disruptions when they did not perform as well as they expected on an academic assignment or discovered their method of organization was STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 136 inadequate to achieve their goals. Matuska and Christiansen (2008) did not discuss what happens when a disruption to lifestyle balance occurs nor did they provide strategies to achieve or regain the perception of lifestyle balance. Like Westhorp (2003), Matuska and Christiansen (2008) acknowledged that the environment might influence a persons occupational engagement. The authors explained that this environmental influence might affect lifestyle balance; however, they did not provide specific strategies a person could implement if a disruption to lifestyle balance occurred. Study Limitations In the present study, the sample of 26 participants included students from seven universities; however, all universities were in the Midwest; therefore, the results may not apply to entry-level OT graduate students in other parts of the country. Sampling students from other parts of the country may produce a theory with propositions of occupational balance other than the ones derived in this study. Students were from different types of entry-level OT graduate programs, including masters and doctoral levels. In addition, students entered their entry-level OT graduate program at different points of their academic career, including direct entry as firstyear undergraduate students and post-baccalaureate students. Sampling students from one type of program may produce results specific to the program that would not apply to other educational levels, such as post-professional. Lastly, sampling of students occurred from various points in their entry-level OT graduate program from the first semester through the end of their program. Sampling students who are at the same place in their program may provide insights into how occupational balance varies across programs at specific points in the program. The researcher is an occupational therapist and works as a program director of an MOT program at a small university in the Midwest. The researcher interacts with students daily and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 137 discusses occupational balance in class and during advising sessions with students. As a result of these two facts, the researchers bias toward occupational balance as a useful concept may have unintendedly influenced the data collection and analysis processes. However, the researcher took steps to mitigate this personal bias during data collection and analysis, including using a reflective journal, establishing an audit trail, and writing memos. Additionally, 13 participants were current students at the university where the researcher works. As outlined in the method section, the researcher took steps to avoid coercion of these students during the data collection portion of this study; however, because participants were current students in the program, they may not have been forthcoming with information. Implications for Education and Research This study may benefit students in entry-level OT graduate programs, administrators, and faculty of those programs. Understanding student occupational balance and circumstances that can cause disruptions may help prevent disruptions from creating unmanageable stress. In addition, understanding strategies students can implement to return to occupational balance may help faculty suggest options for students who cannot self-manage an occupational disruption. Students in graduate programs may benefit from using the strategies the participants described in this study to return to occupational balance following a disruption. The information presented in this paper may be beneficial especially to OT students transitioning to entry-level graduate school. Data analysis from this study led the researcher to suggest that entry-level students experience disruptions to balance that are the most difficult to manage during the first semester of graduate school. Graduate programs present a new way of learning, yet many students are not equipped with study habits to transition without increased anxiety and stress. Additionally, many students relocate to a new city for their graduate program and do not have an STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 138 easily accessible social network. Students in this study explained that time along with trial and error were necessary to figure out how to navigate the entry-level OT graduate program. Retaining occupational balance involved determining a study plan and selecting methods of organizing course work to manage the rigor of the program. Integrating the strategies from this study can provide a starting point for figuring out an effective method. This researcher found that students are uncomfortable speaking with faculty about concerns, especially at the outset of the entry-level OT graduate program. Faculty in entry-level OT graduate programs focus on the required curricular standards in the courses they teach. If students do not communicate concerns, faculty may not realize the anxiety and stress students experience in the entry-level OT graduate program. The results from this study provide faculty with insight into students viewpoints and encourage faculty to initiate communication with more reserved students who do not contact faculty. In addition, faculty can provide OT students with strategies discussed in this study as suggestions for improving occupational balance after experiencing disruptions throughout the entry-level graduate program. Finally, faculty can facilitate the relationship-building of students within the program. For example, faculty can assign peer mentors who can assist new entry-level OT graduate students in navigating some of the initial challenges of starting a new program (Mitschke et al., 2021). Another suggestion is to host networking sessions for new cohorts so students can meet peers and build relationships outside of the classroom (Mitschke et al., 2021). Results of the present study can inform program administrators and faculty about the implications of curriculum design for the occupational balance of entry-level OT graduate students. Accreditation standards require faculty in entry-level OT graduate programs to include extensive content (ACOTE, 2022). Leadership and faculty in entry-level OT graduate programs STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 139 often are clinicians who transition to academics and do not possess extensive knowledge in curriculum design (Frantz & Smith, 2013; Lockhart-Keene & Potvin, 2018). This lack of knowledge can lead to unevenly dispersed credit hours among semesters. Students may experience several courses with greater difficulty or courses with dense and complex information in the same semester, which may increase student stress. Faculty may not discuss adequately course content and requirements with other faculty in the program leading to content redundancies or lengthy assignments due at the same time. All of these curriculum scenarios can cause an occupational balance disruption for entry-level OT graduate students. To assist entry-level OT graduate students return to occupational balance or avoid a disruption, faculty can plan time in class to complete assignments. Faculty meetings should include discussions about student behaviors that may indicate occupational balance disruptions. Faculty can plan curriculum retreats to review course content to ensure it is scaffolded and reinforced, avoiding unnecessary redundancies (Krusen, 2020). Integrating a curricular thread of self-care to teach OT students mindfulness techniques and other strategies may improve the ability of students to manage stress (Cahill, 2021). These skills may improve job satisfaction and quality of life once students become occupational therapists (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). Overworked staff are more prone to errors and inconsistent attendance at work, which lead to decreased quality of care for service recipients (Costa, 2018). Teaching OT students the importance of self-care is imperative so students develop strategies to manage the stress that accompanies a career in healthcare (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). As noted throughout this study, other circumstances may arise in a students career that may create a disruption of a similar or greater magnitude as the initial transition to graduate school. The COVID-19 pandemic was such a disruption. Understanding the causes of disruptions STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 140 to occupational balance during these unexpected and disruptive situations should encourage faculty to automatically implement strategies to increase student retention and success. Researchers should design future studies to investigate changes in student occupational balance across time in the entry-level OT graduate program. For example, researchers can interview the same students during different points in their academic program to glean further insight into specific strategies to help students succeed. Additionally, separating doctoral level student data from master-level student data may demonstrate differences in occupational balance among OT students in different degree programs. Similarly, investigating the occupational balance strategies for OT students who matriculate into entry-level graduate programs before completing an undergraduate degree would be beneficial. Conclusion This researcher examined how entry-level OT graduate students incorporated strategies to manage occupational balance in their role as a student in the entry-level OT graduate program. Students developed a meaning of occupational balance based on past experiences and personal values. Disruptions to occupational balance occurred throughout the entry-level graduate program and within individual semesters. Students needed to identify disruptions to occupational balance before they could implement a strategy to return to occupational balance. This study reveals several strategies OT students implemented, including adapting methods to effectively and efficiently learn, using support systems, participating in multiple occupational roles, making time for self-care, and knowing when to seek professional assistance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 141 References Accreditation Council for Occupational Therapy Education. (2022). 2018 Accreditation Council for Occupational Therapy Education standards and interpretive guide (effective July 31, 2020) January 2022 interpretive guide version. Accreditation Council for Occupational Therapy Education. https://acoteonline.org/accreditation-explained/standards/ Accreditation Council for Occupational Therapy Education. (2018). Academic programs annual data report: Academic year 2017-2018. https://www.aota.org/~/media/Corporate/Files/EducationCareers/Educators/2017-2018Annual-Data-Report.pdf Acton, A. (2020). Directors stay at home order. Ohio Department of Health. https://governor.ohio.gov/static/DirectorsOrderStayAtHome.pdf American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl.1), S1-S48. https://doi.org/10.5014ajot.2014.682006 Anaby, D. R., Backman, C. L., & Jarus, T. (2010a). Measuring occupational balance: A theoretical exploration of two approaches. Canadian Journal of Occupational Therapy, 77(5), 280-288. https://doi.org/10.2182/cjot.2010.77.5.4 Anaby, D., Jarus, T., Backman, C. L., & Zumbo, B. D. (2010b). The role of occupational characteristics and occupational imbalance in explaining well-being. Applied Research Quality Life, 5, 81-104. https://doi.org/10.1007/s11482-010-9094-6 Aufricht, G. R., Brewer, J. H., Culver, A. L., Fitzpatcirck, R. A., Gottlich, C. P., Gregston, A. P., ... Pippen, J. E. (2019). A medical student perspective on solutions for burnout. Proceedings (Baylor University Medical Center), 32(3), 452-455. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 142 https://doi.org/10.1080/08998280.2019.1613474 Backman, C. L. (2004). Occupational balance: Exploring the relationships among daily occupations and their influence on well-being. Canadian Journal of Occupational Therapy, 71(4), 202-209. https://doi.org/10.1177/000841740407100404 Barrett, J. L., Mazerolle, S. M., & Eason, C. M. (2016). Exploring senior level athletic training students perceptions on burnout and work-life balance. Athletic Training Education Journal, 11(2), 110-118. https://doi.org/10.4085/1102110 Benavides, A. D., & David, H. (2010). Local government wellness programs: A viable option to decrease healthcare costs and improve productivity. Public Personnel Management, 39(4), 291-306. https://doi.org/10.1177/009102601003900401 Benshoff, J. M., Cashwell, C. S., & Rowell, P. C. (2015). Graduate students on campus: Needs and implications for college counselors. Journal of College Counseling, 18(1), 82-94. https://doi.org/10.1002/j.2161-1882.2015.00070.x Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759-769. https://doi.org/10.1377/hlthaff.27.3.759 Birks, M., Mills, J., Francis, K., & Chapman, Y. (2009). A thousand words paint a picture: The use of storyline in grounded theory research. Journal of Research in Nursing, 14(5), 405417. https://doi.org/10.1177/1744987109104675 Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. https://doi.org/10.1370/afm.1713 Buckley, C. A., & Waring, M. J. (2013). Using diagrams to support the research process: Examples from grounded theory. Qualitative Research, 13(2), 148-172. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 143 https://doi.org/10.1177/1468794112472280 Cahill, S. (2021, November 1). Research update: Occupational therapy student stress, wellbeing, and mindfulness in OT education. OT Practice. https://www.aota.org/publications/ot-practice/ot-practice-issues/2021/research-update-otstudent-well-being Centers for Disease Control and Prevention. (2019, December 1). CDC workplace health resource center. https://www.cdc.gov/workplacehealthpromotion/index.html Christiansen, C. (2007). Adolf Meyer revisited: Connections between lifestyles, resilience and illness. Journal of Occupational Science, 14(2), 63-76. https://doi.org/10.1080/14427591.2007.9686586 Cino, K. (2016). Learning balance: Self-care in nursing curriculum. Beginnings, 36(4), 14-15. Clark, H. K., Murdock, N. L., & Koetting, K. (2009). Predicting burnout and career choice satisfaction in counseling psychology graduate students. The Counseling Psychologist, 37(4), 580-606. https://doi.org/10.1177/0011000008319985 Corbin, J., & Strauss, A. (2015). Basics of qualitative research: Techniques and procedures for developing grounded theory (4th ed.). SAGE. Costa, D. (2018). Better days at work: Identifying, preventing burnout in occupational therapy practice. OT Practice, 23(6), 10-15. Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry & research design: Choosing among five approaches (4th ed.). SAGE. Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The Satisfaction with Life Scale. Journal of Personality Assessment, 49(1), 71-75. https://doi.org/10.1207/s15327752jpa4901_13 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 144 Di Pierro, M. (2010). Healthcare education: Making a difference in the lives of graduate students. The Journal for Quality and Participation, 33(1), 15-17. Draucker, C. B., Martsolf, D. S., Ross, R., & Rusk, T. B. (2007). Theoretical sampling and category development in grounded theory. Qualitative Health Research, 17(8), 11371148. https://doi.org/10.1177/1049732307308450 Dur, M., Steiner, G., Fialka-Moser, V., Kautzky-Willer, A., Dejaco, C., Prodinger, B., ... Stamm, T. A. (2014). Development of a new occupational balance-questionnaire: Incorporating the perspectives of patients and healthy people in the design of a self-reported occupational balance outcome instrument. Health and Quality of Life Outcomes, 12(45). https://doi.org/ 10.1186/1477-7525-12-45 Eklund, M., Orban, K., Argentzell, E., Bejerholm, U., Tjrnstrand, C., Erlandsson, L., & Hkansson, C. (2017). The linkage between patterns of daily occupations and occupational balance: Applications within occupational science and occupational therapy practice. Scandinavian Journal of Occupational Therapy, 24(1), 41-56. https://doi.org/10.1080/11038128.2016.1224271 El-Ghoroury, N. H., Galper, D. I., Sawaqdeh, A., & Bufka, L. F. (2012). Stress, coping, and barriers to wellness among psychology graduate students. Training and Education in Professional Psychology, 6(2), 122-134. https://doi.org/10.1037/a0028768 Enns, A., Eldridge, G. D., Montgomery, C., & Gonzalez, V. M. (2018). Perceived stress, coping strategies, and emotional intelligence: A cross-sectional study of university students in helping disciplines. Nurse Education Today, 68, 226-231. https://doi.org/10.1016/j.nedt.2018.06.012 Eriksson, T., Westerberg, Y., & Jonsson, H. (2011). Experiences of women with stress-related ill STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 145 health in a therapeutic gardening program. Canadian Journal of Occupational Therapy, 78(5), 273-281. https://doi.org/10.2182/cjot.2011.78.5.2 Erlandsson, L., & Christiansen, C. H. (2015). The complexity and patterns of human occupations. In C. H. Christiansen, C. M. Baum, & J. D. Bass (Eds.), Occupational therapy: Performance, participation, and well-being (4th ed., pp. 113-127). SLACK. Erlandsson, L., & Hkansson, C. (2009). Aspects of daily occupations that promote life balance among women in Sweden. In K. Matuska, & C. Christiansen (Eds.), Life balance: Multidisciplinary theories and research (pp. 115-1130). SLACK & AOTA Press. Evans, T. M., Bira, L., Gastelum, J. B., Weiss, L. T., & Vanderford, N. L. (2018). Evidence for a mental health crisis in graduate education. Nature Biotechnology, 36(3), 282-284. https://dx.doi.org/10.1038/nbt.4089 Ezzati, A., Jiang, J., Katz, M. J., Sliwinski, M. J., Zimmerman, M. E., & Lipton, R. B. (2014). Validation of the Perceived Stress Scale in a community sample of older adults. International Journal of Geriatric Psychiatry, 29(6), 645-652. https://doi.org/10.1002/gps.4049 Frantz, J. M., & Smith, M. R. (2013). Exploring the subjective experiences of allied health professionals in their transition from clinical educators to academia: Barriers and facilitators to successful transition. African Journal of Health Professions Education, 5(1), 37-41. https:/doi.org/10.7196/ajhpe.224 Google. (2020, March 28). Use Google calendar appointment slots. https://support.google.com/calendar/answer/190998?hl=en&authuser=2&ref_topic=3417 926 Govender, P., Mkhabela, S., Hlongwane, M., Jalim, K., & Jetha, C. (2015). OT student's STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 146 experiences of stress and coping. South African Journal of Occupational Therapy, 45(3), 34-39. https://doi.org/10.17159/2310-3833/2015/v45n3/a7 Haertl, K. (2008). From the roots of psychosocial practice-therapeutic use of self in the classroom: Practical applications for occupational therapy faculty. Occupational Therapy in Mental Health, 24(2), 121-134. https://doi.org/10.1080/01642120802055168 Hkansson, C., Wagman, P, & Hagell, P. (2020). Construct validity of a revised version of the Occupational Balance Questionnaire. Scandinavian Journal of Occupational Therapy, 27(6), 441-449. https://doi: 10.1080/11038128.2019.1660801 How much time per week should I expect to spend on earning a masters degree while working full time? (2017). Best Colleges. https://www.bestcollegesonline.org Janus, E., Gawalkiewicz, P., & Bac, A. (2018). Professional burnout in occupational therapists. Advances in Rehabilitation, 32(2), 49-56. https://doi.org/10.5114/areh.2018.77937 Kee, C. E. (2021). The impact of COVID-19: Graduate students emotional and psychological experiences. Journal of Human Behavior in the Social Environment, 31(14), 476488. https://doi.org/10.1080/10911359.2020.1855285 Krefting, L. (1991). Rigor in qualitative research: The assessment of trustworthiness. The American Journal of Occupational Therapy, 45(5), 214-222. https://doi.org/10.5014/ajot.45.3.214 Krusen, N. (2020). Higher education in challenging times. OT Practice. https://www.aota.org/publications/ot-practice/ot-practice-issues/2020/higher-educationduring-corona Letts, L., Wilkins, S., Law, M., Stewart, D., Bosch, J., & Westmorland, M. (2007). Guidelines for critical review form: Qualitative studies (Version 2.0). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 147 https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.600.223&rep=rep1&type=pdf Little, B. R. (1984). Personal projects analysis - a methodology for the moral science of action. Bulletin of the British Psychological Society, 37, A115-A115 Lockhart-Keene L., & Potvin, M. (2018). Occupational therapy adjunct faculty self-perceptions of readiness to teach. Open Journal of Occupational Therapy, 6(2). https://doi.org/ 10.15453/2168-6408.1415 Malek-Ismail, J., & Krajnik, S. (2018). Thriving in the first semester of graduate school: A process of rebalancing and self-determination. Journal of Occupational Therapy Education, 2(3). https://doi.org/10.26681/jote.2018.020302 Maslach, C., & Leiter, M. P. (2008). Early predictors of job burnout and engagement. Journal of Applied Psychology, 93(3), 498-512. https://doi.org/10.1037/0021-9010.93.3.498 Mattke, S., Liu, H., Caloyeras, J., Huang, C. Y., Van Busum, K. R., Khodyakov, D., & Shier, V. (2013). Workplace wellness programs study. Rand Health Quarterly, 3(2), 7. Matuska, K., & Barrett, K. (2019). Patterns of occupation. In B. A. B. Schell, & G. Gillen (Eds.), Willard and Spackmans occupational therapy (13th ed., pp. 212-222). Philadelphia, PA: Wolters Kluwer. Matuska, K., & Christiansen, C. H. (2008). A proposed model of life balance. Journal of Occupational Science, 15(1), 9-19. https://doi.org/10.1080/14427591.2008.9686602 Matuska, K., & Christiansen, C. (2009). Life balance: Multidisciplinary theories and research. AOTA Press & SLACK. Matuska, K. M., (2010). Workaholism, life balance, and well-being: A comparative analysis. Journal of Occupational Science, 17(2), 104-111. https://doi.org/10.1080/14427591.2010.9686681 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 148 McCombie, R. P., Evans, A., & Miller, M. J. (2016). Alcohol use by occupational therapy students: An exploratory student. Occupational Therapy in Mental Health, 32(1), 1-15. https://doi.org/10.1080.0164212X.2015.1079514 Meyer, A. (1922). The philosophy of occupation therapy. Archives of Occupational Therapy, 1(1), 1-10. Mitschke, D. B., Praetorius, R. T., Magruder, K., Hong, I., Tran, H. T. K., & Mammah, R. (2021). A Hand in the fog: Graduate students as virtual peer mentors in the COVID-19 crisis. Journal of Social Work Education, 57, 4457. https://doi.org/10.1080/10437797.2021.1943586 Morse, J. M. (2000). Determining sample size. Qualitative Health Research, 10(1), 3-5. https://dx.doi.org/10.1177/104973200129118183 Myers, S. B., Sweeney, A. C., Popick, V., Wesley, K., Bordfeld, A., & Fingerhut, R. (2012). Self-care practices and perceived stress levels among psychology graduate students. Training and Education in Professional Psychology, 6(1), 55-66. https://doi.org/10.1037/a0026534 Octaberlina, L. R., & Muslimin, A. I. (2020). EFL students perspective towards online learning barriers and alternatives using Moodle/Google classroom during COVID-19 pandemic. International Journal of Higher Education, 9(6), 19. https://doi.org/10.5430/ijhe.v9n6p1 Page, K. M., Milner, A. J., Martin, A., Turrell, G., Giles-Corti, B., & LaMontagne, A. D. (2014). Workplace stress: What is the role of positive mental health? Journal of Occupational and Environmental Medicine, 56(8), 814-819. https://doi.org/10.1097/JOM.0000000000000230 Pentland, W., & McColl, M. A. (2009). Another perspective on life balance: Living in integrity STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 149 with values. In K. Matuska, & C. Christiansen (Eds.), Life balance: Multidisciplinary theories and research (pp. 165-179). SLACK & AOTA Press. Pettican, A., & Prior, S. (2011). Its a new way of life: An exploration of the occupational transition of retirement. British Journal of Occupational Therapy, 74(1), 12-19. https://doi.org/10.4276/030802211X12947686093521 Pfeifer, T. A., Kranz, P. L., & Scoggin, A. E. (2008). Perceived stress in occupational therapy students. Occupational Therapy International, 15(4), 221-231. https://doi.org/10.1002/oti.256 Phillips, J. K. (2010). Exploring student nurse anesthetist stressors and coping using grounded theory methodology. American Association of Nurse Anesthesiology Journal, 78(6), 474482. Porath, M., & Rosenblum, S. (2019). Interaction between time organization and participation dimensions among higher education students. British Journal of Occupational Therapy, 82(5), 306-315. https://doi.org/10.1177/0308022618816641 Poulsen, A. A., Meredith, P., Khan, A., Henderson, J., Castrisos, V., & Khan, S. R. (2014). Burnout and work engagement in occupational therapists. British Journal of Occupational Therapy, 77(3), 156-164. https://doi.org/10.4276/030802214X13941036266621 Proven By Users, LLC. (2020, April 19). Getting started: Card sorting with proven by users. https://provenbyusers.com/card-sort-help-getting-started.php Riediger, M., & Freund, A. M. (2004). Interference and facilitation among personal goals: Differential associations with subjective well-being and persistent goal pursuit. Personality and Social Psychology Bulletin, 30(12), 1511-1523. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 150 https://doi.org/10.1177/0146167204271184 Rummell, C. M. (2015). An exploratory study of psychology graduate student workload, health, and program satisfaction. Professional Psychology: Research & Practice, 46(6), 391-399. https://doi.org/10.1037/pro0000056 Schmidt, M., & Hansson, E. (2018). Doctoral students well-being: A literature review. International Journal of Qualitative Studies on Health and Well-being, 13(1), 1508171. https://doi.org/10.1080/17482631.2018.1508171 Sikka, R., Morath, J. M., & Leape, L. (2015). The quadruple aim: Care, health, cost and meaning in work. BMJ Quality & Safety, 24(10), 608-610. https://doi.org/10.1136/bmjqs-2015004160 Sirgy, M., J., & Lee, D. (2018). Work-life balance: An integrative review. Applied Research Quality of Life, 13(1), 229-254. https://doi.org/10.1007/s11482-017-9509-8 Spradley, J. P. (2016). The ethnographic interview. Waveland Press. Survey Monkey. (2020, March 28). Security statement. https://www.surveymonkey.com/mp/legal/security/?ut_source=footer Tompkins, K. A., Brecht, K., Tucker, B., Neander, L. L., & Swift, J. K. (2016). Who matters most? The contribution of faculty, student-peers, and outside support in predicting graduate student satisfaction. Training and Education in Professional Psychology, 10(2), 102-108. https://doi.org/10.1037/tep0000115 Varadarajan, J., Brown, A. M., & Chalkley, R. (2021). Biomedical graduate student experiences during the COVID-19 university closure. PLoS ONE, 16(9), 114. https://doi.org/10.1371/journal.pone.0256687 Van Veld. R., Slaven, E. J., Reynolds, B., Shupe, P., & Woolery, C. (2018). First-year doctor of STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 151 physical therapy students demonstrate change in coping with stress. Journal of Physical Therapy Education, 32(2), 138-144. https://doi.org/10.1097/JTE.0000000000000037 Veenhoven, R. (2009). Optimal lifestyle-mix: An inductive approach. In K. Matuska, & C. Christiansen (Eds.), Life balance: Multidisciplinary research and theories (pp. 33-42). AOTA & SLACK. Volstedt, M., & Rezat, S. (2019). An introduction to grounded theory with a special focus on axial coding and the coding paradigm. In G. Kaiser, & N. Presmeg (Eds.), Compendium for early career researchers in mathematics education (pp. 81-100). https://doi.org/10.1007/978-3-030-15636-7_4 Wagman, P., Ahlstrand, I., Bjrk, M., & Hkansson, C. (2020). Occupational balance and its association with life satisfaction in men and women with rheumatoid arthritis. Musculoskeletal Care, 18(2), 187-194. https://doi.org/10.1002/msc.1454 Wagman, P., & Hkansson, C. (2014a). Exploring occupational balance in adults in Sweden. Scandinavian Journal of Occupational Therapy, 21(6), 415-420. https://doi.org/ 10.3109/11038128.2014.934917 Wagman, P., & Hkansson, C. (2014b). Introducing the Occupational Balance Questionnaire (OBQ). Scandinavian Journal of Occupational Therapy, 21(3), 227-231. https://doi.org/10.3109/11038128.2014.900571 Wagman, P., Hkansson, C., & Bjorklund, A. (2012a). Occupational balance as used in occupational therapy: A concept analysis. Scandinavian Journal of Occupational Therapy, 19(4), 322-327. https://doi.org/10.3109/11038128.2011.596219 Wagman, P., Hkansson, C., Jacobsson, C., Falkmer, T., & Bjorklund, A. (2012b). What is considered important for life balance? Similarities and differences among some working STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 152 adults. Scandinavian Journal of Occupational Therapy, 19(4), 377-384. https://doi.org/10.3109/11038128.2011.645552 Wagman, P., Hjrthag, F., Hkansson, C., Hedin, K., & Gunnarsson, A. B. (2021). Factors associated with higher occupational balance in people with anxiety and/or depression who require occupational therapy treatment. Scandinavian Journal of Occupational Therapy, 28(6), 426432. https://doi.org/10.1080/11038128.2019.1693626 Wagman, P., Lindmark, U., Rolander, B., Whlin, C., & Hkansson, C. (2017). Occupational balance in health professionals in Sweden. Scandinavian Journal of Occupational Therapy, 24(1), 18-23. https://doi.org/10.1080/11038128.2016.1203459 Wagner, M. E., & Causey-Upton, R. (2017). Perfectionism in occupational science students: Occupational therapy implications. Irish Journal of Occupational Therapy, 45(2), 62-77. https://doi.org/10.1108/IJOT-06-2017-0014 Ware, J. E. (2000). SF-36 health survey update. Spine Journal, 25(24), 3130-3139. https://doi.org/10.1097/00007632-200012150-00008 Watkins, K. D., Roos, V., & Van der Walt, E. (2011). An exploration of personal, relational and collective well-being in nursing students during their training at a tertiary education institution. Journal of Interdisciplinary Health Sciences, 16(1). https://doi.org/10.4102/hsag. v16i1.552 Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54(6), 1063-1070. https://doi.org/10.1037/0022-3514.54.6.1063 Westhorp, P. (2003) Exploring balance as a concept in occupational science. Journal of Occupational Science, 10(2), 99-106. https://doi.org/10.1080/14427591.2003.9686516 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 153 Wilcock, A. A., Chelin, M., Hall, M., Hamley, N., Morrison, B., Scrivener, L., ... Treen, K. (1997). The relationship between occupational balance and health: A pilot study. Occupational Therapy International, 4(1), 17-30. https://doi.org/10.1002/oti.45 Wilcock, A. A., & Hocking, C. (2015). An occupational perspective of health (3rd ed.). SLACK. Willyard, C. (2012). Need to heal thyself? GradPSYCH, 10, 28-31. Wolf, T. (2020). Order of the Governor of the Commonwealth of Pennsylvania for individuals to stay at home. Commonwealth of Pennsylvania Office of the Governor. https://www.governor.pa.gov/wp-content/uploads/2020/04/20200401-GOV-StatewideStay-at-Home-Order.pdf World Health Organization. (2019, October 29). Burn-out an occupational phenomenon: International Classification of Diseases. https://www.who.int/mental_health/evidence/burn-out/en/ Wressle, E., & Samuelsson, K. (2014). High job demands and lack of time: A future challenge in occupational therapy. Scandinavian Journal of Occupational Therapy, 21(6), 421-428. https://doi.org/10.3109/11038128.2014.941929 Yazdani, F., Harb, A., Rassafiani, M., Nobakht, L., & Yazdani, N. (2018). Occupational therapists perception of the concept of occupational balance. Scandinavian Journal of Occupational Therapy, 25(4), 288-297. https://doi.org/10.1080/11038128.2017.1325934 Yu, Y., Manku, M., & Backman, C. L. (2018). Measuring occupational balance and its relationship to perceived stress and health. Canadian Journal of Occupational Therapy, 85(2), 117-127. https://doi.org/10.117/0008417417734355 Zoom. (2019). Zoom security guide. https://zoom.us/docs/doc/Zoom-Security-WhitePaper.pdf STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 154 Table 1 Characteristics of Students by OBQ11 Scores Low balance (score 17; n = 7) Gap between undergraduate and graduate school n=0 Medium balance (score 18 to 23; n = 11) n=3 High balance (score 24; n = 4) Employed n=6 n=8 n=4 Reported life was occupationally balanced at time of interview n=5 n = 10 n=4 n=3 Note. The total number of students who completed the OBQ11 was 22. Four students did not complete the OBQ11. Only data from the 22 students who completed the OBQ11 were included in Table 1. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 155 Table 2 Most Frequently Used Occupational Balance Strategies by OBQ11 Score Low balance (score 17; n = 7) Medium balance (score 18 to 23; n = 11) High balance (score 24; n = 4) Shared experiences with cohort peers Shared experiences with cohort peers Shared experiences with cohort peers Developed individualized plan for organization Developed individualized plan for organization Developed individualized plan for organization Scheduled time for self-care Scheduled time for self-care Scheduled time for self-care Use free time for self-care or to work on homework Used free time for self-care or to work on homework Made time for friends Made time for friends Used peer mentor Used peer mentor Reached out to faculty for assistance when needed Reached out to faculty for assistance when needed Took responsibility for own learning Prioritized time to balance time for all course work Obtained flexible paid employment Set realistic goals for completion and quality of academic work Note. The strategies above reflect those utilized by 50% of students with the designated OBQ11 score. The total number of students who completed the OBQ11 was 22. Four students did not complete the OBQ11. Only data from the 22 students who completed the OBQ11 were included in Table 2. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 156 Table 3 Propositional Statements Developed During Data Analysis Research question How do entry-level students in OT incorporate strategies to manage occupational balance in their role as a student in the graduate program? Propositional Statement The meaning of occupational balance is expressed through personal values and past life experience Sub Propositional Statement Student life experiences provide them a perspective of occupational balance Student personal values assist students in maintaining occupational balance Postponing occupational balance for a temporary disruption is acceptable Occupational balance disruptions can be identified Students self-identify disruptions to occupational balance Other people in a students life can identify disruptions to occupational balance Students implement strategies to return to occupational balance Students in OT adapted methods for learning to improve their effectiveness and efficiency Students use support systems to assist with managing disruptions to occupational balance Students seek parental support to assist with managing disruptions to occupational balance STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Research question Propositional Statement Students seek faculty support to assist with managing disruptions to occupational balance 157 Sub Propositional Statement Faculty who do not provide support to students contribute to occupational balance disruptions Developing and maintaining peer relationships assist students in managing disruptions to occupational balance Students who made time for self-care demonstrated the ability to minimize disruptions to occupational balance Knowing when to seek professional assistance helped students manage disruptions to occupational balance What are the differences in the occupational balance strategies of entry-level OT graduate students who report high, medium, and low occupational balance? What happens to the way entry-level OT graduate students manage occupational balance when they experience a change in the expectations of their student role or in other life roles? Participating in multiple occupational roles contributes to student occupational balance Changes in life roles during the graduate program influence occupational balance STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Research question Propositional Statement Experiencing the COVID-19 pandemic created traumatic disruptions that significantly challenged occupational balance and required altered strategies to manage 158 Sub Propositional Statement Reflecting on past graduate program experiences helped students manage disruptions to occupational balance For entry-level graduate students in different semesters of the OT program, how do the strategies for managing the student role change? Occupational balance fluctuates within the graduate program experience Occupational balance fluctuates from the beginning to the end of the program The first semester of the OT graduate program creates a disruption to occupational balance Being in the middle of the graduate program led to improved occupational balance Being at the end of the graduate program led to improved occupational balance Occupational balance fluctuates from the beginning to the end of a semester STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Figure 1 Phase Diagram 159 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Figure 2 Conditional/Consequential Matrix of Graduate Student Occupational Balance 160 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 161 Appendix A Initial Interview Guide Thank you for agreeing to be interviewed today. My name is Stephanie Bachman. I am a student at the University of Indianapolis in the Doctor of Health Science Program. I will be conducting this interview as a part of my final doctoral project. The responses you provide during the interview will be kept confidential. Your responses will be used in the data analysis, written paper, and presentation of the final project, but any identifying information will be removed. The purpose of this project is to learn more about the experiences of entry-level graduate occupational therapy students. The purpose of this interview is to gain a greater understanding of what it is like to be a graduate student, including the challenges and successes you have with being a student while managing your other life roles. The time frame for the initial interview will be approximately 60 minutes. Your participation is voluntary, and you may choose not to answer one or more questions. Upon your request, the interview may be terminated at any time. Do you have any questions about the interview or how the data will be used? I will be taking notes during the interview, but to ensure I accurately record all of your responses, I would also like to audio record the interview. The recording will be deleted following its written transcription per institutional IRB protocol. All identifying information will be omitted from the transcription. Do you mind if I record the interview? (If the response is yes I will push the record button on the cellular phone digital audio recorder) Thank you, I have begun recording. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 162 Questions and Prompts Opening Question 1. Please tell me a little bit about your background, including how long you have been a OT graduate student. Possible prompts: How much schooling had you completed before you entered graduate school? How much longer do you have until you graduate? Grand Tour Question (Spradley, 2016) 2. Could you describe what a typical week is like for you as a OT graduate student? Possible prompts: Tell me about any time you might spend caring for other people or animals? Or the time you might spend on leisure activities or hobbies? Or the time you might spend in paid employment and/or volunteer work? Possible Mini-Tour Questions (Spradley, 2016) 3. Tell me about how you organize your time while in OT graduate school? Possible prompts: Tell me more about the way you fit everything you want to do into your daily or weekly routine? How do you make everything work? When you make everything work, what words or phrases would describe that feeling? 4. Tell me about a situation when you were unable to get everything done that you planned to do. How did you feel about that experience? Tell me about what you did to address the situation. What words or phrases would you use to describe when you cant make things work? 5. How does being in graduate school influence how you fit your daily activities together? (or substitute the native language that they give about words or phrases) Possible prompts: Tell me how your ability to get everything done changes each STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE semester? What happens? 163 ...